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Approach to Improving Safety
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Search results for "Active Errors"

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Journal Article > Study

Association of a surgical task during training with team skill acquisition among surgical residents: the missing piece in multidisciplinary team training.

Sparks JL, Crouch DL, Sobba K, et al. JAMA Surg. 2017 May 24; [Epub ahead of print].

Multiple studies have linked poor teamwork and communication to adverse events in the operating room. There is a growing recognition that surgeons must learn these nontechnical skills during training in addition to the traditional focus on technical ability. In this controlled study, surgical residents participated in an educational intervention (a simulated surgical emergency) that simultaneously targeted technical and nontechnical skill development. The study used two different types of simulation—high fidelity (a cadaver) and medium fidelity (an anatomically correct mannequin)—compared to a control group, which used a nonanatomic simulator. Investigators found that nontechnical skills improved in both intervention groups compared to the control group, measured using validated teamwork assessments. As the accompanying editorial notes, the study findings indicate that technical and nontechnical skills may be best taught together, as teamwork skills improved when residents also had to perform a simulated surgical task simultaneously.

Journal Article > Study

We are going to name names and call you out! Improving the team in the academic operating room environment.

Bodor R, Nguyen BJ, Broder K. Ann Plast Surg. 2017;78(suppl 4):S222-S224.

This study of operating room teams found that nursing staff, attending surgeons, and anesthesiologists did not always know the name or postgraduate year rank of trainees participating in surgery with them. The authors describe this lack of familiarity with team members as a knowledge gap that has the potential to affect surgical safety.

Audiovisual > Audiovisual Presentation

Diagnosis as a team sport.

Armstrong Center for Diagnostic Excellence. March 1, 2017; 1:00–2:00 PM (Eastern).

Teamwork is an important strategy to reduce diagnostic error. This webinar will outline barriers to effective collaboration and highlight the value of a multidisciplinary approach to preventing diagnostic error. Dr. David Newman-Toker is the featured speaker.

Book/Report

Safer delivery of surgical services: a programme of controlled before-and-after intervention studies with pre-planned pooled data analysis.

McCulloch P, Morgan L, Flynn L, et al. Health Services and Delivery Research. Southampton, UK: NIHR Journals Library; 2016.

This publication reports five British hospitals' experiences with teamwork interventions in surgical teams. Although teamwork training alone improved how teams functioned, it did not always enhance clinical performance. The investigators found that integrated training that combines technical and social improvements, such as Lean, resulted in more effective improvements.

Journal Article > Study

Opportunities to enhance laboratory professionals' role on the diagnostic team.

Taylor JR, Thompson PJ, Genzen JR, Hickner J, Marques MB. Lab Med. 2017;48:97-103.

Diagnostic error represents a significant source of patient harm. In this study, researchers surveyed physicians to understand how to improve the involvement of laboratory professionals in assisting with diagnostic challenges. They conclude that there may be a greater role for laboratory professionals in the diagnostic process beyond providing test results.

Journal Article > Commentary

How communication among members of the health care team affects maternal morbidity and mortality.

Brennan RA, Keohane CA. J Obstet Gynecol Neonatal Nurs. 2016;45:878-884.

Communication failures in obstetric care can increase risk of harm for the mother and the infant. This commentary highlights how nurses can incorporate teamwork principles and structured communication to reduce risks of maternal injury.

Cases & Commentaries

Cognitive Overload in the ICU

  • Spotlight Case
  • CME/CEU
  • Web M&M

Vimla L. Patel, PhD, and Timothy G. Buchman, PhD, MD; July/August 2016

Admitted to the intensive care unit (ICU) with acute respiratory distress syndrome due to severe pancreatitis, an older woman had a central line placed. Despite maximal treatment, the patient experienced a cardiac arrest and was resuscitated. The intensivist was also actively managing numerous other ICU patients and lacked time to consider why the patient's condition had worsened.

Journal Article > Study

Combining systems and teamwork approaches to enhance the effectiveness of safety improvement interventions in surgery: the Safer Delivery of Surgical Services (S3) program.

  • Classic

McCulloch P, Morgan L, New S, et al. Ann Surg. Ann Surg. 2017;265:90-96.

Safety culture and work systems influence safety, but it is unclear whether safety improvement efforts should focus on one or both factors. This study sought to improve adherence to the WHO surgical safety checklist and to enhance technical and nontechnical team performance using several safety interventions. One intervention focused on improving safety culture, while another was directed at the work system. Investigators also tested a combined approach. Although both team training and system redesign individually demonstrated improvement, the combined approach was more successful than either individual approach. This finding suggests that in order to truly enhance surgical safety, organizations must invest in both systems and culture interventions.

