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Search results for "Hospitals"

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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 > 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 > 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

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.

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

Integrated approach to reduce perinatal adverse events: standardized processes, interdisciplinary teamwork training, and performance feedback.

Riley W, Begun JW, Meredith L, et al. Health Serv Res. 2016;51(suppl 3):2431-2452.

Prior research has shown that reducing preventable perinatal harm leads to a decrease in malpractice claims. In this prospective study involving the perinatal units across 14 hospitals from 12 states and accounting for almost 350,000 deliveries, researchers found that successful implementation of 3 standard care processes resulted in a 14% decrease in harm in perinatal care from the baseline period.

Journal Article > Study

Simulated settings; powerful arenas for learning patient safety practices and facilitating transference to clinical practice. A mixed method study.

Reime MH, Johnsgaard T, Kvam FI, et al. Nurse Educ Pract. 2016;21:75-82.

Teamwork and communication are critical to safe patient care. Investigators sought to determine how a simulation-based interprofessional team training course for medical and nursing students affected professional skills and patient safety practices. Similar to prior research, this study suggests that interprofessional team training can have a positive impact on patient care.

Journal Article > Commentary

S-TEAMS: a truly multiprofessional course focusing on nontechnical skills to improve patient safety in the operating theater.

Stewart-Parker E, Galloway R, Vig S. J Surg Educ. 2017;74:137-144.

Before teamwork behaviors became a key component of medical error reduction, little research focused on nontechnical skill development in surgery. This commentary discusses a program designed to teach multidisciplinary teams nontechnical skills and enable participants to practice them in simulations. The authors found that teams continued to apply what they learned long after completing the training.

Journal Article > Study

Cluster randomized trial to evaluate the impact of team training on surgical outcomes.

Duclos A, Peix JL, Piriou V, et al; IDILIC Study Group. Br J Surg. 2016;103:1804-1814.

Teamwork training programs have been implemented in a large variety of health care settings, and growing evidence suggests a positive impact. However, the effect of teamwork training programs in the context of surgical safety checklists is less clear. In this randomized study, researchers examined whether adding a team training program to surgical safety checklist utilization affected major surgical complications. All 31 hospitals in the study had implemented a surgical safety checklist a median of 19 months prior to the study. Team training was introduced across operating room teams in 16 hospitals randomized to the intervention arm. Investigators found a significant reduction in major adverse events in both the intervention and control arms. These results suggest that team training may not provide additional benefit when combined with a checklist. A past PSNet interview discussed challenges associated with implementing surgical safety checklists.

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.

Journal Article > Commentary

Patient safety in the emergency department.

Farmer BM. Emerg Med. 2016;48:396-404.

Emergency departments are high-risk environments due to the urgency of care needs and complexity of communication. This commentary explores challenges associated with medication administration, handoffs, discharge processes, and electronic health records in emergency medicine and recommends strategies to reduce risks.

Journal Article > Commentary

Effective perioperative communication to enhance patient care.

Garrett JH Jr. AORN J. 2016;104:111-120.

Poor team communication can detract from safe medical care. Discussing communication as a critical component of multidisciplinary perioperative teamwork, this commentary describes the importance of leadership and staff in addressing barriers and highlights several strategies that support improvement including the TeamSTEPPS program.

Tools/Toolkit > Multi-use Website

TeamSTEPPS: Strategies and Tools to Enhance Performance and Patient Safety.

  • Classic

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.

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