Mary Salisbury

The Potential for Improved Teamwork to Reduce Medical Errors in the Emergency Department

This article describes emergency department care work teams designed to improve team communication and coordination and reduce error. The core of this teamwork system is the teaching of teamwork behaviors and skills, development of teamwork habits, and creation of small work teams, all of which are key teamwork concepts largely drawn from successful aviation programs. Arguments for enculturating teamwork into ED practice are drawn from a retrospective study of ED malpractice incidents. Fifty-four incidents (1985-1996), a sample of convenience drawn from 8 hospitals, were identified and judged mitigable or preventable by better teamwork. An average of 8.8 teamwork failures occurred per case. More than half of the deaths and permanent disabilities that occurred were judged avoidable. Better teamwork could save nearly

Simulation based teamwork training for emergency department staff: does it improve clinical team performance when added to an existing didactic teamwork curriculum?

3.50 per ED patient visit. Caregivers must improve teamwork skills to reduce errors, improve care quality, and reduce litigation risks.

Effects of teamwork training on adverse outcomes and process of care in labor and delivery: a randomized controlled trial.

Objective: To determine if high fidelity simulation based team training can improve clinical team performance when added to an existing didactic teamwork curriculum. Setting: Level 1 trauma center and academic emergency medicine training program. Participants: Emergency department (ED) staff including nurses, technicians, emergency medicine residents, and attending physicians. Intervention: : ED staff who had recently received didactic training in the Emergency Team Coordination Course (ETCC®) also received an 8 hour intensive experience in an ED simulator in which three scenarios of graduated difficulty were encountered. A comparison group, also ETCC trained, was assigned to work together in the ED for one 8 hour shift. Experimental and comparison teams were observed in the ED before and after the intervention. Design: Single, crossover, prospective, blinded and controlled observational study. Teamwork ratings using previously validated behaviorally anchored rating scales (BARS) were completed by outside trained observers in the ED. Observers were blinded to the identification of the teams. Results: There were no significant differences between experimental and comparison groups at baseline. The experimental team showed a trend towards improvement in the quality of team behavior (p = 0.07); the comparison group showed no change in team behavior during the two observation periods (p = 0.55). Members of the experimental team rated simulation based training as a useful educational method. Conclusion: High fidelity medical simulation appears to be a promising method for enhancing didactic teamwork training. This approach, using a number of patients, is more representative of clinical care and is therefore the proper paradigm in which to perform teamwork training. It is, however, unclear how much simulator based training must augment didactic teamwork training for clinically meaningful differences to become apparent.

Measuring team performance in simulation-based training: Adopting best practices for healthcare

OBJECTIVE: To evaluate the effect of teamwork training on the occurrence of adverse outcomes and process of care in labor and delivery. METHODS: A cluster-randomized controlled trial was conducted at seven intervention and eight control hospitals. The intervention was a standardized teamwork training curriculum based on crew resource management that emphasized communication and team structure. The primary outcome was the proportion of deliveries at 20 weeks or more of gestation in which one or more adverse maternal or neonatal outcomes or both occurred (Adverse Outcome Index). Additional outcomes included 11 clinical process measures. RESULTS: A total of 1,307 personnel were trained and 28,536 deliveries analyzed. At baseline, there were no differences in demographic or delivery characteristics between the groups. The mean Adverse Outcome Index prevalence was similar in the control and intervention groups, both at baseline and after implementation of teamwork training (9.4% versus 9.0% and 7.2% versus 8.3%, respectively). The intracluster correlation coefficient was 0.015, with a resultant wide confidence interval for the difference in mean Adverse Outcome Index between groups (–5.6% to 3.2%). One process measure, the time from the decision to perform an immediate cesarean delivery to the incision, differed significantly after team training (33.3 minutes versus 21.2 minutes, P=.03). CONCLUSION: Training, as was conducted and implemented, did not transfer to a detectable impact in this study. The Adverse Outcome Index could be an important tool for comparing obstetric outcomes within and between institutions to help guide quality improvement. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00381056 LEVEL OF EVIDENCE: I

Debriefing Medical Teams: 12 Evidence-Based Best Practices and Tips

Team performance measurement is a critical and frequently overlooked component of an effective simulation-based training system designed to build teamwork competencies. Quality team performance measurement is essential for systematically diagnosing team performance and subsequently making decisions concerning feedback and remediation. However, the complexities of team performance pose a challenge to effectively measuring team performance. This article synthesizes the scientific literature on this topic and provides a set of best practices for designing and implementing team performance measurement systems in simulation-based training.