Journal Article > Study

Diagnostic performance by medical students working individually or in teams.

Hautz WE, Kämmer JE, Schauber SK, Spies CD, Gaissmaier W. JAMA. 2015;313:303-304.

This simulation study found that diagnostic performance by fourth-year medical students improved when they worked in pairs compared to when they worked individually. The authors suggest that working collaboratively allowed students to avoid cognitive biases that can impede timely and correct diagnosis. These results emphasize the importance of real-time feedback in the diagnostic process.

Newspaper/Magazine Article

The high cost of low morale in the clinical laboratory: how workplace environment impacts patient safety.

Barker T, Noguez J. Clinical Laboratory News. January 1, 2015.

Reporting on the importance of a supportive workplace environment that engages employees in tasks to help ensure safety, this news article discusses root causes for low staff morale in the laboratory environment and suggests tactics to build healthy staff relationships.

Journal Article > Commentary

Diagnostic error: untapped potential for improving patient safety?

Groszkruger D. J Healthc Risk Manag. 2014;34:38-43.

Highlighting how uncertainty around identifying diagnostic errors hinders measuring its incidence and developing solutions, this commentary outlines methods to augment diagnostic safety including teamwork activities, establishing best practices, and utilizing decision support systems.

Journal Article > Study

The influence of organizational factors on patient safety: examining successful handoffs in health care.

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.

Journal Article > Commentary

Improving safety and quality of care with enhanced teamwork through operating room briefings.

Hicks CW, Rosen M, Hobson DB, Ko C, Wick EC. JAMA Surg. 2014;149:863-868.

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.

Journal Article > Commentary

Nearing zero...reducing grade C medication errors.

Cockerham J, Figueroa-Altmann A, Foxen C, Paffett C, Sullivan A, Wellner J. Nurs Manage. 2014;45:26-31.

This commentary outlines an initiative at a 15-bed pediatric nursing unit that used quiet zones, safety huddles, and independent double checks to reduce medication errors of the type that reach the patient but neither cause harm nor require additional intervention.

Journal Article > Review

Disclosure of adverse events and errors in surgical care: challenges and strategies for improvement.

Lipira LE, Gallagher TH. World J Surg. 2014;38:1614-1621.

Error disclosure is receiving increased attention as a strategy to improve communication and patient safety. This review discusses elements of surgical care that hinder disclosure, including frequency of adverse events, teamwork and hierarchy, and lack of surgery-specific guidelines.

Journal Article > Commentary

Current challenges and future perspectives for patient safety in surgery.

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.

Journal Article > Study

The surgical safety checklist and teamwork coaching tools: a study of inter-rater reliability.

Huang LC, Conley D, Lipsitz S, et al. BMJ Qual Saf. 2014;23:639-650.

The effectiveness of safety checklists depends mostly on how well they are implemented and performed—a recent study found no improvements in surgical outcomes with their adoption. This study created reliable observation tools for measuring surgical safety checklist performance and teamwork in the operating room.

Journal Article > Review

Do safety checklists improve teamwork and communication in the operating room? A systematic review.

Russ S, Rout S, Sevdalis N, Moorthy K, Darzi A, Vincent C. Ann Surg. 2013;258:856-871.

This systematic review found that safety checklists in the operating room measurably augment teamwork and communication, which may explain how they improve patient outcomes.

Journal Article > Organizational Policy/Guidelines

Patient safety in the cardiac operating room: human factors and teamwork: a scientific statement from the American Heart Association.

Wahr JA, Prager RL, Abernathy JH 3rd, et al; American Heart Association Council on Cardiovascular Surgery and Anesthesia, Council on Cardiovascular and Stroke Nursing, Council on Quality of Care and Outcomes Research. Circulation. 2013;128:1139-1169.

This scientific statement from the American Heart Association (AHA) reviews the current state of knowledge on safety issues in the operating room (OR) and provides detailed recommendations for hospitals to implement to improve safety and patient outcomes. These recommendations include using checklists and formal handoff protocols for every procedure, teamwork training and other approaches to enhance safety culture, applying human factors engineering principles to optimize OR design and minimize fatigue, and taking steps to discourage disruptive behavior by clinicians. AHA scientific statements, which are considered the standard of care for cardiac patients, have traditionally focused on clinical issues, but this article (and an earlier statement on medication error prevention) illustrates the critical importance of ensuring safety in this complex group of patients.

Newspaper/Magazine Article

'You talking to me?' Docs and feedback.

Diamond F. Manag Care. July 2013;22:30-32.

Reporting on barriers to teamwork, this magazine article relates how hierarchy influences speaking up about concerns and recommends tactics to improve communication.

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