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Approach to Improving Safety
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Search results for "Hospitals"

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Book/Report

Safe Patients, Smart Hospitals: How One Doctor's Checklist Can Help Us Change Health Care from the Inside Out.

  • Classic

Pronovost P, Vohr E. New York, NY: Hudson Street Press; 2010. ISBN: 9781594630644.

Over the past decade, Johns Hopkins intensivist Dr. Peter Pronovost has emerged as the world's most influential patient safety researcher. In this book, written with Eric Vohr, Pronovost describes how his work was inspired by two deaths from medical mistakes: of young Josie King at Johns Hopkins Hospital (chronicled by her mother Sorrel in another book) and of his own father. The meat of the volume is a detailed chronicle of Pronovost's journey from neophyte faculty member to internationally acclaimed researcher and change agent. In earnest and plainspoken prose, he describes the inside story of interventions and studies that have transformed the safety world: the Comprehensive Unit-Based Safety Program (CUSP), the use of ICU goal cards, and most importantly, the use of checklists to reduce central line infections in more than 100 Michigan ICUs, a story also recently described by Dr. Atul Gawande in The Checklist Manifesto. Dr. Pronovost was the subject of an AHRQ WebM&M interview in 2005.

Journal Article > Commentary

Relationships among teams, culture, safety, and cost outcomes.

Brewer BB. West J Nurs Res. 2006;28:641-653.

The investigator analyzed staff perceptions and found that hospital culture and team design affect patient safety and cost.

Journal Article > Study

Persistence of unsafe practice in everyday work: an exploration of organizational and psychological factors constraining safety in the operating room.

Espin S, Lingard L, Baker GR, Regehr G. Qual Saf Health Care. 2006;15:165-170.

The authors used three theoretical models to analyze ways in which unsafe behaviors become accepted by operating room team members.

Journal Article > Commentary

Improving hospital performance: culture change is not the answer.

Leggat SG, Dwyer J. Healthc Q. 2005;8:60-68.

The authors suggest that people management qualities such as teamwork development, performance management, and training should be the primary emphasis during culture change initiatives within hospitals. They argue that better people management leads to, rather than results from, an improved organizational culture.

Journal Article > Commentary

A piece of my mind. Speak up.

Merrill DG. JAMA. 2017;317:2373-2374.

Team support and respect are key elements of a culture of safety. This commentary highlights how clinicians can experience disrespectful encounters with patients and explains why insufficient awareness and reporting by team members of such incidents can normalize the behavior to diminish the safety of the practice environment.

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.

Audiovisual > Audiovisual Presentation

Presenting TeamSTEPPS in the Perioperative Setting.

TeamSTEPPS Webinar Series. Agency for Healthcare Research and Quality. May 10, 2017; 1:00–2:00 PM (Eastern).

TeamSTEPPS is a process to enhance communication and teamwork in health care. This webinar will offer insights on implementing TeamSTEPPS in a large health system to improve perioperative practice. The session will highlight developing leadership as program champions, creating learning materials, and monitoring as tactics for sustaining improvements. This is part of a monthly series of educational modules on TeamSTEPPS.

Tools/Toolkit > Government Resource

Toolkit To Improve Safety in Ambulatory Surgery Centers.

Agency for Healthcare Research and Quality: Rockville, MD.

Ambulatory surgery centers provide care to growing numbers of patients. This toolkit draws from AHRQ's Comprehensive Unit-based Safety Program to help ambulatory surgical center teams develop communication and teamwork skills to reduce infections and other iatrogenic harms.

Journal Article > Study

Translating concerns into action: a detailed qualitative evaluation of an interdisciplinary intervention on medical wards.

Pannick S, Archer S, Johnston MJ, et al. BMJ Open. 2017;7:e014401.

