This document discusses improving safety culture in operating rooms. It notes that while aviation has developed strong safety practices like checklists and crew resource management, medicine still has weaknesses in areas like communication, checklists, and reporting errors without blame. The document advocates learning from other high-risk industries and applying principles like checklists, pause points, multidisciplinary teams, just culture reporting, and using data recorders to continuously learn and improve safety practices in surgery.
EU General Data Protection Regulation top 8 operational impacts in personal c...Erik Vollebregt
Presentation to the Personal Connected Health Alliance about the top 8 operational impacts of the EU General Data Protection Regulation on companies in the personal connected health field.
Steps to Compliance with the European Medical Device RegulationsApril Bright
The trilogue negotiations for the European Medical Device Regulations are expected to conclude by June. Whether or not the long-awaited regulations receive another postponement, orthopaedic manufacturers cannot put off preparation or they risk their ability to sell products in Europe. Dr. Tariah will walk attendees through the greatest pain points for orthopaedic manufacturers when complying with the new regulations.
Presentation at the Health Consumers Council Patient Experience Week Events, by Dr Carmel Crock and Ms Anita Deakin.
The Emergency Medicine Events Register is an "adverse event and near-miss reporting system that is peer-led, online, anonymous and confidential. It is a means of supporting improvement in safety and quality in emergency medicine by understanding of contributing factors and how the risk of harm to patients can be minimised or prevented."
See http://www.emer.org.au/
WHO has undertaken a number of global and regional initiatives to address surgical safety. The Global Initiative for Emergency and Essential Surgical Care and the Guidelines for Essential Trauma Care focussed on access and quality. The Second Global Patient Safety Challenge: Safe Surgery Saves Lives addresses the safety of surgical care.
EU General Data Protection Regulation top 8 operational impacts in personal c...Erik Vollebregt
Presentation to the Personal Connected Health Alliance about the top 8 operational impacts of the EU General Data Protection Regulation on companies in the personal connected health field.
Steps to Compliance with the European Medical Device RegulationsApril Bright
The trilogue negotiations for the European Medical Device Regulations are expected to conclude by June. Whether or not the long-awaited regulations receive another postponement, orthopaedic manufacturers cannot put off preparation or they risk their ability to sell products in Europe. Dr. Tariah will walk attendees through the greatest pain points for orthopaedic manufacturers when complying with the new regulations.
Presentation at the Health Consumers Council Patient Experience Week Events, by Dr Carmel Crock and Ms Anita Deakin.
The Emergency Medicine Events Register is an "adverse event and near-miss reporting system that is peer-led, online, anonymous and confidential. It is a means of supporting improvement in safety and quality in emergency medicine by understanding of contributing factors and how the risk of harm to patients can be minimised or prevented."
See http://www.emer.org.au/
WHO has undertaken a number of global and regional initiatives to address surgical safety. The Global Initiative for Emergency and Essential Surgical Care and the Guidelines for Essential Trauma Care focussed on access and quality. The Second Global Patient Safety Challenge: Safe Surgery Saves Lives addresses the safety of surgical care.
Patient safety is the cornerstone of high-quality healthcare services. In the presentation, A summary of the frameworks & practical approaches to improve safety of patient care.
Lecture presented by Dr Jose Maria Nicolas at e-ICU Egypt conference held at Cairo Egypt on 3and 4 December 2014.Organized by Scribe(www.scribeofegypt.com)
Stuart Reid - When Passion Obscures the Facts:The Case For Evidence-Based Te...TEST Huddle
EuroSTAR Software Testing Conference 2010 presentation on When Passion Obscures the Facts:The Case For Evidence-Based Testing by Stuart Reid. See more at: http://conference.eurostarsoftwaretesting.com/past-presentations/
A presentation given by international keynote speaker Dr. Stephen Muething from Cincinnati Children's Hospital, USA at the CHA conference The Journey, in October 2012.
Presentation at 2007 Meeting of Indian Health Service in San DiegoNoel Eldridge
This is based on Jim Bagian's "Why Bother" (about patient safety) presentation. Jim was invited but had a conflict so I wen to the national meeting of the Indian Health Service. I think this was maybe a 75 minute presentation. I added some things to make it personal to me like the Jimi Hendrix Experience slide and slide 81 on the "tissue issue" in VA that I helped resolve during my work on hand hygiene improvement. The audience also seemed to like my closing slide.
