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1 - 20 of 54
Hoonakker PLT, Wooldridge AR, Hose B-Z, et al. Intern Emerg Med. 2019;14:797-805.
Patient acuity and the need for interdisciplinary collaboration contribute to patient safety issues in trauma care. This qualitative study explored perceptions of handoff safety in pediatric trauma patients and found a high potential for information loss due to the rapidity of handoffs and the multiple disciplines involved.
Hendrickson MA, Schempf EN, Furnival RA, et al. Jt Comm J Qual Patient Saf. 2019;45:431-439.
This project report describes a novel procedure for handoffs from the emergency department to the inpatient service. The study team implemented a daily conference call that included nurses, residents, and attending physicians rather than separating physician and nursing handoff workflows. The overall reaction to the interdisciplinary workflow was positive.
Dietz AS, Salas E, Pronovost PJ, et al. Crit Care Med. 2018;46:1898-1905.
This study aimed to validate a behavioral marker as a measure of teamwork, specifically in the intensive care unit setting. Researchers found that it was difficult to establish interrater reliability for teamwork when observing behaviors and conclude that assessment of teamwork remains complex in the context of patient safety research.
Duffy JR, Culp S, Padrutt T. J Nurs Adm. 2018;48:361-367.
Prior research has shown that missed nursing care may in part result from reduced nurse staffing and is associated with adverse outcomes for patients. Using survey data from a sample of nurses at a single community hospital, researchers found that reduced nurse staffing, lower job satisfaction, and decreased satisfaction with teamwork were important factors related to missed nursing care.
Sheth S, McCarthy E, Kipps AK, et al. PEDIATRICS. 2016;137.
The I-PASS signout tool has become a widely used method of patient handoffs when transferring care from the primary clinician to a covering clinician. This study used the I-PASS framework to develop and implement a standardized signout process for transferring patients from the pediatric cardiac intensive care unit to the general ward. The new process significantly improved clinician workflow and perceived safety culture relating to handoffs.
Epstein NE. Surg Neurol Int. 2014;5:S295-303.
Multidisciplinary teamwork is essential in developing appropriate treatment plans. This review summarizes the literature documenting the benefits of teamwork, including better communication, fewer adverse events, and increased job satisfaction. The author advocates for keeping teams that work well together to further optimize improvements.
Richter JP, McAlearney AS, Pennell ML. Health Care Manage Rev. 2016;41:32-41.
Incomplete handoffs and insufficient communication regarding key clinical information may lead to adverse events or missed or delayed diagnoses. This analysis of data from the AHRQ Hospital Survey of Patient Safety Culture sought to determine how perceptions of organizational factors that affect safety can contribute to optimal handoffs. Perceived teamwork across units was a significant predictor for successful handoffs. Perceptions of staffing adequacy and management support for patient safety efforts were also related to good handoffs. Among frontline staff, open communication was associated with optimal handoffs, while among management safe handoffs were linked to a continuous learning culture. These findings add to existing studies which underscore the need for high-reliability organizations to promote safety efforts. The authors advocate for hospital leadership to promote teamwork and open communication to augment handoffs in their facilities. Dr. Vineet Arora discussed the challenges of handoffs in a prior AHRQ WebM&M interview.
Dietz AS, Pronovost PJ, Mendez-Tellez PA, et al. J Crit Care. 2014;29:908-14.
Improving teamwork and communication is a continued focus in the hospital setting. This systematic review revealed that although studies of teamwork in the intensive care unit abound, the field lacks common definitions and constructs. Teamwork usually entailed joint strategy and shared goals, and quality improvement approaches to enhance teamwork typically involve team training and development of structured protocols. Many interventions target rounds, during which interdisciplinary providers discuss each patient, or handoffs between clinicians. The authors suggest that communication is the most prominent aspect of teamwork and propose further study in conceptualizing teamwork to design effective interventions. The heterogeneity in defining and measuring teamwork may account for mixed results in improving safety outcomes. An AHRQ WebM&M perspective describes the Veterans Health Administration's medical team training program.
Li J, Young R, Williams M. Cleve Clin J Med. 2014;81:312-20.
Care transitions are a vulnerable time for patients as they move through various levels of care. Exploring factors that hinder safety during transitions, this review describes successful improvement initiatives and offers strategies to reduce readmissions, such as enhancing team communication, educating staff, and standardizing transition plans.
Bonifacio AS, Segall N, Barbeito A, et al. Int Anesthesiol Clin. 2013;51:43-61.
This commentary discusses concerns associated with patient transfers from the operating room to the intensive care unit and describes strategies to improve such handoffs, including standardizing processes and offering training to enhance teamwork and communication.
Sarcevic A, Marsic I, Burd RS. ACM Transactions on Computer-Human Interaction. 2012;19.
This study examines the nature of trauma teamwork errors and suggests structures to better support team cognition and decision-making.

Brice JH, Patterson PD, eds. Prehosp Emerg Care. 2012;16:1-108.  

This special issue contains articles exploring safety improvement efforts in emergency medical services.