My copilot is a nurse—Using crew resource management in the OR

Oncology residents' experiences of decision-making in a clinical learning environment: a phenomenological study

Oncology residents routinely engage in ethically complex decision-making discussions with patients, while observing and interacting with their teaching consultant. If clinical competency in oncology decision-making guidance is to be taught deliberately and effectively, it is necessary to understand resident experiences in this context to develop appropriate educational and faculty development initiatives. Four junior and two senior postgraduate oncology residents participated in semi-structured interviews during October and November 2021 which explored their experiences of real-world decision-making scenarios. Van Manen's phenomenology of practice was used in an interpretivist research paradigm. Transcripts were analysed to articulate essential experiential themes, and composite vocative narratives were created. Three essential themes were identified: (1) residents often endorsed different decision-making approaches than supervising consultants, (2) residents experienced inner conflict, and (3) residents struggled to find their own approach to decision-making. Residents experienced being torn between a perceived obligation to defer to consultant directives, and a desire for increasing ownership of decision-making while not feeling empowered to discuss their opinions with the consultants. Residents described their experiences around ethical position awareness during decision-making in a clinical teaching context as challenging, with experiences suggesting moral distress combined with inadequate psychological safety to address ethical conflicts and unresolved questions of decision ownership with supervisors. These results suggest the need for enhanced dialogue and more research to reduce resident distress during oncology decision-making. Future research should be aimed at discovering novel ways in which residents and consultants could interact in a unique clinical learning context including graduated autonomy, a hierarchical gradient, ethical positions, physician values, and sharing of responsibility.

Applying Crew Resource Management tools in Emergency Response Driving and patient transport-Finding consensus through a modified Delphi study

BACKGROUND

Emergency Response Driving (ERD) comprises a significant risk to safety in Emergency Medical Services (EMS). Crew Resource Management (CRM) tools play a major role in securing actions in high-risk procedures. The aim of this study was to find consensus on the important factors to consider when applying CRM tools in ERD and patient transport.

METHODS

ERD experts (n = 50) were recruited for a modified three-round Delphi study. Round 1 was based on previous research. The experts evaluated the items as important, neutral, or not important. The predetermined level of consensus was set at ≥ 80%. Answers given to the open-ended questions were analyzed using inductive content analysis.

RESULTS

Predetermined consensus was reached on 64 of 86 presented items (74.4 %). The mean values of items reaching consensus varied between 3.81 and 4.86 on a five-point Likert scale. The items where consensus was reached were rated as "important" on a trichotomized scale.

CONCLUSION

Multiple important factors to consider when applying CRM tools to ERD and patient transport were highlighted. This study provides valuable information to consider regarding EMS safety improvements. Further scientific research is needed to develop comprehensive recommendations.

Can a targeted educational approach improve situational awareness in paramedicine during 911 emergency calls?

BACKGROUND

Paramedics must be situationally aware in order to avoid human error and protect themselves, their partner, their patient, and the public. Previous research has suggested that paramedics lack situational awareness (SA), possibly due to a lack of an organized approach, distraction, and a poor understanding of SA. There is no educational approach provided to paramedics that is known to improve their levels of SA. If such an approach were provided, it could possibly reduce human error and lead to improved outcomes.

OBJECTIVE

The aim of this study is to determine whether providing paramedics with a targeted educational approach, including aspects from crew resource management (CRM) such as sterile cockpit and Endsley's model for SA, can improve overall SA during emergency calls.

METHODS

A prospective, quasi-experimental before-and-after study was used, in which out-of hospital paramedics were observed during 911 emergency calls. Baseline SA was measured using the situational awareness global assessment technique (SAGAT). Paramedics were then given a targeted educational lesson focusing on elements of SA and CRM as well as a novel quick reference tool to utilize during 911 calls. Post intervention SA was then measured again, and before-and-after results were compared for difference of mean scores.

RESULTS

The overall baseline SA was 62% increasing to 86% following the educational intervention. The Wilcoxon Ranked Sum was used to assess for statistically significant differences between mean SA performance in the same group of paramedics before and after the intervention. The increase in SA was found to be statistically significant where p = 0.011.

CONCLUSIONS

A targeted educational approach focusing on CRM and a novel quick reference tool may increase SA levels of paramedics during 911 emergency calls. Further studies are needed with bigger cohorts. Paramedicine educational institutions and out-of-hospital agencies should consider implementing this targeted approach with their students and currently practicing providers.