ALARM FATIGUE in Nursing
University
Informatics
Why is this important to me?
I am completely numb to most alarms after working in acute care medical surgical. It is scary! I would like to understand more about what can be done since technology will only increase.
What is Alarm Fatigue?
Defined as a Desensitized response to medical alert equipment and technologies due to the frequency
Sensory Overload
Too many phones, pagers and overhead announcements
Missed critical events
Patient safety concerns
Over stimulated staff
Outline
Define Alarm Fatigue
How Alarm Fatigue effects Healthcare
Share the Evidenced Based Data
Explore the Adverse Events
Discover a solution
What are the challenges and benefits
Can a solution be implemented?
Potential References
Citing reports of alarm-related deaths, the Joint Commission issues a sentinel event alert for hospitals to improve medical device alarm safety.
ECRI Institute. Strategies to improve monitor alarm safety.
Alarm fatigue sets off bells. Modern Healthcare
Alarm fatigue a top patient safety hazard. Canadian Medical Association Journal
Over-monitoring and alarm fatigue: For whom do the bells toll? Heart and Lung.
There are so many good sources!!!
5
Why are these Relevant?
These sources are directly relevant to why alarm fatigue is a problem that is only getting worse.
How and why it effects healthcare.
Joint Commission reporting of such incidents that have been directly related to alarm fatigue.
How to change the course of alarm fatigue.
Evidence based reporting and studies for reference support.
What is Alarm Fatigue?
Alarm Fatigue is care givers desensitized do to overwhelming amounts of alarms.
The many “beeps, chimes and bells” are the reason for delayed care and even death.
A 12 day study at John Hopkins determined over 350 alarms per bed.
Over 80% are false alarms.
No standardization of alarm technology
The more false alarms the less likely someone responds.
(Jones, 2014)
Where do We begin?
Review the Joint Commission Reports
Speak to Safety Experts in Other Fields
Create a Culture of Safety
Leadership Buy In
Staff Buy In
Redefine the Framework
Trust, Report and Improve- Concepts
Have accountability for safety protocols
(Chassin & Loeb, 2013)
Joint Commission Reports
-566 Alarm Related Deaths Between 1/2005-6/2010
-Most Often Reported in ER
-85-95% Alarms are false
-The Many False alarms desensitize Staff
(Ed Manag., 2013)
Summary
The amounts of research and data available for alarm fatigue is overwhelming. The data supports a overhaul of the technology systems to become integrated with All of the vital sign alarms. Also to have standards in place for baseline alarm settings. Alarms should also be in reference to baseline health status of patient to prevent false alarms. I still have a lot of work to complete and will be ready to present next week!
Annotated Bibliography
Citing reports of alarm related deaths, the.
Opening academisch jaar medische informatiekunde AMCMartijn Kriens
Presentatie in het kader van de opening van het academisch jaar bij Medische Informatiekunde van het AMC. De rol van actionable data en het belang van ondernemerschap in de zorg
Patient safety is the cornerstone of high-quality healthcare services. In the presentation, A summary of the frameworks & practical approaches to improve safety of patient care.
Lecture presented by Dr Jose Maria Nicolas at e-ICU Egypt conference held at Cairo Egypt on 3and 4 December 2014.Organized by Scribe(www.scribeofegypt.com)
Stuart Reid - When Passion Obscures the Facts:The Case For Evidence-Based Te...TEST Huddle
EuroSTAR Software Testing Conference 2010 presentation on When Passion Obscures the Facts:The Case For Evidence-Based Testing by Stuart Reid. See more at: http://conference.eurostarsoftwaretesting.com/past-presentations/
A presentation given by international keynote speaker Dr. Stephen Muething from Cincinnati Children's Hospital, USA at the CHA conference The Journey, in October 2012.
Presentation at 2007 Meeting of Indian Health Service in San DiegoNoel Eldridge
This is based on Jim Bagian's "Why Bother" (about patient safety) presentation. Jim was invited but had a conflict so I wen to the national meeting of the Indian Health Service. I think this was maybe a 75 minute presentation. I added some things to make it personal to me like the Jimi Hendrix Experience slide and slide 81 on the "tissue issue" in VA that I helped resolve during my work on hand hygiene improvement. The audience also seemed to like my closing slide.
ALARM FATIGUE in Nursing
University
Informatics
Why is this important to me?
