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Approach to Improving Safety
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Search results for "United States of America"

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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.

Journal Article > Commentary

Improving care teams' functioning: recommendations from team science.

Fiscella K, Mauksch L, Bodenheimer T, Salas E. Jt Comm J Qual Patient Saf. 2017;43:361–368.

Research on teamwork as a key component of safe care delivery has primarily focused on the hospital setting. This commentary highlights six elements that enable development, functionality, and assessment of teamwork in the ambulatory setting.

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 > 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.

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.

Journal Article > Commentary

Challenging the status quo: focusing on patient safety and joy at work.

Peach AG. J Perianesth Nurs. 2016;31:535-538.

A key component of a culture of safety is staff willingness to raise concerns about care delivery and work processes. This commentary encourages nurse engagement in challenging established practices to drive improvement and innovation and enhance teamwork and nurse satisfaction.

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.

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 > Review

Moving toward improved teamwork in cancer care: the role of psychological safety in team communication.

Jain AK, Fennell ML, Chagpar AB, Connolly HK, Nembhard IM. J Oncol Pract. 2016;12:1000-1011.

Psychological safety can empower staff to communicate concerns and offer suggestions in a collaborative way that contributes to effective care. This review spotlights the importance of high-quality communication to help teams manage the complexity of oncology care regimens, geographically dispersed team members, and hierarchy. The authors advocate for further evidence to understand how to improve psychological safety for care team members and patients.

Special or Theme Issue

National Cancer Institute–American Society of Clinical Oncology Teams in Cancer Care Project.

J Oncol Pract. 2016;12:955-1194.

Team-based care has been adopted in various specialties as a strategy to reduce handoff errors and omissions. Highlighting the work of a collaborative project to apply team science to oncology, articles in this special issue explore topics such as engaging patients as team members, the role of psychological safety, and use of shared mental models to augment cancer care.

Journal Article > Commentary

TeamSTEPPS in long-term care—an academic partnership: part 1 and part 2.

Roman TC, Abraham K, Dever K. J Contin Educ Nurs. 2016;47:490-492, 534-535.

TeamSTEPPS was developed to enhance teamwork and communication in health care settings. This two-part commentary discusses the development of TeamSTEPPS training for the long-term care environment and describes the implementation and evaluation of the program.

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

Antimicrobial stewardship and patient safety.

Zukowski CM. AORN J. 2016;104:354-356.

Antimicrobial stewardship has been highlighted as a strategy to improve antibiotic use in order to reduce hospital-acquired infections. This commentary discusses antimicrobial stewardship teams, their impact in the surgical setting, and the role of nurses in ensuring appropriate use of antibiotics.

Journal Article > Study

Investigating teamwork in the operating room: engaging stakeholders and setting the agenda.

Frasier LL, Pavuluri Quamme SR, Becker A, et al. JAMA Surg. 2017;152:109-111.

Teamwork training can improve communication and prevention of adverse events in the operating room. In this study, focus groups with clinicians and operating room staff found that team members perceived the concept of the "team" and their roles in ensuring optimal handoff communication differently. This exploratory work has implications for the design of effective teamwork training programs.

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.

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