TEAMWORK AND COMMUNICATION TRAINING. WHY WE CARE: IMPACT OF PATIENT ERROR. 98,000 Americans die each year as a result of preventable medical errors* Costs associated with all medical errors is $29 billion annually*. “NATIONAL PROBLEM OF EPIDEMIC PROPORTIONS”**.
“NATIONAL PROBLEM OF EPIDEMIC PROPORTIONS”**
* To Err Is Human: Building a Safer Health System
** Doing What Counts for Patient Safety: Federal Actions to Reduce Medical Errors and Their Impact
WHY DO ERRORS HAPPEN?
In 2004, a Sentinel Alert issued by JACHO revealed that most cases of perinatal death and injury are caused by problems with an organization’s culture and communicationfailures between providers.
“Conduct team training in perinatal
areas to teach staff to work together and communicate more effectively”
“…conduct clinical drills ….and conduct debriefings to evaluate team performance and identify areas for improvement.”
twelve minutes (33 mins 21mins)
Teamwork behaviors can be transferred to clinical environments
In the Labor and Delivery setting, every delivery is, by necessity, a multidisciplinary event involving nursing, obstetrics (OB/CNM), anesthesiology, pediatrics, and unit support staff (scrub tech/unit coordinator).
“Individual competence in clinical skills is not enough; team coordination, communication, and cooperative skills are essential to effective and safe performance.”
Team Support Staff
Teamwork is a safety net that catches errors before they can do harm
Held at 8AM & 8PM
Called anytime, by anyone for concerns about
clinical developments, management plans or conflict resolution
Used for resource management and planning
This can only occur in a climate where it is expected that assistance will be actively offered, accepted and sought as a method of avoiding mistakes.
For communication to be effective it needs to be complete, clear, brief, and timely
Patient Risk Zone
Patient Risk Zone
WorkloadACCOUNTABILITY AND COLLECTIVE EFFORT
Debriefing allows for evaluation of the effectiveness of the team following an “event”.
Facilitated reflection has been shown to be a critical element for improving future performance of individuals and teams.
Allows identification of systems issues and opportunities for improvement
“The nice thing about teamwork is you always have others on your side”