As noted in the review by Weaver et al. (2014), simulation is commonly used to train healthcare teams and can have high or low fidelity. High- fidelity simulations refer to those that strongly mimic real life scenarios, the actions that should be takenby the participant(s), and the actual work environment, including equipment and patients. Low-fidelity simulations present realistic scenarios and require participants to react as they would in the real world but do not replicate all aspects of the environment (e.g., a doll could be used in place of a mannequin). Briefings Briefings have a long history of use in the field of aviation and have been included as a tool within healthcare CRM programs, as well as in the TeamSTEPPS training program. Prebriefings help set the stage for teamwork by reviewing tasks that need to be accomplished, identifying which team member(s) will be responsible for each task, and discussing any contingency plans. Debriefings then review (post- performance) what went well and what could have gone better, with the goal of improving performancein the future. Debriefings can cover a combination of individual and team performance as well as system issues. Handoff protocol Handoff protocol is a tool that can be used to increase teamwork during patient transitions. Such transitions occur between shifts within a unit or when a patient is transferred from one unit to another (e.g., from the OR to the surgical ICU). During this time, critical information needs to be passed that, if missed, can affect the quality of care. A standardized handoff protocol can ensure that information is consistently exchanged between providers. Checklists Checklists constitute another tool that has historically been used in the aviation industry, specifically during the pre-flight phase. Checklists are well suited for completing procedural tasks and have been implemented as a way to improve teamwork (especially to increase communication among team members) and to reduce technical errors. Conclusions In terms of team training programs, training was most often delivered in a 4- to 5-hour session and evaluated within a specific unit (e.g., obstetrics, ICU), although some studies conducted training at the hospital level. Improvements were demonstrated on a variety of process measures (indicative of reaction, learning, and transfer criteria) and outcome measures (i.e., results criteria) relevant to the participants’ settings. Tools such as checklists and briefings may appear to require less time or fewer resources to implement than team training programs such as those described. However, time and due diligence are needed to educate staff on why the selected
tool is being implemented, how to use the tool, and how the tool fits into the established workflow. Once implemented, new protocols sometimes required greater time and participation by the entire team to ensure all elements were covered. Leadership involvement and project champions are key regardless of the specific practice used to improve teamwork. Leadership support is needed not only to help get a practice off the ground, but also to ensure compliance over time. For example, leaders may be involved in promoting or endorsing the training, as well as participating in (or being present during) team training workshops. In the case of implementing performance support tools on the job, leadership support can signal that the improvement tools are critical to quality and safety of care rather than merely an additional administrative task. Additionally, leadership can provide reinforcement when staff use the tools as intended and help ensure that their use is sustained over time. As mentioned earlier, researchers suggest that studies that assess multiple criteria, measure KSAs at multiple levels, and/or incorporate multiple measurement methods provide the most meaningful evaluation data regarding an intervention’s effectiveness. Collectively, research supports the use of team training interventions and performance support tools for improving teamwork, sustaining those improvements on the job, and positively influencing clinical and patient outcomes. Learning activity Summary This activity covers a range of patient safety practices chosen for the high-impact harms they address and interest in the status of their use. The harms include diagnostic errors, failure to rescue, sepsis, infections due to multi-drug resistant organisms, adverse drug events, and nursing- sensitive conditions. The most significant harms patients face continue to be found in higher acuity settings, such as the emergency department and intensive care units. Research on the use of sepsis screening tools, for example, predominantly takes place in the acute care setting. As the importance of early identification has gained traction, sepsis screening tools are now being investigated for use in pre- hospital and long-term care settings, although with widely varied results. Other harms, such as adverse drug events and diagnostic errors, occur in a variety of settings. For example, reducing adverse drug events in the elderly using medication deprescribing practices or medication screening, as well as associated research, can be found in ambulatory settings, long-term care facilities, and acute care settings. Similarly, PSPs geared toward reducing diagnostic errors, such as the use of clinical decision support in the diagnostic process, peer review of radiology and pathology studies, or result notification systems, have been studied in both the ambulatory and acute care settings.
One aspect of care or “setting” that poses a unique threat to patients is the transition between one setting and another; from the hospital to the outpatient setting, in particular. Two address harms associated with transitions of care: care transition models as a PSP to reduce readmissions and medication management across transitions to reduce adverse drug events. Regardless of setting, several themes have been repeatedly stressed in this activity: • More than one PSP can be used to reduce a given harm. • Selecting a particular PSP for implementation in a specific healthcare facility or system should be based on the predominant root cause(s) of the harm at that facility or system. For example, in one facility, theroot cause of an increase in sepsis mortality may be a lack of recognition of patients with sepsis arriving to the emergency department. In another facility, it may be due to lack of monitoring of patients who are experiencing deterioration on a medical-surgical unit. • When using a specific PSP, consideration must be given to potential new harms that can be introduced. For example, PSPs and strategies to reduce venous thromboembolism must take intoaccount the potential to unintentionally increase anticoagulation-related events. • PSPs are not implemented in isolation and are often part of a broader safety strategy. The strategy often relies on a strong safety culture, teamwork, communication, and involvement of the patient and family. These cross-cutting practices are the foundation for success. It is clear that when it comes to improving patient safety, the importance of context for implementation cannot be overstated. Setting, safety culture, staffing and other organizational factors contribute to harm reduction as much as a PSP itself. We often know what to do. Now the challenge is how to implement effective PSPs into specific facilities or settings and have them succeed.
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