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- Organizational Behaviorists
Weick KE. Thousand Oaks, CA: Sage Publications; 1995.
Weick's work has influenced many important thinkers in patient safety, most notably Don Berwick, as seen in his story Escape Fire, which illustrates the disasters that befall teams when "sensemaking" is absent or disappears in a crisis. Weick's thinking encompasses the notion that both individuals and teams often overlook important problems because they put on cognitive blinders based on their biases and expectations and that individuals or teams working in complex enterprises often err because they lose the ability to make rational decisions in the face of crises. All of this is useful and intuitively logical, although one finishes Weick's book not entirely sure how to improve sensemaking in a clinical context.
Journal Article > Study
Neily J, Mills PD, Young-Xu Y, et al. JAMA. 2010;304:1693-1700.
Classic studies have demonstrated that operating rooms are rife with communication and teamwork problems, and suboptimal teamwork has been linked to poor postoperative patient outcomes. In this rigorously designed study, surgical teams at 74 Veterans Affairs (VA) hospitals underwent teamwork training through the VA's Medical Team Training program. The training also included implementation of preoperative and postoperative checklists. The teamwork training was associated with a striking reduction in mortality compared to other VA hospitals that had not yet implemented the program, and a dose–response effect was also evident, with continuing training resulting in further reductions in mortality. An accompanying editorial lauds this study as an example of how to conduct a rigorous, evidence-based evaluation of a safety intervention, and stresses that addressing teamwork and safety culture are as essential to improving safety as technical and procedural interventions such as checklists.
Simons DJ. Champaign, IL: Viscog Productions, Inc; 1999.
This instructional tool, commonly known as the "gorilla video," illustrates the importance of selective attention theories. These theories suggest that individuals tend to orient themselves toward, and process information from, only one part of their environment while excluding others. The video is frequently used by patient safety educators in a variety of settings, including teamwork training programs.