Panel 2: Broad-based Systems Approaches
Creating Complementary Roles for Behavioral Solutions and Technology Applications to Patient Safety
Testimony of Robert L Wears, MD, MS, Department of Emergency Medicine
University of Florida;
Robert Simon, EdD, CPE,
Crew Performance Group,
Dynamics Research Corporation;
and the MedTeams Consortium*
* The MedTeams Consortium is comprised of departmental representatives from Darnall Army Community Hospital, David Grant Medical Center, Eisenhower Army Community Hospital, Hasbro Children's Hospital, Holy Family Hospital and Medical Center, Madigan Army Medical Center, Methodist Hospital of Indiana, Naval Medical Center-Portsmouth, Naval Medical Center-San Diego, Rhode Island Hospital, University of Florida Health Science Center, West Virginia University Hospitals, the Army Research Laboratory, and Dynamics Research Corporation
The first National Summit on Medical Errors and Patient Safety Research was held on September 11, 2000, in Washington, DC. Sponsored by the Quality Interagency Coordination Task Force (QuIC), the Summitís goal was to review the information needs of individuals involved in reducing medical errors and improving patient safety. More importantly, the summit set a coordinated and usable research agenda for the future to answer these identified needs.
Individuals were selected by the Agency for Healthcare Research and Quality (AHRQ) to testify at the summit as members of the witness panels. Each submitted written statements for the record before the event, documenting key issues that they confront with regard to patient safety as well as questions to be researched. Other applicants were invited to submit written statements.
Disclaimer and Copyright Statements
Mr. Chairman, members of the panel, distinguished guests, and colleagues. On behalf of the member hospitals and professional organizations of the MedTeams Consortium, we would like to thank you for the opportunity to present our views on the research agenda to reduce medical errors and improve patient safety.
Solutions for improving patient safety and avoiding medical errors have taken various forms. One form is technology, exemplified by the use of error-capturing routines in computers for ordering medications,1 or process control assistance, as in total intravenous anesthesia.2 Another is the incorporation of multi-disciplinary staff to bring additional knowledge resources to patient care. An example is the addition of pharmacists to caregiver teams to advise and to coordinate the use of medications.3 The third is the introduction of teamwork training for care providers. An example is MedTeams, a system for team training drawn from crew resource management training in aviation.4,5
The first of these solutions, the introduction of technology to reduce medical errors, holds great promise among medical professionals and the public. However, much of this promise may not be realized. Part of the problem is that technology is frequently underutilized or does not fit naturally into work patterns. Another part is the limited role of technology in training behavioral and teamwork skills. What is lacking is a body of research that addresses the considerable role that behavioral training can play in reducing errors, and how to integrate behavioral approaches to error avoidance with available technologies. These comments will advance the argument for balancing technological fixes with teamwork training and behavioral solutions.
Technology can support error avoidance behaviors in healthcare and play a significant part in the training and research of more effective behavioral solutions in patient safety. The remarkable safety achievements of the aviation industry are the result of advancing technology, a social and cultural environment that supports safety, and the introduction of crew resource management (CRM) training of flight crews. It is interesting to note that the same technology that has been used to increase safety in the air is available and has been employed in the maritime industry, but without an appreciable improvement in safety.6 This demonstrates that technological "fixes" in themselves are not sufficient to produce safety; they must be supported by behavioral and socio-cultural changes in order to be effective.
The earliest CRM training was developed to reduce accidents caused by "human error" through management skills and leadership training.7 But accident investigations, incident reports, and a growing body of research pointed to the importance of more specific teamwork skill training for flight crews. Today, crew resource management training focuses on behaviors such as explicit communications to offer and to obtain information, deliberate planning and task prioritization, and active workload management among crew members. These behaviors are learnable, doable, and measurable, constituting the specifics of good crew coordination or teamwork. Under the Federal Aviation Administration's Advanced Qualification Program for pilot training, adhered to by all major U.S. airlines, crew resource management training is mandatory and is evaluated on an equal basis with technical flying skills.8 Like their civilian counterparts, military aviators undergo similar crew coordination training.
The similarities between the high risk, time-pressured and uncertain environments of military aviation and emergency medicine suggested the development of MedTeams, a project to adapt crew resource management principles to healthcare. Table 1 shows some teamwork behavior errors identified in military aviation. Figure 1 illustrates the parallels between aviation and emergency care teamwork failures using narrative descriptions of actual errors. Health professionals are almost never trained as teams; medical and nursing education focus almost entirely on individual performance, and assume that somehow "all the parts will work together."
