Patient Safety
Third leading cause of death in the United States
What is medical error?
The team addresses the following: - Was communication clear? - What went well? - What should improve? - Were errors made or avoided?
What is a debrief?
Characteristics include: brief, timely, clear, and complete
What is effective communication?
It is expected that ANYONE can do this if there is a situation where something is about to be done incorrectly or in an unsafe manner
What is SPEAK UP?
Process of actively scanning and assessing situational elements to gain information or understanding
What is situation monitoring?
Identified root cause of 66% of reported errors to the Joint Commission
What is ineffective communication (communication failures)?
A strategy for sharing the plan when leading a team (e.g., beginning of shift or procedure).
What is a brief?
Closed-loop communication strategy used to verify and validate information exchanged (e.g., verbal orders).
What is check-back?
Offering assistance to team members when the opportunity arises.
What is task assistance?
The state of "knowing what's going on around you."
What is situation awareness?
Program developed to improve communication and teamwork among healthcare professionals
What is TeamSTEPPS?
Ad hoc session to review and modify the established plans (e.g., change in patient condition).
What is a huddle?
The transfer of information (e.g. shift change, transferring patient)
What is a handoff?
Invoked when team members’ viewpoints don’t coincide with that of the decision-maker.
What is advocacy and assertion OR CUS?
Monitoring the actions of other team members to ensure mistakes or oversights are caught quickly and easily (e.g., handwashing)
What is cross-monitoring?
Example include - fatigue, interruptions, multi-taking, poor handoffs, ineffective communication
What are reasons medical errors occur?
Informal session to review the team's performance (e.g., after a code).
What is a debrief?
Strategy used to inform all team members simultaneously during emergent situations (e.g., during code).
What is call out?
Assertively voicing concern at least TWO times to ensure that it has been heard.
What is two-challenge rule?
Ensures that all team members are “on the same page."
What is shared mental model?
This is everyone's responsibility.
What is patient safety?
Core teamwork skill that includes the ability to maximize the activities of team members by ensuing the team actions are understood, changes in information are shared, and team members have the necessary resources
What is leadership?
SBAR
What is Situation, Background, Assessment, Recommendation?
Information provided to team members for the purpose of improving team performance.
What is feedback?
Each team member maintaining their situation awareness and sharing relevant facts with the entire team (i.e., multidisciplinary rounding)
What is shared mental model?