Teamwork: Pulling it All Together Part 1 of the Working as a Health Care Team series
Most members of the health care community would be hard-pressed to believe that one single aspect of health care accounts for most errors that occur in medicine; that fixing and perfecting this aspect could lead to an almost error-free health care practice. But recent research suggests that this is the case and that one aspect of health care is teamwork.
Communication failures are the leading cause of inadvertent patient harm. Analysis of 2455 sentinel events reported to The Joint Commission for Hospital Accreditation revealed that the primary root cause in over 70 percent of all events was communication failure. Reflecting the seriousness of these occurrences, approximately 75 percent of these patients died. All too often, clinicians providing care had very divergent perceptions of what was supposed to happen. (1)
These statistics not only reflect the problem with the teamwork culture in health care institutions, but the great importance of effective communication between team members in health care delivery. The health care environment has become more complex as the acuity of hospitalized patients rises and technology becomes a significant presence. The system still relies on humans communicating with each other. Each member has influence on the health care process and, therefore, must work in harmony in order to provide quality care.
Individual mistakes are inevitable. Psychology tells us that the inherent limitations of human memory, effects of stress, impact of fatigue, and limited ability to multi-task ensure that even skilled, experienced providers will make mistakes. Individually, we as human beings are inherently error-prone. However, a team is not. A well-synchronized and collaborative health care delivery team creates a well-understood plan of care, and greatly reduces the chances of errors becoming consequential and injuring patients.
There has been a great deal of research in health care on the limitations of the current way most health care teams function, and steps that can be put into place to eliminate these limitations. Research done by the Department of Defense’s Patient Safety Program in collaboration with the Agency for Healthcare Research and Quality (AHRQ), the World Health Organization (WHO), and other research have all yielded a common theme in the problems of the modern day health care delivery team. They have all identified the following key areas in healthcare that need to be addressed:
Cross monitoring (“I’ve got your back.”)
Assertion of view
Because ineffective teamwork and communication have been identified as leading causes of adverse events reported to CHPSO, the CHPSO Patient Safety News will publish a series of articles addressing these concerns over the next few months.
1. Leonard, M., S. Graham, and D. Bonacum. “The human factor: the critical importance of effective teamwork and communication in providing safe care.” Quality and Safety in Health Care 13.suppl 1 (2004): i85-i90.