Table 1. Recurrent Types of Errors in Army Aviation
- Poor team leadership and team climate manifested by lack of trust, lack of professional respect, or ineffective problem solving.
- Inconsistent understanding of team goals, including poor anticipation of critical events, options, roles, and decision points.
- Poor use of available information, coupled with either excessive or inadequate deliberation among team members.
- Maldistribution of workload, often manifested by a senior team member who "goes it alone" without utilizing other capable team members.
- Diversion of the team's attention to distractions or less important tasks at the expense of accomplishing time urgent tasks.
- Ambiguous communication of critical information manifested by nonstandard terminology, imprecise phrases, excessive chatter, or lack of acknowledgment by the recipient.
- Lack of assertiveness by junior ranking or less experienced team members.
- Failure to recognize factors that can degrade individual attention and decision making capacity, e.g., stress, fatigue, anger.
- Failure to inform others of critical decisions or actions affecting another team member's area of responsibility.
- Failure of team members to anticipate and offer critical information and assistance to one another.
- Failure of team members to request critical information and assistance from one another.
- Failure to cross-monitor actions of others, thereby failing to serve as a safeguard against individual errors and oversights.
- Failure to keep each other routinely informed of critical readings and conditions, manifested by team members becoming exclusively focused on only their own area of responsibility.
- Failure of the team to practice self-improvement through after-action reviews12. and critiques.
Figure 1. Example of comparable teamwork failures.
||Emergency Department Example
A helicopter was attempting a night shipboard landing during a training mission. The landing deck already contained another helicopter which had just landed, and which was on the left side of the approaching aircraft. The pilot in command who was seated in the right seat, attempted to maneuver onto the deck without assistance in obstacle clearance from the other pilot who was sitting in the left seat. The aircraft drifted into the main rotor blades of the parked aircraft. The pilot in the left seat failed to offer assistance in obstacle clearance, despite his location in the left seat, closest to the obstacle.
Non-flying crew members should provide information to the pilot flying concerning obstacle avoidance, altitude, airspeed, and approach angle. Total damage cost exceeded $2.5M.
A 43 year-old male with a known severe allergy to peanuts presents to the ED with an acute allergic reaction after eating some cookies at a friend's house. He is triaged as emergent and treatment is initiated within minutes of arrival. Despite appropriate therapy the patient's condition worsens. He is given Albuterol via nebulizer and the physician orders Epinephrine 1mg IV push to be given. The nurse is concerned about the route and dose but does not ask the physician for clarification of the order. The patient is given 1mg of Epinephrine. He immediately becomes hypertensive from the medication and ultimately sustains an Acute Inferior Wall Myocardial Infarction (MI). The patient requires a cardiac catheterization and is subsequently taken for bypass surgery.
The use of a call-out of the medication order (i.e., repeating the order back to the physician) would have alerted the physician to the drug dosage and route of administration error. In turn the physician's response to the call-out would have either corrected the error or prompted the nurse to further action. In the event of the physician's failure to change the drug order, the nurse would engage in advocacy and assertiveness to initiate further planning and decision making.
Select for Text Version of Figure 1
The first task of the MedTeams project examined current weaknesses and error patterns in emergency care teamwork and projected the potential impacts of improved teamwork on emergency care cost and performance. A closed claim study covering 4.7 million patient visits for an 11 year period ending in 1996 revealed teamwork failures could have mitigated or prevented errors that resulted in cash judgments or settlements to plaintiffs. Using conservative methods, we found that $3.45 (in 1985-96 dollars) of the cost of every ER patient visit is attributable to litigated cash payouts associated with poor teamwork.4 To illustrate the magnitude of this burden, the typical ER physician liability costs are between $2 and $6 per patient visit. Clearly, teamwork failures account for more than half of the physician liability insurance costs.
In addition to the liability costs of poor teamwork, we saw distinct behaviors associated with teamwork failures. Examples of the most frequent and costly errors were:
- Failure to identify an established protocol for the patient's care, or even to develop a treatment plan.
- Failure to advocate and assert an alternative or corrective course of action when a question arose about the patient's care.
- Failure to prioritize caregiver tasks for the patient.
- Failure to cross-monitor actions of other team members.
Many other specific teamwork failures were shown to contribute to medical misadventures in the ER, some of which are shown in Figure 2 (21 KB). On the positive side, it seemed that the same teamwork behaviors that contribute to the success of the aviation CRM programs would also contribute to improvements in teamwork in ERs.
