Ts module 1_slides_introduction_06.1 vic_final2

Strategies and Tools to Enhance Performance

and Patient Safety

TEAMSTEPPS 05.2Mod 1 05.2

Introduction

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Ice Breaker


Introduction

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Sue Sheridan Video


Introduction

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Video Discussion

How are patients harmed as a result ofmedical errors?

How can we prevent medical errors?

What are the solutions?

…Improved teamwork and communications…

Ultimately, a culture of safety


Introduction

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Objectives

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


Introduction

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Teamwork Is All Around Us


Introduction

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Introduction

Evolution of TeamSTEPPS

Curriculum Contributors• Department of Defense

• Agency for Healthcare Research and Quality

• Research Organizations

• Universities

• Medical and Business Schools

• Hospitals—Military and Civilian, Teaching and Community-Based

• Healthcare Foundations

• Private Companies

• Subject Matter Experts in Teamwork, Human Factors, and Crew Resource Management (CRM)


Introduction

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“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


Introduction

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The Components of a Patient Safety Program


Introduction

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Course Agenda

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


Introduction

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If I had a “Magic Wand” and could make changes within my unit or facility in the areas of patient quality and safety…

Introductions and Exercise: Magic Wand


Introduction

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Why Do Errors Occur—Some Obstacles

Workload fluctuations

Interruptions

Fatigue

Multi-tasking

Failure to follow up

Poor handoffs

Ineffective communication

Not following protocol

Excessive professional courtesy

Halo effect

Passenger syndrome

Hidden agenda

Complacency

High-risk phase

Strength of an idea

Task (target) fixation


Introduction

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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


Introduction

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Medical Errors Still Claiming Many Lives

…little progress towards the goalLeape and Berwick,

JAMA May 2005


Introduction

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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).


Introduction

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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)


Introduction

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What Comprises Team Performance?

KnowledgeCognitions

“Think”

…team performance is a science…consequences of errors are great…

AttitudesAffect“Feel”

SkillsBehaviors

“Do”


Introduction

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Outcomes of Team Competencies Knowledge

Shared Mental Model

Attitudes Mutual Trust Team Orientation

Performance Adaptability Accuracy Productivity Efficiency Safety


Introduction

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Teamwork Actions

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."

Ts module 1_slides_introduction_06.1 vic_final2

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