Improving patient safety by identifying latent failures in successful operations

Catchpole, Ken; Giddings, A. E. B.; Wilkinson, M. C.; Hirst, Guy; Dale, Trevor; Leval, Marc R. de

doi:10.1016/j.surg.2007.01.033

Cited by 225 publications

(171 citation statements)

References 25 publications

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“…44 The system of Manser and colleagues assesses different aspects of team coordination including information management, task management, coordination via work environment, and others. The NOTECHS system includes behavioural dimensions such as leadership, teamwork, problemsolving, situation awareness, etc.…”

Section: Discussionmentioning

confidence: 99%

Do Team Processes Really Have an Effect on Clinical Performance? A Systematic Literature Review

Schmutz

Manser

2013

Survey of Anesthesiology

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Editor's key points † This review has examined the impact of team process behaviours on clinical performance. † Twenty-eight studies, which reported at least one relationship between team process or an intervention and outcome, were reviewed. † Team process behaviours have been shown to influence performance. † Training in team behaviours results in improved performance.Summary. There is a growing literature on the relationship between team processes and clinical performance. The purpose of this review is to summarize these articles and examine the impact of team process behaviours on clinical performance. We conducted a literature search in five major databases. Inclusion criteria were: English peer-reviewed papers published between January 2001 and May 2012, which showed or tried to show (i) a statistical relationship of a team process variable and clinical performance or (ii) an improvement of a performance variable through a team process intervention. Study quality was assessed using predefined quality indicators. For every study, we calculated the relevant effect sizes. We included 28 studies in the review, seven of which were intervention studies. Every study reported at least one significant relationship between team processes or an intervention and performance. Also, some non-significant effects were reported. Most of the reported effect sizes were large or medium. The study quality ranged from medium to high. The studies are highly diverse regarding the specific team process behaviours investigated and also regarding the methods used. However, they suggest that team process behaviours do influence clinical performance and that training results in increased performance. Future research should rely on existing theoretical frameworks, valid, and reliable methods to assess processes such as teamwork or coordination and focus on the development of adequate tools to assess process performance, linking them with outcomes in the clinical setting.

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Section: Discussionmentioning

confidence: 99%

Do Team Processes Really Have an Effect on Clinical Performance? A Systematic Literature Review

Schmutz

Manser

2013

Survey of Anesthesiology

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“…In addition, few empirical studies systematically investigated the role of teamwork in preventing minor problems from escalating to more serious situations. 38,39 Nevertheless, it is often claimed that many adverse events could have been prevented by improved teamwork.…”

Section: Teamwork As An Important Contributing Factor To Adverse Eventsmentioning

confidence: 99%

Teamwork and patient safety in dynamic domains of healthcare: a review of the literature

Manser

2009

Acta Anaesthesiol Scand

1,006

700

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Aims/Background: This review examines current research on teamwork in highly dynamic domains of healthcare such as operating rooms, intensive care, emergency medicine, or trauma and resuscitation teams with a focus on aspects relevant to the quality and safety of patient care. Results: Evidence from three main areas of research supports the relationship between teamwork and patient safety: (1) Studies investigating the factors contributing to critical incidents and adverse events have shown that teamwork plays an important role in the causation and prevention of adverse events. (2) Research focusing on healthcare providers' perceptions of teamwork demonstrated that (a) staff's perceptions of teamwork and attitudes toward safety-relevant team behavior were related to the quality and safety of patient care and (b) perceptions of teamwork and leadership style are associated with staff well-being, which may impact clinician' ability to provide safe patient care. (3) Observational studies on teamwork behaviors related to high clinical performance have identified patterns of communication, coordination, and leadership that support effective teamwork. Conclusion: In recent years, research using diverse methodological approaches has led to significant progress in team research in healthcare. The challenge for future research is to further develop and validate instruments for team performance assessment and to develop sound theoretical models of team performance in dynamic medical domains integrating evidence from all three areas of team research identified in this review. This will help to improve team training efforts and aid the design of clinical work systems supporting effective teamwork and safe patient care.

