Sallie J. Weaver

Rapid-Response Systems as a Patient Safety Strategy: A Systematic Review

Rapid-response systems (RRSs) are a popular intervention in U.S. hospitals and are supported by accreditors and quality improvement organizations. The purpose of this review is to evaluate the effectiveness and implementation of these systems in acute care settings. A literature search was performed between 1 January 2000 through 30 October 2012 using PubMed, PsycINFO, CINAHL, and the Cochrane Central Register of Controlled Trials. Studies published in any language evaluating outcome changes that occurred after implementing an RRS and differences between groups using and not using an RRS (effectiveness) or describing methods used by RRSs (implementation) were reviewed. A single reviewer (checked by a second reviewer) abstracted data and rated study quality and strength of evidence. Moderate-strength evidence from a high-quality meta-analysis of 18 studies and 26 lower-quality before-and-after studies published after that meta-analysis showed that RRSs are associated with reduced rates of cardiorespiratory arrest outside of the intensive care unit and reduced mortality. Eighteen studies examining facilitators of and barriers to implementation suggested that the rate of use of RRSs could be improved.

Promoting a Culture of Safety as a Patient Safety Strategy: A Systematic Review

Developing a culture of safety is a core element of many efforts to improve patient safety and care quality. This systematic review identifies and assesses interventions used to promote safety culture or climate in acute care settings. The authors searched MEDLINE, CINAHL, PsycINFO, Cochrane, and EMBASE to identify relevant English-language studies published from January 2000 to October 2012. They selected studies that targeted health care workers practicing in inpatient settings and included data about change in patient safety culture or climate after a targeted intervention. Two raters independently screened 3679 abstracts (which yielded 33 eligible studies in 35 articles), extracted study data, and rated study quality and strength of evidence. Eight studies included executive walk rounds or interdisciplinary rounds; 8 evaluated multicomponent, unit-based interventions; and 20 included team training or communication initiatives. Twenty-nine studies reported some improvement in safety culture or patient outcomes, but measured outcomes were highly heterogeneous. Strength of evidence was low, and most studies were pre-post evaluations of low to moderate quality. Within these limits, evidence suggests that interventions can improve perceptions of safety culture and potentially reduce patient harm.

Does Team Training Work? Principles for Health Care

Teamwork is integral to a working environment conducive to patient safety and care. Team training is one methodology designed to equip team members with the competencies necessary for optimizing teamwork. There is evidence of team trainings effectiveness in highly complex and dynamic work environments, such as aviation and health care. However, most quantitative evaluations of training do not offer any insight into the actual reasons why, how, and when team training is effective. To address this gap in understanding, and to provide guidance for members of the health care community interested in implementing team training programs, this article presents both quantitative results and a specific qualitative review and content analysis of team training implemented in health care. Based on this review, we offer eight evidence-based principles for effective planning, implementation, and evaluation of team training programs specific to health care.

Does Teamwork Improve Performance in the Operating Room? A Multilevel Evaluation

BACKGROUND Medical care is a team effort, especially as patient cases are more complex. Communication, cooperation, and coordination are vital to effective care, especially in complex service lines such as the operating room (OR). Team training, specifically the TeamSTEPPS training program, has been touted as one methodology for optimizing teamwork among providers and increasing patient safety. Although such team-training programs have transformed the culture and outcomes of other dynamic, high-risk industries such as aviation and nuclear power, evidence of team training effectiveness in health care is still evolving. Although providers tend to react positively to many training programs, evidence that training contributes to important behavioral and patient safety outcomes is lacking. METHOD A multilevel evaluation of the TeamSTEPPS training program was conducted within the OR service line with a control location. The evaluation was a mixed-model design with one between-groups factor (TeamSTEPPS training versus no training) and two within-groups factors (time period, team). The groups were located at separate campuses to minimize treatment diffusion. Trainee reactions, learning, behaviors in the OR, and proxy outcome measures such as the Hospital Survey on Patient Safety Culture (HSOPS) and Operating Room Management Attitudes Questionnaire (ORMAQ) were collected. RESULTS All levels of evaluation demonstrated positive results. The trained group demonstrated significant increases in the quantity and quality of presurgical procedure briefings and the use of quality teamwork behaviors during cases. Increases were also found in perceptions of patient safety culture and teamwork attitudes. DISCUSSION The hospital system has integrated elements of TeamSTEPPS into orientation training provided to all incoming hospital employees, including nonclinical staff.

Team-training in healthcare: a narrative synthesis of the literature

Background Patients are safer and receive higher quality care when providers work as a highly effective team. Investment in optimising healthcare teamwork has swelled in the last 10 years. Consequently, evidence regarding the effectiveness for these interventions has also grown rapidly. We provide an updated review concerning the current state of team-training science and practice in acute care settings. Methods A PubMed search for review articles examining team-training interventions in acute care settings published between 2000 and 2012 was conducted. Following identification of relevant reviews with searches terminating in 2008 and 2010, PubMed and PSNet were searched for additional primary studies published in 2011 and 2012. Primary outcomes included patient outcomes and quality indices. Secondary outcomes included teamwork behaviours, knowledge and attitudes. Results Both simulation and classroom-based team-training interventions can improve teamwork processes (eg, communication, coordination and cooperation), and implementation has been associated with improvements in patient safety outcomes. Thirteen studies published between 2011 and 2012 reported statistically significant changes in teamwork behaviours, processes or emergent states and 10 reported significant improvement in clinical care processes or patient outcomes, including mortality and morbidity. Effects were reported across a range of clinical contexts. Larger effect sizes were reported for bundled team-training interventions that included tools and organisational changes to support sustainment and transfer of teamwork competencies into daily practice. Conclusions Overall, moderate-to-high-quality evidence suggests team-training can positively impact healthcare team processes and patient outcomes. Additionally, toolkits are available to support intervention development and implementation. Evidence suggests bundled team-training interventions and implementation strategies that embed effective teamwork as a foundation for other improvement efforts may offer greatest impact on patient outcomes.