An additional benefit of our analysis was that teamwork behaviors provide a useful framework for examining the causes of medical errors.9 Until now, risk managers and insurance companies have classified ED errors into categories such as improper procedures, diagnosis errors, improper medication, and failure to treat. These categories are extremely broad, and generic fixes for these problems are not available. For example, diagnosis errors can be remedied only on a case by case or symptom by symptom basis. However, by looking instead at teamwork failures contributing to an error or near miss, it is now possible to identify specific trainable teamwork actions (e.g., offer information to support planning and decision-making, request assistance for task overload) that will enhance effectiveness and reduce errors.
The MedTeams curriculum teaches behaviors that are applicable to the healthcare workplace and are anchored in real world problems. The core of the training is 41 well-defined behaviors that constitute the process of teamwork. The training takes 8 hours, and is augmented by a video depicting examples of good and poor teamwork, practical exercises, and discussion. Practicums, coaching, mentoring, and teamwork review sessions subsequently take place in the emergency department to further instruct and reinforce teamwork behaviors in the operational setting. One of our challenges has been the post-classroom implementation and sustainment phase that translates the teamwork principles into concrete actions. We will return to this training challenge and the potential role of technology later in my comments.
But for now, let me turn to the impact of our training on events in the ER. We conducted an experiment involving nine teaching and community hospitals divided into experimental and control groups.5 The experimental group received the MedTeams training. The control group allowed us to evaluate improvements occurring in the experimental group. Three outcome constructs were assessed: team behaviors, attitudes and opinions, and ED performance. Improvements were obtained in the experimental group for six out of the seven key measures assessed. The quality of team behaviors improved, workload was not increased by practicing teamwork, staff attitudes towards teamwork were enhanced, preparation of patients admitted from the ER improved, and the proportion of highly satisfied patients increased. The most important finding from the validation was that clinical errors were substantially and significantly reduced. A clinical error was defined as any clinical task that actually or potentially put a patient at risk. These errors were witnessed by a specially trained ER nurse or physician observing cases for the purpose of rating teamwork behaviors. An example of a reported error occurred during a resuscitation. A burn patient received duplicate administrations of intravenous morphine when two nurses independently administered the drug after a physician gave a verbal order. The staff recognized the overdose when the patient's breathing slowed, at which point they intervened and the patient recovered. A check-back for a verbal medical order, a teamwork behavior taught in MedTeams, would have avoided or "captured" this error.
The finding that teamwork is a process that serves as a front-line defense against adverse events is perhaps the most important result of our research. Since care is rarely provided by individuals acting in isolation, team members create the redundancy that characterizes highly reliable systems.10 In most of the adverse events that we studied or witnessed in our research, we are struck by the fact that some team member had a piece of information, observed an action, possessed a skill, or had a doubt or suspicion that, if voiced or acted upon, could have altered the ultimate outcome for the patient. The challenge revealed by our research is that caregivers need direction and practice to engage in the teamwork behaviors that they know will affect delivery of care. Specifically, just as in aviation, these behaviors do not emerge spontaneously often enough or reliably enough to expect them to occur without specific training and reinforcement.
This brings me back to the point we raised earlier. Implementing teamwork in emergency departments requires changes to workplace practices, the integration of teamwork with existing technology systems, and a mechanism to reinforce, practice, and fine-tune teamwork behaviors. The changes in workplace practices to support teamwork encompasses such areas as leadership development, infrastructure support systems for teams, and personnel policy changes to reinforce teamwork. These issues can be managed locally in organizations adopting MedTeams.
The other issues are larger and require a research base to find satisfactory solutions. The first issue is creating complementary roles for teamwork, other behavioral solutions, and technology. Our experience is that technology is either underutilized by caregivers or represents piecemeal solutions to needs. The information processes of decision making, planning, communicating, and maintaining situational awareness can be improved through technology, but only if designed with teamwork processes and human factors principles made part of its operational structure. The second issue is the hands-on development of teamwork skills. Healthcare organizations support individual technical skill development but have limited models for collective or team-based skill development. This training gap is noteworthy because much of the taskwork of medical treatment is imbedded in the teamwork of delivering that care. In our view, both of these issues can be addressed through a research agenda that extends simulation into new areas of healthcare.
Universities, the Department of Defense, and industry are working towards making medical simulators functionally relevant and economically feasible for healthcare organizations. Already, high fidelity simulation centers exist for training anesthesiologists in crisis management, and single device simulators for functions such as ultrasound imaging, fetal heart rate monitoring, and pulmonary processes are available for training purposes. In our view, the creation of simulation devices is not a research concern. Rather, the critical need is for research addressing the use of simulation for medical education and evaluation. Our own preliminary investigations into the potential of patient simulators for training teamwork,11 and existing examples of medical simulation, suggests the following avenues for productive research.
