Post on 26-Dec-2015
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Objectives
Describe the TeamSTEPPS training initiative
Describe the impact of errors and why they occur
Describe the TeamSTEPPS framework
State the outcomes of the TeamSTEPPS framework
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How we communicate and work together can make the difference between life and death. This video exemplifies this impact.
TeamSTEPPS is about reducing the likelihood of these stories recurring..
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Sue Sheridan
Sue Sheridan. 76 MB (Click camera to watch. Windows Only)Please wait patiently while movie is downloaded.
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2006
Patient Safety and Quality
Improvement Act of 2005
Patient Safety Movement
Executive Memo from President
DoD MedTeams®
ED Study
Institute for Healthcare
Improvement 100K lives Campaign
“To Err is Human”
IOM Report TeamSTEPPS
1995 1999 2001 2003 2004 2005
JCAHO National Patient Safety Goals
Medical Team Training
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Indemnity Experienc e
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11
0
5
10
15
20
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Malpractice Claims, Suits, and Observations
Pre-Teamwork Training Post-Teamwork Training
Adverse Outcomes
50%Reduction
50%Reduction
(Mann, 2006) Beth Israel Deaconess Medical CenterContemporary OB/GYN
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1.4
1.6
1.8
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June July August Sept Oct Nov Dec Jan Feb M arch April M ay
Avg
. Len
gth
of
Sta
y (d
ays)
Length of ICU Stay After Team Training OR Teamw ork Climate and P os toperative Seps is Rates (per 1000 discharges)
Group Mean
Low Teamwork Climate
Mid Teamwork Climate
High Teamwork Climate
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4
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A HRQ National A verage
Teamwork Climate Based on Safety Attitudes Questionnaire
Low High(Sexton, 2006)Johns Hopkins
(Pronovost, 2003)Johns HopkinsJournal of Critical Care Medicine
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We know that communication is not straightforward. The following video clip exemplifies this reality.
What happened in this video?
It is a question of communication and assumptions.
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Another example of lack of communication resulting from assumptions is contained in this video.
We may chuckle at this honest miscommunication, but what can we do to make sure such a miscommunication does not happen while we are caring for our patients?
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Flowers. 8.7 MB (Click camera to watch. Windows Only)Please wait patiently while movie is downloaded.
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Let’s review our TeamSTEPPS tools and see how we can effect patient outcomes like other organizations who have improved patient outcomes.
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HuddleProblem solving Hold ad hoc, “touch-
base” meetings to regain situation awareness
Discuss critical issues and emerging events
Anticipate outcomes and likely contingencies
Assign resources Express concerns
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The second tool is CUS, an acronym that helps us remember three key signal words which include: concerned, uncomfortable and safety. Signal words, such as “danger,” “warning,” and “caution” are common in the medical arena. They catch the reader's attention. “CUS” and several other signal phrases have a similar effect in verbal communication. When they are spoken, all team members will understand clearly not only the issue but also the magnitude of the issue. This is a way of getting someone’s attention without yelling or using unprofessional language. It has the advantage of not alienating others and perhaps reducing the likelihood they will contact you the next time an emergency occurs.
First, state your Concern.Then state why you are Uncomfortable.If the conflict is not resolved, state that there is a Safety issue. Discuss in what way the concern is related to safety. If the safety issue is not acknowledged, a supervisor should be notified.
Regardless of which word is used, if we hear a someone use any CUS word, it is our cue to stop what we are doing and pay attention because patient safety is at risk.
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Call-Out is…A strategy used to communicate important or critical information
It informs all team members simultaneously during emergency situations
It helps team members anticipate next steps
Important to direct responsibility to a specific individual responsible for carrying out the task
Avoid Thin Air Commands
…On your unit, what information
would you want called out?
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Read-Back is…
Closing the loop on information exchange!
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Handoff
The transfer of information and authority/responsibility during transitions in care.
Includes SBAR information, giving an opportunity to ask questions, solicit a read-back/check back of information shared. Great opportunity for
quality and safety!
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SBARA technique for communicating critical information that requires immediate attention and action concerning a patient’s condition.
Situation – What is going on with the patient?
“I am calling about Mrs. L’s fetal heart rate tracing.
Background – What is the clinical background or context?
She is a primigravida who is being induced
Assessment – What do I think the problem is?
I think she is having late decelerations. I have stopped the Pitocin, and she is on her left side with oxygen on.
Recommendation – What would I do to correct it?
I am concerned. I would like you to come evaluate her tracing. When can I expect you?
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Vig3alg001parathyroidbad.mpeg : 26 MB (Click camera to watch. Windows Only)Please wait patiently while movie is downloaded.
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How could this be prevented?
With better communication as shown inthe next video.
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parathyroidgood.mpeg : 53 MB (Click camera to watch. Windows Only)Please wait patiently while movie is downloaded.