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Health  2022 

Using an Interprofessional Lens to Analyze Serious Adverse Events in a Teaching Hospital: An Analysis with the TeamSTEPPS® Framework

DOI: 10.4236/health.2022.1412085, PP. 1199-1209

Keywords: Team Collaboration, TeamSTEPPS Framework, Incident Analysis, Interprofessional Education

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Abstract:

This paper explores the contribution of teamwork skills in serious adverse events, using the TeamSTEPPS® framework. Adverse events are the undesirable events that are not due to the natural course of a disease; they are considered serious when they prolong a hospital stay, lead to a physical disability or to death. Failures in teamwork, particularly with interprofessional teams, can lead to potential risks to patient safety. Using a dataset of de-identified reports of serious adverse events in 2016 in a tertiary teaching hospital, we explored the contribution of teamwork skills according to the TeamSTEPPS® framework to these adverse events. We found that 61% of the 41 analyzed events involved failures in teamwork skills, with 80% of these involving communication, 52% in situation monitoring and team structure, 44% in mutual support and 40% in leadership. Sixty-four percent of the events involved more than one teamwork component. Our findings emphasize the need to improve teamwork training in healthcare, focusing not only on communication, but also on other teamwork skills as they often contribute together in adverse events. Future analyses of serious adverse events should include a focus on teamwork competencies, to guide the development of future quality and safety training programs.

References

[1]  Frenk, J., Chen, L., Bhutta, Z.A., Cohen, J., Crisp, N., Evans, T., et al. (2010) Health Professionals for a New Century: Transforming Education to Strengthen Health Systems in an Interdependent World. The Lancet, 376, 1923-1958.
https://doi.org/10.1016/S0140-6736(10)61854-5
[2]  Blue, A.V., Mitcham, M., Smith, T., Raymond, J. and Greenberg, R. (2010) Changing the Future of Health Professions: Embedding Interprofessional Education within an Academic Health Center. Academic Medicine, 85, 1290-1295.
https://doi.org/10.1097/ACM.0b013e3181e53e07
[3]  The Canadian Interprofessional Health Collaborative (CIHC). A National Interprofessional Competency Framework 2010.
https://drive.google.com/file/d/1Des_mznc7Rr8stsEhHxl8XMjgiYWzRIn/view
[4]  World Health Organization (2010) Framework for Action on Interprofessional Education and Collaborative Practice. World Health Organization, Geneva.
[5]  Agency for Healthcare Research and Quality (AHRQ). TeamSTEPPS 2.0 2018.
https://www.ahrq.gov/teamstepps/instructor/index.html
[6]  Institute of Medicine (2000) To Err Is Human: Building a Safer Health System. The National Academies Press, Washington DC, 312 p.
[7]  Manser, T. (2009) Teamwork and Patient Safety in Dynamic Domains of Healthcare: A Review of the Literature. Acta Anaesthesiologica Scandinavica, 53, 143-151.
https://doi.org/10.1111/j.1399-6576.2008.01717.x
[8]  Pronovost, P.J., Thompson, D.A., Holzmueller, C.G., Lubomski, L.H., Dorman, T., Dickman, F., et al. (2006) Toward Learning from Patient Safety Reporting Systems. Journal of Critical Care, 21, 305-315.
https://doi.org/10.1016/j.jcrc.2006.07.001
[9]  Capella, J., Smith, S., Philp, A., Putnam, T., Gilbert, C., Fry, W., et al. (2010) Teamwork Training Improves the Clinical Care of Trauma Patients. Journal of Surgical Education, 67, 439-443.
https://doi.org/10.1016/j.jsurg.2010.06.006
[10]  Deering, S., Rosen, M.A., Ludi, V., Munroe, M., Pocrnich, A., Laky, C., et al. (2011) On the Front Lines of Patient Safety: Implementation and Evaluation of Team Training in Iraq. The Joint Commission Journal on Quality and Patient Safety, 37, 350-356.
https://doi.org/10.1016/S1553-7250(11)37045-6
[11]  de Vries, E.N., Ramrattan, M.A., Smorenburg, S.M., Gouma, D.J. and Boermeester, M.A. (2008) The Incidence and Nature of In-Hospital Adverse Events: A Systematic Review. Quality & Safety in Health Care, 17, 216-223.
https://doi.org/10.1136/qshc.2007.023622
[12]  Vincent, C., Taylor-Adams, S., Chapman, E.J., Hewett, D., Prior, S., Strange, P., et al. (2002) How to Investigate and Analyze Clinical Incidents: A Clinical Risk Protocol in Association with Litigation and Risk Management. Annales Francaises d’Anesthésie et de Réanimation, 21, 509-516.
https://doi.org/10.1016/S0750-7658(02)00671-8
[13]  Commission TJ (2015) Sentinel Event Data—Root Causes by Event Type 2004-2015.
https://hcupdate.files.wordpress.com/2016/02/2016-02-se-root-causes-by-event-type-2004-2015.pdf
[14]  Starmer, A.J., Spector, N.D., Srivastava, R., West, D.C., Rosenbluth, G., Allen, A.D., et al. (2014) Changes in Medical Errors after Implementation of a Handoff Program. The New England Journal of Medicine, 371, 1803-1812.
https://doi.org/10.1056/NEJMsa1405556
[15]  De Meester, K., Verspuy, M., Fau-Monsieurs, K.G., Van Bogaert, P., et al. (2013) SBAR Improves Nurse-Physician Communication and Reduces Unexpected Death: A Pre and Post Intervention Study. Resuscitation, 84, 1192-1196.
[16]  Anthony, M.K., Kloos, J., Beam, P. and Vidal, K. (2018) Innovative Approach to Reconstruct Bedside Handoff: Using Simple Rules of Complexity Science to Promote Partnership with Patients. Journal of Nursing Care Quality, 33, 128-134.
https://doi.org/10.1097/NCQ.0000000000000280
[17]  Han, J.H. and Roh, Y.S. (2020) Teamwork, Psychological Safety, and Patient Safety Competency among Emergency Nurses. International Emergency Nursing, 51, Article ID: 100892.
https://doi.org/10.1016/j.ienj.2020.100892
[18]  Blondon, K.S., Maitre, F., Muller-Juge, V., Bochatay, N., Cullati, S., Hudelson, P., et al. (2017) Interprofessional Collaborative Reasoning by Residents and Nurses in Internal Medicine: Evidence from a Simulation Study. Medical Teacher, 39, 360-367.
https://doi.org/10.1080/0142159X.2017.1286309
[19]  Darley, J.M. and Latane, B. (1968) Bystander Intervention in Emergencies: Diffusion of Responsibility. Journal of Personality and Social Psychology, 8, 377-383.
https://doi.org/10.1037/h0025589
[20]  Muller-Juge, V., Cullati, S., Blondon, K.S., Hudelson, P., Maitre, F., Vu, N.V., et al. (2013) Interprofessional Collaboration on an Internal Medicine Ward: Role Perceptions and Expectations among Nurses and Residents. PLOS ONE, 8, e57570.
https://doi.org/10.1371/journal.pone.0057570

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