Patient Safety Primer
Providing safe health care depends on highly trained individuals with disparate roles and responsibilities acting together in the best interests of the patient. Communication barriers across hierarchies, failure to acknowledge human fallibility, and lack of situational awareness combine to cause poor teamwork, which can lead to clinical adverse events.
The aviation industry has long recognized that safety requires crew members to receive specific training in working as a team, in addition to technical training. Several studies have documented poor levels of teamwork in medicine. A classic study that compared perceptions of teamwork between operating room personnel and flight crews found that attending surgeons were significantly less likely to acknowledge fatigue or accept suggestions from junior staff than were pilots.
Growing recognition of the need for teamwork has led to the application of teamwork training principles, originally developed in aviation, to a variety of health care settings. While there is no single standardized teamwork training program for health care, all programs stress several key concepts. Teamwork training attempts to minimize the potential for error by training each team member to respond appropriately in acute situations. Teamwork training thus focuses on developing effective communication skills and a more cohesive environment among team members, and on creating an atmosphere in which all personnel feel comfortable speaking up when they suspect a problem. Team members are trained to cross-check each other's actions, offer assistance when needed, and address errors in a nonjudgmental fashion. Debriefing and providing feedback, especially after critical incidents, are essential components of teamwork training.
Teamwork training also emphasizes the role of human factors—for example, the effects of fatigue, expected or predictable perceptual errors (such as misreading monitors or mishearing instructions), and the impact of different management styles and organizational cultures. Teamwork training may be purely classroom-based or accompanied by simulations of specific scenarios such as cardiopulmonary resuscitation, "crash" Caesarean section, or multiorgan trauma.
Teamwork training programs—implementation and effectiveness
The Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) program was developed in collaboration by the United States Department of Defense and AHRQ in order to support effective communication and teamwork in health care. TeamSTEPPS has been successfully implemented in a variety of clinical settings, including intensive care units and operating rooms. AHRQ offers a comprehensive curriculum and training program for interested organizations, which includes hands-on training through regular meetings and conferences as well as an online toolkit with an implementation guide, training materials, and measurement tools. Although originally developed for hospitals, the TeamSTEPPS program has been expanded to include long-term care and primary care. Other examples of teamwork training programs include the Veterans Affairs Medical Team Training program and crew resource management (which is based on aviation industry teamwork programs).
Teamwork training programs have been implemented in a wide variety of clinical environments, including the emergency department, operating rooms, obstetrics units, and outpatient primary care clinics. They are also being used to train hospital leadership in responding to safety events. The evidence supporting the benefits of such programs in health care is growing. A landmark study conducted in the Veterans Affairs hospital system demonstrated a significant reduction in surgical mortality associated with implementation of the Medical Team Training program. Other studies have consistently demonstrated improvements in participants' knowledge of teamwork principles, attitudes toward the importance of teamwork, and overall safety climate, although these have not necessarily translated into durable behavioral changes or enhanced skills. The effectiveness of teamwork training may depend on baseline perceptions of safety culture and readiness for change within a given unit or organization, as well as the intensity and duration of the intervention.
All military health facilities participate in the TeamSTEPPS program, and the Medical Team Training program is being widely implemented in Veterans Affairs facilities. However, teamwork training is not required for other health care facilities. The Joint Commission's Universal Protocol for preventing wrong-site surgery mandates a preoperative "time out," based on teamwork training principles, in which all team members review the details of the surgery to take place. Many organizations are now coupling teamwork training programs with more specific efforts to structure communication, such as SBAR (situation, background, assessment, recommendation) training. Successful organizational approaches to improving safety, such as the Comprehensive Unit-Based Safety Program, also explicitly incorporate teamwork training principles.