I am completely numb to most alarms after working in acute care medical surgical. It is scary! I would like to understand more about what can be done since technology will only increase.
What is Alarm Fatigue?
Defined as a Desensitized response to medical alert equipment and technologies due to the frequency
Sensory Overload
Too many phones, pagers and overhead announcements
Missed critical events
Patient safety concerns
Over stimulated staff
Outline
Define Alarm Fatigue
How Alarm Fatigue effects Healthcare
Share the Evidenced Based Data
Explore the Adverse Events
Discover a solution
What are the challenges and benefits
Can a solution be implemented?
Potential References
Citing reports of alarm-related deaths, the Joint Commission issues a sentinel event alert for hospitals to improve medical device alarm safety.
ECRI Institute. Strategies to improve monitor alarm safety.
Alarm fatigue sets off bells. Modern Healthcare
Alarm fatigue a top patient safety hazard. Canadian Medical Association Journal
Over-monitoring and alarm fatigue: For whom do the bells toll? Heart and Lung.
There are so many good sources!!!
5
Why are these Relevant?
These sources are directly relevant to why alarm fatigue is a problem that is only getting worse.
How and why it effects healthcare.
Joint Commission reporting of such incidents that have been directly related to alarm fatigue.
How to change the course of alarm fatigue.
Evidence based reporting and studies for reference support.
What is Alarm Fatigue?
Alarm Fatigue is care givers desensitized do to overwhelming amounts of alarms.
The many “beeps, chimes and bells” are the reason for delayed care and even death.
A 12 day study at John Hopkins determined over 350 alarms per bed.
Over 80% are false alarms.
No standardization of alarm technology
The more false alarms the less likely someone responds.
(Jones, 2014)
Where do We begin?
Review the Joint Commission Reports
Speak to Safety Experts in Other Fields
Create a Culture of Safety
Leadership Buy In
Staff Buy In
Redefine the Framework
Trust, Report and Improve- Concepts
Have accountability for safety protocols
(Chassin & Loeb, 2013)
Joint Commission Reports
-566 Alarm Related Deaths Between 1/2005-6/2010
-Most Often Reported in ER
-85-95% Alarms are false
-The Many False alarms desensitize Staff
(Ed Manag., 2013)
Summary
The amounts of research and data available for alarm fatigue is overwhelming. The data supports a overhaul of the technology systems to become integrated with All of the vital sign alarms. Also to have standards in place for baseline alarm settings. Alarms should also be in reference to baseline health status of patient to prevent false alarms. I still have a lot of work to complete and will be ready to present next week!
Annotated Bibliography
Citing reports of alarm related deaths, the.
Opening academisch jaar medische informatiekunde AMCMartijn Kriens
Presentatie in het kader van de opening van het academisch jaar bij Medische Informatiekunde van het AMC. De rol van actionable data en het belang van ondernemerschap in de zorg
INFECTION OF THE BRAIN -ENCEPHALITIS ( PPT)blessyjannu21
Neurological system includes brain and spinal cord. It plays an important role in functioning of our body. Encephalitis is the inflammation of the brain. Causes include viral infections, infections from insect bites or an autoimmune reaction that affects the brain. It can be life-threatening or cause long-term complications. Treatment varies, but most people require hospitalization so they can receive intensive treatment, including life support.
Rate Controlled Drug Delivery Systems, Activation Modulated Drug Delivery Systems, Mechanically activated, pH activated, Enzyme activated, Osmotic activated Drug Delivery Systems, Feedback regulated Drug Delivery Systems systems are discussed here.
CHAPTER 1 SEMESTER V PREVENTIVE-PEDIATRICS.pdfSachin Sharma
This content provides an overview of preventive pediatrics. It defines preventive pediatrics as preventing disease and promoting children's physical, mental, and social well-being to achieve positive health. It discusses antenatal, postnatal, and social preventive pediatrics. It also covers various child health programs like immunization, breastfeeding, ICDS, and the roles of organizations like WHO, UNICEF, and nurses in preventive pediatrics.
KEY Points of Leicester travel clinic In London doc.docxNX Healthcare
In order to protect visitors' safety and wellbeing, Travel Clinic Leicester offers a wide range of travel-related health treatments, including individualized counseling and vaccines. Our team of medical experts specializes in getting people ready for international travel, with a particular emphasis on vaccines and health consultations to prevent travel-related illnesses. We provide a range of travel-related services, such as health concerns unique to a trip, prevention of malaria, and travel-related medical supplies. Our clinic is dedicated to providing top-notch care, keeping abreast of the most recent recommendations for vaccinations and travel health precautions. The goal of Travel Clinic Leicester is to keep you safe and well-rested no matter what kind of travel you choose—business, pleasure, or adventure.