Learning from safety incidents in high-reliability organizations: a systematic review of learning tools that could be adapted and used in healthcare

OBJECTIVE

A high-reliability organization (HRO) is an organization that has sustained almost error-free performance, despite operating in hazardous conditions where the consequences of errors could be catastrophic. A number of tools and initiatives have been used within HROs to learn from safety incidents, some of which have the potential to be adapted and used in healthcare. We conducted a systematic review to identify any learning tools deemed to be effective that could be adapted and used by multidisciplinary teams in healthcare following a patient safety incident.

METHODS

This review followed the Preferred Reporting Items for Systematic Reviews and MetaAnalyses for Protocols reporting guidelines and was registered with the PROSPERO (CRD42017071528). A search of databases was carried out in January 2021, from the date of their commencement. We conducted a search on electronic databases such as Web of Science, Science Direct, MEDLINE in Process Jan 1950-present, EMBASE Jan 1974-present, CINAHL 1982-present, PsycINFO 1967-present, Scopus and Google Scholar. We also searched the grey literature including reports from government agencies, relevant doctoral dissertations and conference proceedings. A customized data extraction form was used to capture pertinent information from included studies and Critical Appraisal Skills Programme tool to appraise on their quality.

RESULTS

A total of 5921 articles were identified, with 964 duplicate articles removed and 4932 excluded at the title (4055), abstract (510) and full-text (367) stages. Twenty-five articles were included in the review. Learning tools identified included debriefing, simulation, crew resource management and reporting systems to disseminate safety messages. Debriefing involved deconstructing incidents using reflective questions, whilst simulation training involved asking staff to relive the event again by performing the task(s) in a role-play scenario. Crew resource management is a set of training procedures that focus on communication, leadership and decision-making. Sophisticated incident-reporting systems provide valuable information on hazards and were widely recommended as a way of disseminating key safety messages following safety incidents. These learning tools were found to have a positive impact on learning if conducted soon after the incident with efficient facilitation.

CONCLUSION

Healthcare organizations should find ways to adapt to the learning tools or initiatives used in HROs following safety incidents. It is challenging to recommend any specific one as all learning tools have shown considerable promise. However, the way these tools or initiatives are implemented is critical, and so further work is needed to explore how to successfully embed them into healthcare organizations so that everyone at every level of the organization embraces them.

The Collective Leadership for Safety Culture (Co-Lead) Team Intervention to Promote Teamwork and Patient Safety

Traditional hierarchical leadership has been implicated in patient safety failings internationally. Given that healthcare is almost wholly delivered by multidisciplinary teams, there have been calls for a more collective and team-based approach to the sharing of leadership and responsibility for patient safety. Although encouraging a collective approach to accountability can improve the provision of high quality and safe care, there is a lack of knowledge of how to train teams to adopt collective leadership. The Collective Leadership for Safety Cultures (Co-Lead) programme is a co-designed intervention for multidisciplinary healthcare teams. It is an open-source resource that offers teams a systematic approach to the development of collective leadership behaviours to promote effective teamworking and enhance patient safety cultures. This paper provides an overview of the co-design, pilot testing, and refining of this novel intervention prior to its implementation and discusses key early findings from the evaluation. The Co-Lead intervention is grounded in the real-world experiences and identified needs and priorities of frontline healthcare staff and management and was co-designed based on the evidence for collective leadership and teamwork in healthcare. It has proven feasible to implement and effective in supporting teams to lead collectively to enhance safety culture. This intervention overview will be of value to healthcare teams and practitioners seeking to promote safety culture and effective teamworking by supporting teams to lead collectively.

Impact of the communication and patient hand-off tool SBAR on patient safety: a systematic review

OBJECTIVES

Communication breakdown is one of the main causes of adverse events in clinical routine, particularly in handover situations. The communication tool SBAR (situation, background, assessment and recommendation) was developed to increase handover quality and is widely assumed to increase patient safety. The objective of this review is to summarise the impact of the implementation of SBAR on patient safety.

DESIGN

A systematic review of articles published on SBAR was performed in PUBMED, EMBASE, CINAHL, Cochrane Library and PsycINFO in January 2017. All original research articles on SBAR fulfilling the following eligibility criteria were included: (1) SBAR was implemented into clinical routine, (2) the investigation of SBAR was the primary objective and (3) at least one patient outcome was reported.

SETTING

A wide range of settings within primary and secondary care and nursing homes.

PARTICIPANTS

A variety of heath professionals including nurses and physicians.

PRIMARY AND SECONDARY OUTCOME MEASURES

Aspects of patient safety (patient outcomes) defined as the occurrence or incidence of adverse events.

