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- Communication Improvement 4
- Culture of Safety 1
- Education and Training
- Error Reporting and Analysis 1
- Quality Improvement Strategies 1
- Teamwork 3
- Transparency and Accountability 1
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Tools/Toolkit > Multi-use Website
Washington, DC: Department of Defense. Rockville, MD: Agency for Healthcare Research and Quality; 2016.
Effective teamwork plays an essential role in providing safe patient care. 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. This updated version of the widely implemented program provides new tools to measure its impact, supports increased emphasis on the role of effective communication in team training, and includes a new course management guide. Teamwork training programs have been shown to improve knowledge and attitudes, but have received mixed reviews on their effectiveness in changing behaviors. An AHRQ WebM&M commentary discussed how improved teamwork and shared decision-making might have prevented the unnecessary placement of a peripherally inserted central catheter that led to significant complications.
Web Resource > Government Resource
United States Department of Defense.
This Web site includes information on several initiatives within the US Military Health System to support its culture of safety and reduce medical error through leadership, transparency, teamwork, and communication.
Journal Article > Commentary
Clancy CM, Tornberg DN. Am J Med Qual. 2007;22:214-217.
The authors discuss the TeamSTEPPS training program—a collaboration of the US Department of Defense and Agency for Healthcare Research and Quality to enhance patient safety through improved teamwork.
Journal Article > Study
Standardized sign-out reduces intern perception of medical errors on the general internal medicine ward.
Salerno SM, Arnett MV, Domanski JP. Teach Learn Med. 2009;21:121-126.
This study describes the development and implementation of a standardized written sign-out sheet that improved the completeness and effectiveness of handoffs between housestaff.
Journal Article > Commentary
Chief of Residents for Quality Improvement and Patient Safety: a recipe for a new role in graduate medical education.
Ferraro K, Zernzach R, Maturo S, Nagy C, Barrett R. Mil Med. 2017;182:e1747-e1751.
This commentary describes how one hospital established a resident leader to embed quality improvement and patient safety education into daily care processes. The authors review strategies the resident leader championed to drive improvement, including quarterly hospital-wide morbidity and mortality conferences, mock root cause analyses, and a feedback mechanism to respond to resident concerns.