The Anatomy of Health Care Team Training and the State of Practice: A Critical Review

Purpose As the U.S. health care system enters a new era, the importance of team-based care approaches grows. How is the health care community ensuring that providers and administrators are equipped with the knowledge, skills, and attitudes (KSAs) foundational for effective teamwork? Are these KSAs transferring into daily practice? This review summarizes the present state of practice for health care team training described in published literature. Drawing from empirical investigations of training effectiveness, the authors explore training design, implementation, and evaluation to provide insight into the shape, structure, and anatomy of team training in health care. Method A 2009 literature search yielded 40 peer-reviewed articles detailing health care team training evaluations. Guided by 11 focal questions, two trained raters extracted details regarding training design, implementation, evaluation metrics, and outcomes. Results Findings indicate that team training is being implemented across a wide spectrum of providers and is primarily targeting communication, situational awareness, leadership, and role clarity. Relatively few details indicate how training needs were established. Most studies collected data immediately posttraining; however, less than 30% collected data six months or more posttraining. Content analyses highlight the need for enhanced detail in published training evaluation reports. Conclusions In many respects, health care team training implementation and evaluation align with best practices suggested from the science of training, adult learning, and human performance; however, opportunities for improvement exist. The authors suggest several mechanisms for furthering the health care team training evidence base to enhance patient safety and work environment quality for clinicians.

Promoting Teamwork: An Event‐based Approach to Simulation‐based Teamwork Training for Emergency Medicine Residents

The growing complexity of patient care requires that emergency physicians (EPs) master not only knowledge and procedural skills, but also the ability to effectively communicate with patients and other care providers and to coordinate patient care activities. EPs must become good team players, and consequently an emergency medicine (EM) residency program must systematically train these skills. However, because teamwork-related competencies are relatively new considerations in health care, there is a gap in the methods available to accomplish this goal. This article outlines how teamwork training for residents can be accomplished by employing simulation-based training (SBT) techniques and contributes tools and strategies for designing structured learning experiences and measurement tools that are explicitly linked to targeted teamwork competencies and learning objectives. An event-based method is described and illustrative examples of scenario design and measurement tools are provided.

In Situ Simulation in Continuing Education for the Health Care Professions: A Systematic Review

Introduction: Education in the health sciences increasingly relies on simulation‐based training strategies to provide safe, structured, engaging, and effective practice opportunities. While this frequently occurs within a simulation center, in situ simulations occur within an actual clinical environment. This blending of learning and work environments may provide a powerful method for continuing education. However, as this is a relatively new strategy, best practices for the design and delivery of in situ learning experiences have yet to be established. This article provides a systematic review of the in situ simulation literature and compares the state of the science and practice against principles of effective education and training design, delivery, and evaluation. Methods: A total of 3190 articles were identified using academic databases and screened for descriptive accounts or studies of in situ simulation programs. Of these, 29 full articles were retrieved and coded using a standard data extraction protocol (kappa = 0.90). Results: In situ simulations have been applied to foster individual, team, unit, and organizational learning across several clinical and nonclinical areas. Approaches to design, delivery, and evaluation of the simulations were highly variable across studies. The overall quality of in situ simulation studies is low. A positive impact of in situ simulation on learning and organizational performance has been demonstrated in a small number of studies. Discussion: The evidence surrounding in situ simulation efficacy is still emerging, but the existing research is promising. Practical program planning strategies are evolving to meet the complexity of a novel learning activity that engages providers in their actual work environment.

Cognitive and System Factors Contributing to Diagnostic Errors in Radiology

OBJECTIVE In this article, we describe some of the cognitive and system-based sources of detection and interpretation errors in diagnostic radiology and discuss potential approaches to help reduce misdiagnoses. CONCLUSION Every radiologist worries about missing a diagnosis or giving a false-positive reading. The retrospective error rate among radiologic examinations is approximately 30%, with real-time errors in daily radiology practice averaging 3-5%. Nearly 75% of all medical malpractice claims against radiologists are related to diagnostic errors. As medical reimbursement trends downward, radiologists attempt to compensate by undertaking additional responsibilities to increase productivity. The increased workload, rising quality expectations, cognitive biases, and poor system factors all contribute to diagnostic errors in radiology. Diagnostic errors are underrecognized and underappreciated in radiology practice. This is due to the inability to obtain reliable national estimates of the impact, the difficulty in evaluating effectiveness of potential interventions, and the poor response to systemwide solutions. Most of our clinical work is executed through type 1 processes to minimize cost, anxiety, and delay; however, type 1 processes are also vulnerable to errors. Instead of trying to completely eliminate cognitive shortcuts that serve us well most of the time, becoming aware of common biases and using metacognitive strategies to mitigate the effects have the potential to create sustainable improvement in diagnostic errors.

What does nursing teamwork look like? A qualitative study.

A qualitative study was conducted applying a theoretically based model of teamwork to determine relevant team processes among nurses. Nurses from 5 patient care units participated in focus groups, describing team processes in their daily work. Responses were analyzed in the Salas framework to develop a concrete conceptualization of teamwork within nursing teams. Results support the framework as a means for describing teamwork among nurses.