RESULTS

Eight studies with a before-after design and three controlled clinical trials performed in different clinical settings met the inclusion criteria. The objectives of the studies were to improve team communication, patient hand-offs and communication in telephone calls from nurses to physicians. The studies were heterogeneous with regard to study characteristics, especially patient outcomes. In total, 26 different patient outcomes were measured, of which eight were reported to be significantly improved. Eleven were described as improved but no further statistical tests were reported, and six outcomes did not change significantly. Only one study reported a descriptive reduction in patient outcomes.

CONCLUSIONS

This review found moderate evidence for improved patient safety through SBAR implementation, especially when used to structure communication over the phone. However, there is a lack of high-quality research on this widely used communication tool.

TRIAL REGISTRATION

none.

A qualitative investigation of healthcare workers' strategies in response to readmissions

BACKGROUND

Readmission of a patient to a hospital is typically associated with significant clinical changes in the patient's condition, but it is unknown how healthcare workers modify their provision of care when considering these changes. The purpose of the present study was to determine how healthcare workers shift their care strategies when treating readmitted patients.

METHODS

A typical case sampling study of healthcare workers was conducted using the grounded theory approach. The study setting comprised several patient care units at an academic center and tertiary-care hospital. We purposively sampled 34 healthcare workers (19 women, 15 men) to participate in individual interviews, either face-to-face or by telephone. We asked the participants semi structured questions regarding their thoughts on readmissions and how they altered their process and behavior for readmitted patients. Interviews were audio-recorded and transcribed. We used a qualitative data analyses based on an inductive approach to generate themes about how healthcare workers shift their strategies for readmitted patients.

RESULTS

Healthcare workers' shifts in strategy for readmissions were reflected in three major themes: clinical assessment, use and management of information, and communication patterns. Participants reported that they became more conservative in their assessment of the clinical condition of a readmitted patient. The participants also indicated that readmitted patients would be treated in a similar way to normal admission based on care requirements; however, somewhat paradoxically, they also expressed that having access to prior patient information changed the way they treated a readmitted patient.

CONCLUSIONS

Although healthcare workers may exhibit a tendency to become more conservative with readmissions, readily available patient information from the previous admission played a large part in guiding their thinking. A more conservative approach with a readmitted patient, on its own, does not necessarily lead to improved documentation or better patient care.

Interprofessional education in team communication: working together to improve patient safety

BACKGROUND

Communication failures in healthcare teams are associated with medical errors and negative health outcomes. These findings have increased emphasis on training future health professionals to work effectively within teams. The Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) communication training model, widely employed to train healthcare teams, has been less commonly used to train student interprofessional teams. The present study reports the effectiveness of a simulation-based interprofessional TeamSTEPPS training in impacting student attitudes, knowledge and skills around interprofessional communication.

METHODS

Three hundred and six fourth-year medical, third-year nursing, second-year pharmacy and second-year physician assistant students took part in a 4 h training that included a 1 h TeamSTEPPS didactic session and three 1 h team simulation and feedback sessions. Students worked in groups balanced by a professional programme in a self-selected focal area (adult acute, paediatric, obstetrics). Preassessments and postassessments were used for examining attitudes, beliefs and reported opportunities to observe or participate in team communication behaviours.

RESULTS

One hundred and forty-nine students (48.7%) completed the preassessments and postassessments. Significant differences were found for attitudes toward team communication (p<0.001), motivation (p<0.001), utility of training (p<0.001) and self-efficacy (p=0.005). Significant attitudinal shifts for TeamSTEPPS skills included, team structure (p=0.002), situation monitoring (p<0.001), mutual support (p=0.003) and communication (p=0.002). Significant shifts were reported for knowledge of TeamSTEPPS (p<0.001), advocating for patients (p<0.001) and communicating in interprofessional teams (p<0.001).

CONCLUSIONS

Effective team communication is important in patient safety. We demonstrate positive attitudinal and knowledge effects in a large-scale interprofessional TeamSTEPPS-based training involving four student professions.

Evaluation of aviation-based safety team training in a hospital in The Netherlands

PURPOSE

The purpose of this paper is to evaluate the implementation of a broad-scale team resource management (TRM) program on safety culture in a Dutch eye hospital, detailing the program's content and procedures. Aviation-based TRM training is recognized as a useful approach to increase patient safety, but little is known about how it affects safety culture.

