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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.
Journal Article > Study
Evaluating efforts to optimize TeamSTEPPS implementation in surgical and pediatric intensive care units.
Mayer CM, Cluff L, Lin WT, et al. Jt Comm J Qual Patient Saf. 2011;37:365-374.
Teamwork training programs have resulted in some notable successes, but many other attempts have failed to yield improved patient outcomes, in part because of a lack of evidence showing that teamwork training results in durable provider behavior change. In this AHRQ-funded study, the TeamSTEPPS training program was introduced in two intensive care units (one pediatric and one adult surgical), after meticulous preparatory planning that emphasized the utility of the training for frontline care providers, engaged higher-level support for the effort, and established clear metrics for effectiveness. The program resulted in improvement in directly observed team behaviors and measures of safety culture, and also improved 2 of 3 targeted patient-level outcomes. A related editorial discusses the role of targeted teamwork training interventions in the context of efforts to develop high reliability organizations.
Journal Article > Study
Intensive care unit safety incidents for medical versus surgical patients: a prospective multicenter study.
Sinopoli DJ, Needham DM, Thompson DA, et al. J Crit Care. 2007;22:177-183.
This AHRQ-funded multicenter prospective study used data from a previously described voluntary reporting system, the Intensive Care Unit Safety Reporting System (ICUSRS), to compare the types and severity of safety problems for medical and surgical ICU patients. Despite differences in the types of patients, the types of errors reported were generally similar between the two groups, with most errors being attributable to training and team system factors (such as communication). Prior studies using data from the ICUSRS have analyzed factors contributing to medication order entry errors and procedural errors.
Tools/Toolkit > Fact Sheet/FAQs
Rockville, MD: Agency for Healthcare Research and Quality; May 2006. AHRQ Publication No. 06-P023.
This document briefly describes a selection of AHRQ-funded patient safety research projects.
Grant > Government Resource
Rockville, MD: Agency for Healthcare Research and Quality; June 2005. AHRQ Publication No. 05-P003-3.
This program brief summarizes patient safety research projects funded by the Agency for Healthcare Research and Quality (AHRQ) since 2001.