Deep Leg Vein Thrombosis (DVT): Meaning, Causes, Symptoms, Treatment, and Mor...The Lifesciences Magazine
Deep Leg Vein Thrombosis occurs when a blood clot forms in one or more of the deep veins in the legs. These clots can impede blood flow, leading to severe complications.
PET CT beginners Guide covers some of the underrepresented topics in PET CTMiadAlsulami
This lecture briefly covers some of the underrepresented topics in Molecular imaging with cases , such as:
- Primary pleural tumors and pleural metastases.
- Distinguishing between MPM and Talc Pleurodesis.
- Urological tumors.
- The role of FDG PET in NET.
The dimensions of healthcare quality refer to various attributes or aspects that define the standard of healthcare services. These dimensions are used to evaluate, measure, and improve the quality of care provided to patients. A comprehensive understanding of these dimensions ensures that healthcare systems can address various aspects of patient care effectively and holistically. Dimensions of Healthcare Quality and Performance of care include the following; Appropriateness, Availability, Competence, Continuity, Effectiveness, Efficiency, Efficacy, Prevention, Respect and Care, Safety as well as Timeliness.
ALKAMAGIC PLAN 1350.pdf plan based of door to door delivery of alkaline water...rowala30
Alka magic plan 1350 -we deliver alkaline water at your door step and you can make handsome money by referral programme
we also help and provide systematic guideline to setup 1000 lph alkaline water plant
This document is designed as an introductory to medical students,nursing students,midwives or other healthcare trainees to improve their understanding about how health system in Sri Lanka cares children health.
10. We nemen het anderen meer kwalijk dat ze onze fouten kennen, dan
onszelf dat wij daaraan mank gaan.
Multatuli
We hold it more against others to know our
failures, than to hold our failures against
ourselves
Multatuli (Dutch writer)
14. 1. (Vrijwel) geen aanwijzingen
2. Geringe aanwijzingen
3. minder dan 50-50 maar ‘close call’
4. meer dan 50-50 maar ‘close call’
5. Sterke aanwijzingen
6. (Vrijwel) zeker aanwijzingen
Vermijdbaarheid van schade
15. 0,0%
0,4%
0,8%
1,2%
1,6%
Diagnose Surgical Treatment Medication Care Release Others
2004
2008
2012
Surgery is responsible for 60% of all Avoidable Errors (22.500)
Monitor Zorggerelateerde Schade 2012, NIVEL
Direct costs are > 126M euro per year
16.
17.
18. Systemic learning
I am always ready to learn
although I do not always like
to be taught
Winston Churchill
19.
20. Small errors, serious consequences
Split second decisions
Individual skills and teamwork
21. I know a lot of doctors who became recreational pilots, but
I don’t know one pilot who became a recreational doctor.
http://skepticalscalpel.blogspot.nl/2011/01/surgeons-are-not-pilots.html
27. KLM (RADIO) Ah roger, sir, we are cleared to the Papa Beacon flight level nine
zero until intercepting the three two five. We are now at take-off
…
TENERIFE TOWER OK....[static noise]
... (KLM initiates take-off)
TENERIFE TOWER Ah, papa alpha one seven three six report the runway clear.
PAN AM (RADIO) OK, will report when we're clear.
...
KLM FLT ENGR (CVR) [Is he not clear, that Pan American?]
KLM CAPTAIN (CVR) [Oh yes. - emphatic]
[Pan Am captain sees landing lights of KLM Boeing at approx. 700 m]
PAN AM CAPTAIN There he is ... look at him. Goddamn that son-of-a-bitch is
coming!
http://planecrashinfo.com/cvr770327.htm
28. KLM (RADIO) Ah roger, sir, we are cleared to the Papa Beacon flight level nine
zero until intercepting the three two five. We are now at take-off
…
TENERIFE TOWER OK....Stand by for take-off, I will call you.
... (KLM initiates take-off)
TENERIFE TOWER Ah, papa alpha one seven three six report the runway clear.
PAN AM (RADIO) OK, will report when we're clear.
...
KLM FLT ENGR (CVR) [Is he not clear, that Pan American?]
