Opinion: Patient Safety Starts With Teams

In the June issue of the Pennsylvania Patient Safety Advisory, Christina Hunt, RN, MSN, MBA, HCM, patient safety liaison for the Pennsylvania Patient Safety Authority, states that in a review of 2009’s incidents and serious events reports, more than 1,000 included the key terms teamwork, communication, team, handoff communication and SBAR, a reporting acronym for Situation, Background, Assessment, Recommendation.

Hunt found that healthcare providers in facilities she visited were looking for tools to increase team interaction and effectiveness. One evidence-based initiative she endorses is TeamSTEPPS, which stands for Team Strategies and Tools to Enhance Performance and Patient Safety.

Patient care teams that use the TeamSTEPPS model focus on four skills to improve performance — leadership, situation monitoring, mutual support and communication.

TeamSTEPPS was developed by the U.S. Department of Defense and the Agency for Healthcare Research and Quality, and can be adapted to any healthcare setting. To read how TeamSTEPPS was successfully implemented at Abington (Pa.) Memorial Hospital, visit innovations.ahrq.gov/content.aspx?id=1783. (Nurses also can read about other implementations at the AHRQ Innovations Exchange page at innovations.ahrq.gov.)

Abington Memorial created a dedicated hospital department called the Center for Patient Safety and Healthcare Quality in 2006, directed by Maureen Ann Frye, RN, MSN, CRNP. Mandatory TeamSTEPPS training began in 2008. According to the AHRQ summary, “the hospital has experienced significant improvements in patient outcomes and care processes.”

These include a 27% drop in inpatient adverse events as measured by the Global Trigger Tool and a 30% decrease “in crude mortality rate, more proactive rescue of at-risk patients, better hand hygiene, improved staff perceptions of teamwork and anecdotal reports of better communication processes.”

Abington instituted “walk-arounds” to give hospital leaders, including board members, a firsthand look at safety concerns. During monthly rounds with patient care staff, leaders ask about adverse outcomes and suggestions for improvements, with open-ended questions such as, “What’s the next medical error that’s likely to cause harm here?”

According to Frye, “It helps bedside nurses recognize that senior leaders really do want to enable them to be the safest providers of care.”

Two local universities have announced specialized curriculum to train nurses and other healthcare professionals. The University of Delaware offers a certificate program in Health Care Risk Management and Patient Safety, and Thomas Jefferson University offers certificate and master’s programs in Healthcare Quality and Safety.

Frye says patient safety hinges on the people who work in hospitals, and the decisions they make day to day, under the duress of multiple patients and responsibilities. Her team created a video to inspire their efforts, viewable on the Abington Memorial website at amh.org.

Based on a popular “Good Morning America” segment, staff members were asked to summarize their commitment to patient safety in three words. Some came up with succinct rules, such as “always double identify.”

But one message evokes a deeper reason to make safety the first priority — “Love your patient.”

Donna M. Novak, RN, MSN, CRNP, serves as Director, Nursing Communications & Initiatives, for Nursing Spectrum.

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