A study of error reporting by nurses: the significant impact of nursing team dynamics.

Background: Error reporting is crucial for organisational learning and improving patient safety in hospitals, yet errors are significantly underreported. Aims: The aim of this study was to understand how the nursing team dynamics of leader inclusiveness, safety climate and psychological safety affected the willingness of hospital nurses to report errors. Methods: The study was a cross-sectional design. Self-administered surveys were used to collect data from nurses and nurse managers. Data were analysed using linear mixed models. Bootstrap confidence intervals with bias correction were used for mediation analysis. Results: Leader inclusiveness, safety climate and psychological safety significantly affected willingness to report errors. Psychological safety mediated the relationship between safety climate and error reporting as well as the relationship between leader inclusiveness and error reporting. Conclusion: The findings of the study emphasise the importance of nursing team dynamics to error reporting and suggest that psychological safety is especially important to error reporting.

Improved Teamwork and Implementation of Clinical Pathways in a Congenital Heart Surgery Program.

INTRODUCTION: Complex surgical populations are at increased risk of morbidity, especially when experiencing variations in care and poor teamwork. The goal of this project was to improve teamwork and decrease variations in care in a pediatric congenital heart surgery population by implementing Integrated Clinical Pathways (ICPs) on a foundation of teamwork training. METHODS: A core team used project management for completion of the project and measurement of success. The leadership team created a new operations infrastructure for the program to effectively implement and sustain improvement. Master trainers targeting teams caring for the patient population completed teamwork training and coaching. ICPs were designed and implemented using iterative tests of change with the assistance of an expert panel. RESULTS: Three of the 4 units experienced a significant improvement in teamwork after training and coaching. The area without a significant change was one with high-level teamwork training already in place. ICPs were implemented in 2 patient subpopulations. We detected a decrease in total hours intubated using statistical process control charts in both of the ICP patient populations. Despite a decrease in intubation hours, we did not detect a reduction in length of stay in days. The infrastructure for the program was successfully implemented and remains in place 6 years later. CONCLUSIONS: Teamwork can be improved with an efficiently delivered training and coaching program. On a foundation of teamwork, ICPs can be implemented and sustained if a supporting infrastructure is in place including program leadership, buy-in from all teams, project management, and ongoing measurement.

Partnering With a Family Advisor to Improve Communication in a Pediatric Intensive Care Unit.

Inadequate communication between medical teams and families can lead to errors and poor-quality care. The objective was to understand why communication between the clinical team and families was not occurring consistently in the pediatric intensive care unit and improve the system using a multidisciplinary improvement team including a family advisor. This improvement project used Lean Six Sigma. The team observed updates and collected documented communication, survey, interview, and focus group data from families and staff. Root causes of failures included lack of assigned responsibility, lack of defined daily update, and lack of a daily communication standard. Process changes were implemented, resulting in an increased mean documented communication rate from 13% pre intervention to 65% post intervention that was sustained for more than 2 years (P < .001). Including a family advisor as an equal member of an improvement team provides family empowerment and a greater chance of success in complex areas.

Strict hand hygiene and other practices shortened stays and cut costs and mortality in a pediatric intensive care unit.

Efforts to reduce infections acquired during a hospital stay through improvements in the quality of care have had measurable results in many hospital settings. In pediatric intensive care units, the right quality interventions can save lives and money. We found that improving practices of hand hygiene, oral care, and central-line catheter care reduced hospital-acquired infections and improved mortality rates among children admitted to a large pediatric intensive care unit in 2007-09. In addition, on average patients admitted after the quality interventions were fully implemented spent 2.3 fewer days in the hospital, their hospitalization cost $12,136 less, and mortality was 2.3 percentage points lower, compared to patients admitted before the interventions. The projected annual cost savings for the single pediatric intensive care unit studied was approximately $12 million. Given the modest expenses incurred for these improvements-which mainly consisted of posters for an educational campaign, a training "fair," roughly $21 per day for oral care kits, about $0.60 per day for chlorhexidine antiseptic patches, and hand sanitizers attached to the walls outside patients' rooms-this represents a significant return on investment. Used on a larger scale, these quality improvements could save lives and reduce costs for patients, hospitals, and payers around the country, provided that sustained efforts ensure compliance with new protocols and achieve long-lasting changes.

Evaluating efforts to optimize TeamSTEPPS implementation in surgical and pediatric intensive care units.

BACKGROUND: An evidence-based teamwork system, Team-STEPPS, was implemented in an academic medical center's pediatric and surgical ICUs. METHODS: A multidisciplinary change team of unit- and department-based leaders was formed to champion the initiative; develop a customized action plan for implementation; train frontline staff; and identify process, team outcome, and clinical outcome objectives for the intervention. The evaluation consisted of interviews with key staff, teamwork observations, staff surveys, and clinical outcome data. RESULTS: All PICU, SICU, and respiratory therapy staff received TeamSTEPPS training. Staff reported improved experience of teamwork posttraining and evaluated the implementation as effective. Observed team performance significantly improved for all core areas of competency at 1 month postimplementation and remained significantly improved for most of the core areas of competency at 6 and 12 months postimplementation. Survey data indicated improvements in staff perceptions of teamwork and communication openness in both units. From pre- to posttraining, the average time for placing patients on extracorporeal membrane oxygenation (ECMO) decreased significantly. The average duration of adult surgery rapid response team events was 33% longer at postimplementation versus pre-implementation. The rate of nosocomial infections at postimplementation was below the upper control limit for seven out of eight months in both the PICU and the SICU. CONCLUSIONS: The implementation of a customized 2.5-hour version of the TeamSTEPPS training program in two areas--the PICU and SICU--that had demonstrated successful ability to innovate suggests that the training was successful.

Family alert: implementing direct family activation of a pediatric rapid response team.

A hospital's "no false alams" policy has been validated by staff's and families' appropriate activation of the rapid response team.

Implementing a pediatric rapid response system to improve quality and patient safety.

Life-threatening events are common in today's hospitals, where an increasing proportion of patients with urgent admission are cared for by understaffed, often inexperienced personnel. Medical errors play a key role in causing adverse events and failure to rescue deteriorating patients. In-hospital cardiac arrest outcomes are generally poor, but these events are often preceded by a pattern of deterioration with abnormal vital signs and mental status. When hospital staff or family members observe warning signs and trigger timely intervention by a rapid response team, rates of cardiac arrest and mortality can be reduced. Rapid response team involvement can be used to trigger careful review of preceding events to help uncover important systems issues and allow for further improvements in patient safety.