KLM CAPTAIN (CVR) [Oh yes. - emphatic]
[Pan Am captain sees landing lights of KLM Boeing at approx. 700 m]
PAN AM CAPTAIN There he is ... look at him. Goddamn that son-of-a-bitch is
coming!
29. PLANE1234: [call sign] ready for departure at Runway three zero
TOWER: [call sign], you are cleared for take off Runway three zero
PLANE5678: [call sign] Runway vacated
Lessons Tenerife
33. Not Received 7%Not Transmitted 49% Misunderstanding 44%
Patterns of Communication Breakdowns Resulting in Injury to Surgical Patients, Greenberg, 2007
Failures due to communication errors (60 out of 258)
35. (my) Observations
• High fault tolerance
• Strong hierarchy
• Going through the motions of checklists
• Chasm between disciplines
• Unreliable documentation
http://www.icrowds.net/2014/01/observatie-in-de-operatiekamer/
38. Central line checklist
1. Wash your hands with soap.
1. Clean the patient’s skin with chlorhexidine
antiseptic.
2. Put sterile drapes over the entire patient.
3. Wear a sterile mask, hat, gown and gloves.
4. Put a sterile dressing over the catheter site.
Berenholtz, S. M., Pronovost, P. J., Lipsett, P. a., Hobson, D., Earsing, K., Farley, J. E., … Perl, T. M. (2004). Eliminating
catheter-related bloodstream infections in the intensive care unit*. Critical Care Medicine, 32(10), 2014–2020
39.
40. Stop and count to 10
Think about your options
Do what you think is best
V
V
V
Checklists
46. Safety culture
45% of surgeons think junior team members
should not question decisions compared to 6%
of pilots
70% of surgeons say they have no averse effect
of fatigue compared to 26% of pilots
62% of surgeons rate teamwork with
anaesthetists high compared to 42% of
anaesthetists with surgeons
Error, stress, and teamwork in medicine and aviation: cross sectional surveys
J Bryan Sexton, Eric J Thomas, Robert L Helmreich, 2000
47. Reporting errors
50% find it difficult to report errors
reasons of underreporting
personal reputation (75%)
Claims (71%)
Expectations of surroundings (68%)
Error, stress, and teamwork in medicine and aviation: cross sectional surveys
J Bryan Sexton, Eric J Thomas, Robert L Helmreich, 2000
48. 1. Compensate quickly and
fairly when unreasonable
medical care causes injury.
2. Defend medically
reasonable care vigorously
3. Reduce patient injuries (and
therefore claims) by learning
from patients’ experiences.
Boothman, R., & Blackwell, A. (2009). A better approach to medical malpractice claims? The University of Michigan experience. Journal of health & life sciences law, 2(2)
• 50% less judicial costs
• From 20 to 8 months
University of Michigan claims
49. Safety culture
• Reporting culture
• Just culture
• Flexible culture
• Learning culture
Informed culture
}
James Reason: Managing the risks of organizational accidents
50. Reporting culture
• Indemnity for honest mistakes
• Confidentiality
• Separation of analysis and authority
• Timely and relevant feedback
• Ease of reporting
Trust
64. Non-Technical skills
• Situational awareness
• Gathering information, Understanding information, Projecting
and anticipating future state
• Decision making
• Considering options, Selecting and communicating options,
Implementing and reviewing decisions
• Communication and teamwork
• Exchanging information, Establishing a shared understanding,
Coordinating team activities
• Leadership
• Setting and maintaining standards, Supporting others, Coping
with pressure
NOTSS handbook 1.2, 2006
65. AnticipationContaiment
• Preoccupation with failure
• Actively find failures and learn
• Reluctance to simplify
– Challenge beliefs, don’t stop asking why
• Sensitivity to operations
• Grasp context and flow
• Commitment to resilience
• Discipline, know what is important
• Deference to expertise
– Open channels
http://www.beckershospitalreview.com/hospital-management-administration/5-traits-of-high-reliability-organizations-how-to-
hardwire-each-in-your-organization.html?goback=%2Egde_4877284_member_240196966
High reliability organisations
Failure
Succes
? ? ?
80. 2009: start ReMarketable
2010: idea for OR black box
2010: 1st Contact RadboudUMC
2013: Trial in animal OR
2014: Agreement Justice department
& Inspection
2015: first 10 takes in RadboudUMC
2016: Start UMCG?