Defining Team Performance for Simulation‐based Training: Methodology, Metrics, and Opportunities for Emergency Medicine

BACKGROUND Medical teams are commonly called on to perform complex tasks, and when those tasks involve saving the lives of critically injured patients, it is imperative that teams perform optimally. Yet, medical care settings do not always lend themselves to efficient teamwork. The human factors and occupational sciences literatures concerning the optimization of team performance suggest the usefulness of a debriefing process--either for critical incidents or recurring events. Although the debrief meeting is often used in the context of training medical teams, it is also useful as a continuous learning tool throughout the life of the team. WHAT ARE GOOD DEBRIEFS? AN OVERVIEW The debriefing process allows individuals to discuss individual and team-level performance, identify errors made, and develop a plan to improve their next performance. BEST PRACTICES AND TIPS FOR DEBRIEFING TEAMS THE DEBRIEF PROCESS: The list of 12 best practices and tips--4 for hospital leaders and the remainder for debrief facilitators or team leaders--should be useful for teams performing in various high-risk areas, including operating rooms, intensive care units, and emergency departments. The best practices and tips should help teams to identify weak areas of teamwork and develop new strategies to improve teamwork competencies. Moreover, they include practices that support both regular, recurring debriefs and critical-incident debriefings. Team members should follow these main guidelines--also provided in checklist form--which include ensuring that the organization creates a supportive learning environment for debriefs (concentrating on a few critical performance issues), providing feedback to all team members, and recording conclusions made and goals set during the debrief to facilitate future feedback.

High performance teamwork training and systems redesign in outpatient oncology

Across health care, teamwork is a critical element for effective patient care. Yet, numerous well-intentioned training programs may fail to achieve the desired outcomes in team performance. Hope for the improvement of teamwork in health care is provided by the success of the aviation and military communities in utilizing simulation-based training (SBT) for training and evaluating teams. This consensus paper 1) proposes a scientifically based methodology for SBT design and evaluation, 2) reviews existing team performance metrics in health care along with recommendations, and 3) focuses on leadership as a target for SBT because it has a high likelihood to improve many team processes and ultimately performance. It is hoped that this discussion will assist those in emergency medicine (EM) and the larger health care field in the design and delivery of SBT for training and evaluating teamwork.

Introducing Teamwork Training into Healthcare Organizations: Implementation Issues and Solutions

Background Oncology care is delivered largely in ambulatory settings by interdisciplinary teams. Treatments are often complex, extended in time, dispersed geographically and vulnerable to teamwork failures. To address this risk, we developed and piloted a team training initiative in the breast cancer programme at a comprehensive cancer centre. Methods Based on clinic observations, interviews with key staff and analyses of incident reports, we developed interventions to address four high-risk areas: (1) miscommunication of chemotherapy order changes on the day of treatment; (2) missing orders on treatment days without concurrent physician appointments; (3) poor follow-up with team members about active patient issues; and (4) conflict between providers and staff. The project team developed protocols and agreements to address team members’ roles, responsibilities and behaviours. Results Using a train-the-trainer model, 92% of breast cancer staff completed training. The incidence of missing orders for unlinked visits decreased from 30% to 2% (p<0.001). Patient satisfaction scores regarding coordination of care improved from 93 to 97 (p=0.026). Providers, infusion nurses and support staff reported improvement in efficiency (75%, 86%, 90%), quality (82%, 93%, 93%) and safety (92%, 92%, 90%) of care, and more respectful behaviour (92%, 79%, 83%) and improved relationships among team members (91%, 85%, 92%). Although most clinicians reported a decrease in non-communicated changes, there was insufficient statistical power to detect a difference. Conclusions Team training improved communication, task coordination and perceptions of efficiency, quality, safety and interactions among team members as well as patient perception of care coordination.

Effects of teamwork training on adverse outcomes and process of care in labor and delivery : A randomized controlled trial

This practitioner paper describes a variety of training development, assessment, and implementation issues and solutions that emerged from our research to develop behavior-based teamwork training for healthcare providers. These lessons-learned are based on our experiences in adapting aviation crew resource management (CRM) training for healthcare providers in the specialty areas of emergency care and labor and delivery. The discussion covers (a) issues surrounding training content and delivery, (b) methodological issues in conducting training evaluations, and (c) institutional characteristics, cultural change, and sustaining the behavioral intervention.

Error Reduction and Performance Improvement in the Emergency Department through Formal Teamwork Training: Evaluation Results of the MedTeams Project

ABSTRACT Reports from the Institute of Medicine propose that team training—and implementing team behaviors—can cut down on medical errors and enhance patient safety. The present investigators tested this idea in the area of obstetrics, a discipline that calls for intensive and error-free vigilance as well as effective communication between numerous disciplines. A cluster-randomized controlled trial was undertaken at 15 US hospitals: at seven a standardized teamwork training curriculum was introduced that focused on free communication and team structure. The remaining eight hospitals made up a control group. The curriculum (MedTeams Labor and Delivery Team Coordination Course) was based on care resource management, which attempts to utilize the ability of each team member to analyze and react to situations in ways that lessen the potential for error. A total of 1307 individuals were trained, and 28,536 deliveries were analyzed. Negative outcomes were quantified using an index outcome measure, the Adverse Outcome Index. The intervention and control groups were similar demographically and obstetrically at the outset. Adverse outcome indices also were comparable, and remained so after teamwork training was implemented. The only process measure that differed significantly after team training was in the interval from deciding to perform an immediate cesarean delivery to making the incision, which decreased from 33 to 21 minutes. There was considerable variability across hospitals in the commonest maternal outcome, a third- or fourth-degree perineal laceration following vaginal delivery, and also in the most prevalent neonatal outcome, unplanned admission to the neonatal intensive care unit. Postimplementation outcome measures did not differ significantly even after controlling for baseline differences. This study failed to show that teamwork training in obstetrical practices had any important clinical impact. Nevertheless, the Adverse Outcome Index might prove helpful when comparing obstetrical outcomes within and between institutions.