By Shamanth Kuramkote, Undergraduate Research Assistant
The majority of the population considers their physicians to be trustworthy. Doctors and healthcare professionals are some of the most trusted professionals in the country, but also some of the most stressed. The average work day of healthcare professionals can be very hectic and stressful, which leads to sometimes catastrophic preventable errors. In their publication on Patient Safety and Team Training, Dr. David Birnbach and CORE Lab’s Dr. Eduardo Salas explore the cause of these patient safety errors as well as some possible solutions.
To begin, a major problem Birnbach and Salas addressed was that physicians and hospital administrators have refused to acknowledge the frequency of the occurrence of preventable patient mortality. A vast number of these patient deaths were caused by medical errors. In order to address these issues, Birnbach and Salas describe how many changes were introduced to improve patient safety from reducing the duty hours for resident physicians to introducing mandatory minimum nurse to patient ratios.
Birnbach and Salas then proceeded to introduce the Swiss Cheese Model of organizational accidents. The Swiss cheese model is how underlying system failures tended to be caused by smaller individual failures leading up to the adverse event. This is modeled as layers of swiss cheese slices, which each slice acting as a safety barrier, and the holes in the cheese being preventable ways to slip past these safety barriers. Occasionally, the holes will align enough to allow a catastrophic event to occur. And while this is rare, Birnbach and Salas stress how even rare cases of preventable harm are unacceptable. Birnbach and Salas then run through a scenario of how numerous systems errors almost led to a catastrophic event, such as from there being a language barrier and there not being a translator present to illegible handwriting on the patient chart.
Finally, prior to discussing solutions to some of these issues the authors define what a medical error constitutes. A medical error, according to the paper, is defined as a failure of a planned action to be completed as intended, or the use of the incorrect plain to achieve an aim. The article discusses how communication problems are the leading cause of medical errors. Lack of communication is also one of the leading factors of sentinel events, or unexpected occurrences involving death or serious physical or psychological harm. In order to improve this system, Birnbach and Salas believe that there must be a cultural change in the operating system within the health care system.
To begin, one of these changes is an increase in teamwork. Teamwork is an important part of the healthcare system, since it is teams that care for patients. Teamwork is defined as a set of behaviors, actions and attitudes that work to help complete the task at hand. Teamwork is essential for patient safety and implementation of team work enhancing behaviors can improve patient safety. Successful team performance consists of three factors: successful accomplishment of goals, team member satisfaction in those goals, and the ability of the team to improve the effectiveness of the team overtime. Birnbach and Salas then proceed to describe the concept of high reliability organizations or teams. A team can be classified as high reliability by using closed loop communication, developing shared mental models, demonstrating collective organization, recognizing complexities in the task environment. And using semi structured feedback. Team performance can be improved through team training. This is because performance improves when trainees have an opportunity to practice relevant skills in a structured scenario and then receive feedback. Birnbach and Salas then go on to describe the use of simulation based training in obstetrics. As stated above, simulation is a useful tool for assessment of performance in emergency situations when combined with practice and formal teaching.
Overall, Birnbach and Salas address an important issue in our modern healthcare system. The public places their trust in healthcare professionals to provide the utmost quality of care and expects that healthcare professionals will not commit preventable mistakes. It is for this region that Birnbach and Salas’ report on teamwork and team training situations are necessary for greatly improving the current healthcare system.
Reflection on Patient Safety and Team Training Chapter by Dr. David J. Birnbach & Dr. Eduardo Salas.