83. External forces
• Production pressures
• Visibility of accidents for the general public
• Can it happen to everyone or only a small group
• Can we depend on our skills
86. Defences
• Understanding and awareness
• Guidance
• Alarms and warnings
• Restore
• Containment
• Escape and rescue
87. Barriers
• the need to limit the discretion of workers
• the need to reduce worker autonomy
• the need to make the transition from a craftsmanship
mindset to that of equivalent actors
• the need for system-level (senior leadership)
arbitration to optimize safety strategies
• the need for simplification
Editors, S., Barach, P., Amalberti, R., Auroy, Y., & Berwick, D. (2005). Improving Patient
Care Five System Barriers to Achieving Ultrasafe Health Care.
88. Risks
Known un-knowns
(meta instructions (think!))
“If .. stop and think”
Known knowns
(training, checklists, ..)
“Do this”
Un-known knowns
(implicit culture)
“This is how we do it”
Un-known un-knowns
(resilience)
“Do not take anything for
granted”
Do we
know
the
risk?
Do we know how to deal with the risk?
89. Dimensions
• type of expected performance
• from daily routine work to highly innovative, and standardized or repetitive
• interface of health care providers with patients
• from full autonomy to full supervision
• type of regulations
• from few recommendations to full specification of regulations at an international level
• pressure for justice after an accident
• from little judicial scrutiny to routine lawsuits against people and systems
• supervision and transparency by media and people in the street of the activity
• from little concern to high demand for national supervision
Editors, S., Barach, P., Amalberti, R., Auroy, Y., & Berwick, D. (2005). Improving Patient
Care Five System Barriers to Achieving Ultrasafe Health Care.
90. “A lot of you are going to have to make decisions above
your level. Make the best decision that you can with the
information that’s available to you at the time, and, above
all, do the right thing”
Lee Scott, CEO Walmart (day before Katrina)
96. • To be human is to err …
• “Safe” incident reporting
• Systemic errors
• Learning, not prosecution
• Gross negligence remains punishable
– Honest mistakes not
punitive blame free
safety
105. Situation
“Blood pressure is below 60”
Background
“Life signs are critical”
Assessment
“Extensive blood loss will lead to a dangerous situation”
Recommendation
“Do not proceed”
108. • Team Leadership
• Backup Behavior
• Mutual performance monitoring
• Communication adaptability
• Shared mental models
• Mutual trust
• Team orientation
Baker, D. P., Day, R., & Salas, E. (2006). Teamwork as an essential component of high-reliability organizations. Health services research, 41(4 Pt 2), 1576–98
109. • hypercomplexity
• tightly coupled
• extreme hierarchical (role) differentiation
• many decision makers working in complex communication networks
• high degree of accountability
• frequent, im- mediate feedback regarding decisions
• compressed time factors
• synchronized outcomes
Charactaristics HRO’s
111. 3,7% adverse events (3,2 to 4,2)
27,6% of adverse events are preventable (22,5 to 32,6)
70,5% > 6 month, 2,6% permanent, 13,6% death
Harvard Medical Practice Study, 1991
(records from 1984)
112. Safety culture
Act
lessons learned
adaption to instruments
analyses of outcomes
analysis of processes
Check
observation
Do
Plan
checklists
training syllabi
formal communication
113. Plan the proces
- checklists, … Do accoording to
agreed processes
Check expected
outcomes with
reality
Act on deviations
- analise and adapt
114.
115.
116. Cabana, M., Rand, C., & Powe, N. (1999). Why Don’t Physicians Follow Clinical Practice Guidelines?
117. Gut feeling
Task management
Teamwork
Leadership
1. The team leader let the team know what was expected of them through
direction and comma
2. The team leader maintained a global prospect
3. The team communicated effectively
4. The team worked together to complete tasks in a timely manner
5. The team acted with composure and control
6. The team morale was positive
7. The team adapted to changing situations
8. The team monitored and reassessed the situation
9. The team anticipated potential actions
10.The team prioritized tasks
11.The team followed approved standards/guidelines Total
12.global rating
Cooper, S., Cant, R., Porter, J., Sellick, K., Somers, G., Kinsman, L., & Nestel, D. (2010). Rating medical emergency
teamwork performance: development of the Team Emergency Assessment Measure (TEAM). Resuscitation, 81(4), 446–52.
118. we do well
we could do more of
we could do less of
One thing