Frontline providers possess unique insights for improving patient safety and their perceptions may be different from those of managers and clinical leaders. In this qualitative study, researchers sought to harness this expertise and perspective through a multifaceted intervention that involved structured multidisciplinary briefings, increased organizational awareness of challenges identified by frontline providers, and feedback—referred to as prospective clinical team surveillance. They found that the prospective safety intervention created a sense of psychological safety in which team members were more likely to raise concerns without fear of punishment and increased frontline provider engagement in improvement opportunities. The authors emphasize that such an approach provides managers with better insights into issues affecting care delivery. A past PSNet perspective discussed workarounds and resiliency on the front lines of health care.

Journal Article > Review

Developing team cognition: a role for simulation.

Fernandez R, Shah S, Rosenman ED, Kozlowski SWJ, Parker SH, Grand JA. Sim Healthc. 2017;12:96-103.

Simulation training has been advocated as a way to improve individuals' technical and nontechnical skills. This review explores how simulation can help teams enhance their situation awareness and responsiveness. The authors recommend that future research should draw on team science to inform design of simulation strategies that augment team mental models.

Journal Article > Commentary

Patient safety and interprofessional education: a report of key issues from two interprofessional workshops.

Anderson ES, Gray R, Price K. J Interprof Care. 2017;31:154-163.

Interprofessional education is a key strategy to improve patient safety. This commentary summarizes results of two workshops that discussed strategies for interdisciplinary clinician development to enhance teamwork and manage hierarchy. The authors highlight the importance of engaging patients in interprofessional education efforts.

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.

Journal Article > Review

Challenging hierarchy in healthcare teams—ways to flatten gradients to improve teamwork and patient care.

Green B, Oeppen RS, Smith DW, Brennan PA. Br J Oral Maxillofac Surg. 2017;55:449-453.

Navigating hierarchy in health care is challenging at both team and organizational levels. This review discusses the necessity of managing hierarchy in high-risk environments and reviews tactics to improve nontechnical skills to help clinicians address authority gradients during care activities.

Journal Article > Review

A systematic review of team training in health care: ten questions.

Marlow SL, Hughes AM, Sonesh SC, et al. Jt Comm J Qual Patient Saf. 2017;43:197–204.

This systematic review found that team training programs primarily focus on improving communication among providers, generally involve simulation, and usually assess efficacy with self-report. The authors conclude that team training is improving but remains suboptimal.

Perspectives on Safety > Interview

In Conversation With… Amy C. Edmondson, PhD, AM

Update on Teamwork, February 2017

Dr. Edmondson is the Novartis Professor of Leadership and Management at Harvard Business School. She is an expert on leadership, teams, and organizational learning. We spoke with her about the role of teamwork in health care and why it is becoming increasingly important.

Perspectives on Safety > Perspective

New Insights About Team Training From a Decade of TeamSTEPPS

with commentary by David P. Baker, PhD; James B. Battles, PhD; Heidi B. King, MS, Update on Teamwork, February 2017

This piece outlines 10 insights about team training in health care learned from experience with the AHRQ-supported teamwork training program, TeamSTEPPS.

Journal Article > Review

Monitoring teamwork: a narrative review.

Rutherford JS. Anaesthesia. 2017;72(suppl 1):84-94.

Anesthesiology was an early adopter of teamwork as a safety improvement strategy. This review explored models of assessing teamwork behaviors in anesthesiology. The authors found both implicit and explicit methods in place to monitor teamwork and determined that team training improves patient safety.

Journal Article > Commentary

Implementation of the safety huddle.

Kylor C, Napier T, Rephann A, Spence SJ. 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.

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

Development and preliminary testing of the Coordination Process Error Reporting Tool (CPERT), a prospective clinical surveillance mechanism for teamwork errors in the pediatric cardiac ICU.

Bates KE, Shea JA, Bird GL, et al. Jt Comm J Qual Patient Saf. 2016;42:562-571.

Hospitals rely on incident reporting systems to detect safety issues, but these systems are voluntary and do not capture all adverse events or near misses. Researchers developed and tested a prospective surveillance tool to identify teamwork errors in the pediatric intensive care unit. They found that this tool helped uncover safety issues not captured by the hospital's patient safety reporting system.

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