Strategies and Tools to Enhance Performance and Patient Safety
Sue Sheridan Video
How are patients harmed as a result of medical errors?
How can we prevent medical errors?
What are the solutions?
… Improved teamwork and communications… Ultimately, a culture of safety
Describe the TeamSTEPPS training initiative
Explain your organization’s patient safety program
Describe the impact of errors and why they occur
Describe the TeamSTEPPS framework
State the outcomes of the TeamSTEPPS framework
Teamwork Is All Around Us
Evolution of TeamSTEPPS
Department of Defense
Agency for Healthcare Research and Quality
Medical and Business Schools
Hospitals—Military and Civilian, Teaching and Community-Based
Subject Matter Experts in Teamwork, Human Factors, and Crew Resource Management (CRM)
“ Initiative based on evidence derived from team performance…leveraging more than 25 years of research in military, aviation, nuclear power, business and industry…to acquire team competencies ”
Team Strategies & Tools to Enhance Performance & Patient Safety
The Components of a Patient Safety Program
Module 1 — Introduction
Module 2 — Team Structure
Module 3 — Leadership
Module 4 — Situation Monitoring
Module 5 — Mutual Support
Module 6 — Communication
Module 7 — Summary — Pulling It All Together
Introductions and Exercise: Magic Wand If I had a “ Magic Wand ” and could make changes within my unit or facility in the areas of patient quality and safety …
Why Do Errors Occur — Some Obstacles
Failure to follow up
Not following protocol
Excessive professional courtesy
Strength of an idea
Task (target) fixation
Quality in Australian Healthcare Study
Impact of Error:
Up to 16% of admissions associated with an adverse event
51% considered preventable
18% cause death or disability
The number of iatrogenic deaths exceeds the road toll
Cost associated with medical errors is $ 2 Billion per year (pre 2000) Action : Reporting of Sentinel Events Root Cause Analysis/ AIMS analysis Patient Safety Report Safety and Quality Projects – Clinical Practice Improvement Human Factors Engineering SA S&Q Council Action Areas Commission Priorities
Medical Errors Still Claiming Many Lives
… little progress towards the goal
Leape and Berwick, JAMA May 2005
Why Teamwork and Communication?
Clinical handover is a high risk scenario for patient safety. Dangers include discontinuity of care, adverse events and legal claims of malpractice (Wong et al, 2008).
Survey of Australian doctors revealed that 95% believed that there were no formal or set procedures for handover (Bomba and Praska, 2005).
An Australian study of emergency department handover found that in 15.4% of cases, not all required information was transferred, resulting in adverse events (Ye et al, 2007).
A detailed analysis of nursing handover revealed that some handovers promote confusion and did not assist in patient care (Sexton et al, 2004).
Handover is among the most common cause of malpractice claims in the USA, especially among trainees, accounting for 20% of cases (Singh et al, 2007).
Sentinel Events in Victoria – contributing factors from RCA
Communication between the team e.g. clinical handover
Communication between staff and patient/family
Cultural diversity (involvement of interpreters) 1
Communication was cited in sentinel events RCA reports as a major contributing factor from 2002/03 (16% of reports) to 2008/09 (20% of reports) and related to: 1. www.health.vic.gov.au/clinrisk/downloads/sentinel_event_program_0809.pdf (accessed 27/9/2010)
What Comprises Team Performance? Knowledge Cognitions “Think” … team performance is a science…consequences of errors are great… Attitudes Affect “Feel” Skills Behaviors “Do”
Outcomes of Team Competencies
Shared Mental Model
Recognize opportunities to improve patient safety
Assess your current organizational culture and existing Patient Safety Program components
Identify teamwork improvement action plan by analyzing data and survey results
Design and implement initiative to improve team-related competencies among your staff
Integrate TeamSTEPPS into daily practice.
“ High-performance teams create a safety net for your healthcare organization as you promote a culture of safety."