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“…122 Even when communication and teamwork failures do not result in an adverse event, they can limit the surgical team's ability to compensate for a major event, 123 whereas effective teamwork in the OT can reduce the number of small problems and prevent them from escalating to more serious situations. 124 Thus, teamwork and communication are both considered to be markers of surgical excellence. 125 While such work on the relationship between communication and teamwork in the OT and patient safety has been important in highlighting the significance of this area, a limitation of existing work is that too often the emphasis has been on applying the label of failure, rather than seeking to understand and explain, with the terms communication and teamwork often being used interchangeably.…”

Section: Communication and Teamwork In The Operating Theatrementioning

confidence: 99%

A realist process evaluation of robot-assisted surgery: integration into routine practice and impacts on communication, collaboration and decision-making

Randell

Honey

Hindmarsh

et al. 2017

Health Serv Deliv Res

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Health Services and Delivery ResearchISSN 2050-4349 (Print) ISSN 2050-4357 (Online) This journal is a member of and subscribes to the principles of the Committee on Publication Ethics (COPE) (www.publicationethics.org/).Editorial contact: journals.library@nihr.ac.ukThe full HS&DR archive is freely available to view online at www.journalslibrary.nihr.ac.uk/hsdr. Print-on-demand copies can be purchased from the report pages of the NIHR Journals Library website: www.journalslibrary.nihr.ac.uk Criteria for inclusion in the Health Services and Delivery Research journalReports are published in Health Services and Delivery Research (HS&DR) if (1) they have resulted from work for the HS&DR programme or programmes which preceded the HS&DR programme, and (2) they are of a sufficiently high scientific quality as assessed by the reviewers and editors. HS&DR programmeThe Health Services and Delivery Research (HS&DR) programme, part of the National Institute for Health Research (NIHR), was established to fund a broad range of research. It combines the strengths and contributions of two previous NIHR research programmes: the Health Services Research (HSR) programme and the Service Delivery and Organisation (SDO) programme, which were merged in January 2012.The HS&DR programme aims to produce rigorous and relevant evidence on the quality, access and organisation of health services including costs and outcomes, as well as research on implementation. The programme will enhance the strategic focus on research that matters to the NHS and is keen to support ambitious evaluative research to improve health services.For more information about the HS&DR programme please visit the website: http://www.nets.nihr.ac.uk/programmes/hsdr This reportThe research reported in this issue of the journal was funded by the HS&DR programme or one of its preceding programmes as project number 12/5005/04. The contractual start date was in September 2013. The final report began editorial review in September 2016 and was accepted for publication in February 2017. The authors have been wholly responsible for all data collection, analysis and interpretation, and for writing up their work. The HS&DR editors and production house have tried to ensure the accuracy of the authors' report and would like to thank the reviewers for their constructive comments on the final report document. However, they do not accept liability for damages or losses arising from material published in this report.This report presents independent research funded by the National Institute for Health Research (NIHR). The views and opinions expressed by authors in this publication are those of the authors and do not necessarily reflect those of the NHS, the NIHR, NETSCC, the HS&DR programme or the Department of Health. If there are verbatim quotations included in this publication the views and opinions expressed by the interviewees are those of the interviewees and do not necessarily reflect those of the authors, those of the NHS, the NIHR, NETSCC, the HS&DR programme or the Department...

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Improving patient safety by identifying latent failures in successful operations

Cited by 225 publications

References 25 publications

Do Team Processes Really Have an Effect on Clinical Performance? A Systematic Literature Review

Do Team Processes Really Have an Effect on Clinical Performance? A Systematic Literature Review

Teamwork and patient safety in dynamic domains of healthcare: a review of the literature

A realist process evaluation of robot-assisted surgery: integration into routine practice and impacts on communication, collaboration and decision-making

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