- Expand the use of patient simulators from a single practitioner focus to a team focus. This will require investigations to determine the optimal mix of computer-driven simulations and live role-playing patients, the development of scenario design guidance, and refinement of methods for recording and providing feedback of training simulations to participants.
- Investigate the use of simulation to train initial teamwork skills to healthcare providers, using aviation training models as a start-point.
- Use simulators to identify the appropriate team structure best suited to different settings of care.
- Investigate the use of simulation to reinforce, retrain, and refresh technical skills (taskwork) together with teamwork skills. This advanced training needs to incorporate scenarios that portray examples of medical errors with a focus on teamwork to capture and remediate error. Important issues are the frequency of training, its availability, and its modalities.
- Establish medical simulation centers of excellence to
- advance the design of training and evaluation environments that use existing or emerging simulation technology
- investigate the effective integration of existing and emerging technologies, especially information and communication systems, into the workplace
- conduct usability assessments of emerging technology and redesigns of existing technologies, recognizing that technologies run the gamut from effective product labeling to computer-based systems. One major difficulty with technology in the health care workplace is that it is seldom rigorously evaluated by potential users before production and dissemination, or if it is evaluated at all, the evaluations take place under "normal operations." What is needed is a test bed where the effect of technological innovations could be evaluated under emergency or critical incident conditions, without placing patients at risk
- design standard procedures and protocols with a teamwork focus
- recreate unsafe or problematic situations to understand the dynamics of error and to determine alternative solutions
This research agenda emerges from the successful demonstration of the effectiveness of teamwork in emergency medicine and the growing availability of simulators designed for healthcare. It is also based on a similar path taken in aviation team training. We are now extending teamwork interventions beyond the emergency department to other domains of healthcare. Because we are now beyond doing basic research, the applications of existing behavioral interventions and simulation technology can be rapidly focused on the training for error reduction in numerous areas of healthcare. Our successes so far, and the existing base of simulation technology, have moved us well onto the path indicated in the Institute of Medicine report's Recommendation 8.1 to "establish interdisciplinary team training programs, such as simulation, that incorporate proven methods of team management."12
Thank you for this opportunity to share our views with you.
1. Bates DW, Teich JM, Lee J, et al. The impact of computerized physician order entry on medication error prevention. J Am Med Inform Assoc 1999;6:313-321.
2. Cook RI, Woods DD. Implications of automation surprises in aviation for the future of total intravenous anesthesia (TIVA). J Clin Anesth 1996;8:29S-37S.
3. Bates DW, Leape LL, Cullen DJ, et al. Effect of computerized physician order entry and a team intervention on prevention of serious medication errors. JAMA 1998;280:1311-6.
4. Risser DT, Rice MM, Salisbury ML, et al. The potential for improved teamwork to reduce medical errors in the emergency department. Ann Emerg Med 1999; 34:373-83.
5. Morey JC, Simon R, Jay GD, et al. Error reduction and performance improvement in the emergency department through formal teamwork training: validation results of the MedTeams project. Ann Emerg Med (in review).
6. Perrow C. Marine Accidents. In: Normal Accidents: Living With High-Risk Technologies. Princeton, NJ: Princeton University Press; 1999:170-231.
7. Helmreich, RL, Merritt, AC, Wilhelm, JA. The evolution of crew resource management training in commercial aviation. International J Aviation Psych 1999; 9:19-32.
8. Longridge, TM. Overview of the advanced qualification program. Available at http://www.faa.gov/avr/afs/tlpaper.htm
9. Risser DT, Simon R, Rice MM, et al. A structured teamwork system to reduce clinical errors. In: Spath PL, ed. Error Reduction in Health Care. San Francisco, CA: Jossey-Bass; 1999:235-78.
10. Knox, GE, Simpson, KR, Garite, TJ. High reliability perinatal units: an approach to the prevention of patient injury and medical malpractice claims. J Healthcare Risk Management 1999; 19:24-32.
11. Small, SD, Wuerz, RC, Simon, R., et al. Demonstration of high-fidelity simulation team training for emergency medicine. Acad Emer Med 1999; 6:312-23.
12. Kohn, LT, Corrigan, JM, Donaldson, MS (eds.) To Err is Human: Building a Safer Health System. Washington, DC: National Academy Press, 1999:156.
Current as of September 2000
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