Ricciardi R, Shofer M. J Nurs Care Qual. 2019;34:1-3.
This commentary discusses the importance of the nurse-patient relationship and engagement with patients and their family members to improve patient safety practices. The article also provides an overview of AHRQ resources intended to facilitate engagement between providers and their patients and family members.
Wright B, Faulkner N, Bragge P, et al. Diagnosis (Berl). 2019;6:325-334.
The hectic pace of emergency care detracts from reliability. This review examined the literature on evidence, practice, and patient perspectives regarding diagnostic error in the emergency room. A WebM&M commentary discussed an incident involving a diagnostic delay in the emergency department.
Casali G, Cullen W, Lock G. J Thorac Dis. 2019;11:S998-S1008.
Nontechnical skills, such as teamwork, communication, and leadership, are essential human-centered components of safe surgical practice. This commentary discusses contextual characteristics needed to support nontechnical skill development to improve health care outcomes. The authors recommend a cultural shift away from focusing on technical performance to one that incorporates training in nontechnical skills.
The second victim effect has been used to describe the emotional impact that providers may experience when involved in a medical error, adverse event, or unanticipated patient outcome. In this survey study, researchers found that members of a critical care society frequently admitted to experiencing negative emotions such as blame and guilt when responding to questions involving scenarios of different types of errors. Nearly 70% of respondents suggested that team debriefings and talking with colleagues could help mitigate the second victim effect.
Rönnerhag M, Severinsson E, Haruna M, et al. J Adv Nurs. 2019;75:585-593.
Inadequate communication in obstetrics can compromise safety. In this qualitative study, researchers conducted focus groups of multidisciplinary teams including obstetricians, midwives, and nurses working in a single maternity ward to examine their perceptions of adverse events during childbirth. Analysis of data collected suggests that support for high-quality interprofessional teamwork is important for safe maternity care.
Pattni N, Arzola C, Malavade A, et al. Br J Anaesth. 2019;122:233-244.
Effective teamwork and communication are critical to ensuring patient safety in the busy environment of the operating room. This review examined the evidence on preparing staff to challenge authority in the perioperative environment. Common themes that affect speaking up included hierarchy, organizational culture, and education. Teaching that promotes open communication in the postgraduate environment and utilizing tactics such as simulation training can help address barriers to challenging authority.
The surgeon–anesthesiologist relationship is crucial to effective teamwork and safe perioperative care. This commentary explores factors that influence the relationship, outlines mental models that affect its effectiveness, suggests research to inform improvement efforts, and provides recommendations to help these two specialists work in tandem to better support safety.
Romijn A, Teunissen PW, de Bruijne MC, et al. BMJ Qual Saf. 2018;27:279-286.
This qualitative study assessed perceptions of teamwork and interprofessional collaboration between obstetricians, nurses, and hospital-based and primary care midwives in the Netherlands. Overall, obstetricians perceived teamwork to be better than participants from other disciplines. The gap between physicians, nurses, and midwives was largest with regard to perceived openness to sharing opinions and discussing new ideas.
Leslie M, Paradis E, Gropper MA, et al. Health Serv Res. 2017;52:1330-1348.
As implementation of comprehensive health information technology (IT) systems becomes more widespread, concern regarding the unintended consequences of such technologies has increased as well. Usability testing is helpful for optimizing implementation of health IT. Researchers analyzed the impact of health IT use on relationships among clinicians over a year-long period across three academic intensive care units. In the two units with higher health IT use, clinicians were more likely to work in an isolated manner, which was associated with an adverse effect on situational awareness, communication, and patient satisfaction. A previous PSNet perspective discussed some of the pitfalls in the development, implementation, and regulation of health IT and what can be learned to improve patient safety going forward.
Kylor C, Napier T, Rephann A, et al. Crit Care Nurse. 2016;36:80-82.
The safety huddle is becoming common within health care practice as a way to inform clinicians about what is happening during their shift. This commentary describes how huddles can help improve communication and teamwork in the acute care setting.
Cabral RA, Eggenberger T, Keller K, et al. AORN J. 2016;104:206-216.
Surgical team communication is an important element of safe care. This project report describes how one hospital implemented a checklist program that utilized time outs and debriefings to support transparency and improve surgical teamwork behaviors.
SBAR has been widely implemented to improve communication in health care settings. This simulation study compared the use of SBAR with a newly developed Traffic Lights tool to assess the communication between anesthesia teams in different operating rooms in 12 validated clinical scenarios. The authors found that the new tool yielded more accurate information transfer, took less time to use, and was preferred by the majority of study participants.
According to this qualitative study at a single academic institution, staff surgeons and intensivists frequently exclude resident physicians from patient care conversations. Reasons included lack of trust, need for timely communication, and a perception that residents cannot adequately contribute to decision making. This finding has important implications for the integration of communication training during medical education.
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.
Failure-to-rescue is considered a potential contributing factor in the wide variations in surgical mortality rates. This review explored the evidence regarding the surgical mortality of older patients and found system factors that affected failure-to-rescue rates, including safety culture and access to technology. The authors suggest that teamwork and communication improvement can help reduce failure-to-rescue in this patient population.
Sacks GD, Shannon EM, Dawes AJ, et al. BMJ Qual Saf. 2015;24:458-67.
Previous literature has shown that safety culture and nontechnical skills (such as communication) can affect safety and clinical outcomes in patients undergoing surgery. This systematic review identified several interventions that demonstrated effectiveness at improving various aspects of surgical culture, including teamwork and communication. A past AHRQ WebM&M commentary discussed disruptive behavior as a contributor to safety issues in surgery.
Hicks CW, Rosen M, Hobson DB, et al. JAMA Surg. 2014;149:863-8.
Operating room briefings or time-outs are mandated by The Joint Commission as a strategy to prevent wrong-site surgery. This commentary explores the use of briefings both before and after surgery, evidence regarding their impact, and how a comprehensive unit-based safety program (CUSP) initiative designed and implemented a briefing and debriefing process.
Bethune R, Blencowe NS. J Perioper Pract. 2014;24:56-58.
Briefings have been identified as a promising method to enhance team communication. This commentary describes an initiative to improve the use of preoperative briefings as a training mechanism through strategies like increased emphasis on identifying team members and assigning specific tasks.
Stahel PF, Mauffrey C, Butler N. Patient Saf Surg. 2014;8:9.
Communication failures are a common cause of patient harm in surgical settings. This commentary reviews safety challenges in this setting and describes how models used by NASA and the FAA can be applied in health care to improve safety culture, education, and surgeon leadership.
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