DESIGN/METHODOLOGY/APPROACH

Pre- and post-assessments of the hospitals' safety culture was based on interviews with ophthalmologists, anesthesiologists, residents, nurses, and support staff. Interim observations were made at training sessions and in daily hospital practice.

FINDINGS

The program consisted of safety audits of processes and (team) activities, interactive classroom training sessions by aviation experts, a flight simulator session, and video recording of team activities with subsequent feedback. Medical professionals considered aviation experts inspiring role models and respected their non-hierarchical external perspective and focus on medical-technical issues. The post-assessment showed that ophthalmologists and other hospital staff had become increasingly aware of safety issues. The multidisciplinary approach promoted social (team) orientation that replaced the former functionally-oriented culture. The number of reported near-incidents greatly increased; the number of wrong-side surgeries stabilized to a minimum after an initial substantial reduction.

RESEARCH LIMITATIONS/IMPLICATIONS

The study was observational and the hospital's variety of efforts to improve safety culture prevented us from establishing a causal relation between improvement and any one specific intervention.

ORIGINALITY/VALUE

Aviation-based TRM training can be a useful to stimulate safety culture in hospitals. Safety and quality improvements are not single treatment interventions but complex socio-technical interventions. A multidisciplinary system approach and focus on "team" instead of "profession" seems both necessary and difficult in hospital care.

Exploring intensive care nurses' team performance in a simulation-based emergency situation, - expert raters' assessments versus self-assessments: an explorative study

BACKGROUND

Effective teamwork has proven to be crucial for providing safe care. The performance of emergencies in general and cardiac arrest situations in particular, has been criticized for primarily focusing on the individual's technical skills and too little on the teams' performance of non-technical skills. The aim of the study was to explore intensive care nurses' team performance in a simulation-based emergency situation by using expert raters' assessments and nurses' self-assessments in relation to different intensive care specialties.

METHODS

The study used an explorative design based on laboratory high-fidelity simulation. Fifty-three registered nurses, who were allocated into 11 teams representing two intensive care specialties, participated in a videotaped simulation-based cardiac arrest setting. The expert raters used the Ottawa Crisis Resource Management Global Rating Scale and the first part of the Mayo High Performance Teamwork Scale to assess the teams' performance. The registered nurses used the first part of the Mayo High Performance Teamwork Scale for their self-assessments, and the analyses used were Chi-square tests, Mann-Whitney U tests, Spearman's rho and Intraclass Correlation Coefficient Type III.

RESULTS

The expert raters assessed the teams' performance as either advanced novice or competent, with significant differences being found between the teams from different specialties. Significant differences were found between the expert raters' assessments and the registered nurses' self-assessments.

CONCLUSIONS

Teams of registered nurses representing specialties with coronary patients exhibit a higher competence in non-technical skills compared to team performance regarding a simulated cardiac arrest. The use of expert raters' assessments and registered nurses' self-assessments are useful in raising awareness of team performance with regard to patient safety.

Surgical team composition differs between laparoscopic and open procedures

BACKGROUND

Performing laparoscopic procedures requires different skill sets and team dynamics compared with open procedures. We evaluated team composition and procedure time between these two surgical approaches using data collected from hospitals in the United State and Canada.

METHODS

A total of 1,260 general surgical cases were reviewed retrospectively, recording the number of operation personnel, procedure complexity, and the procedure time.

RESULTS

Laparoscopic procedures (n = 930), on average, had a higher procedure difficulty coding which led to a longer procedure time and involved more people in the surgical team than open procedures (n = 330). When we selected cases with matched procedure difficulty coding, laparoscopic procedures (n = 450) still required longer procedure times and involved more operative personnel than open procedures (n = 92).

DISCUSSION

Increased laparoscopic team size and procedure time must be influenced by factors other than case difficulty. The factors may derive from inherent complexity of the surgical setting and team dynamics unique to laparoscopic procedures.

Intensive care nurses' perceptions of simulation-based team training for building patient safety in intensive care: a descriptive qualitative study

OBJECTIVES

To describe intensive care nurses' perceptions of simulation-based team training for building patient safety in intensive care.

BACKGROUND

Failures in team processes are found to be contributory factors to incidents in an intensive care environment. Simulation-based training is recommended as a method to make health-care personnel aware of the importance of team working and to improve their competencies.

DESIGN

The study uses a qualitative descriptive design.

METHODS

Individual qualitative interviews were conducted with 18 intensive care nurses from May to December 2009, all of which had attended a simulation-based team training programme. The interviews were analysed by qualitative content analysis.

RESULTS

One main category emerged to illuminate the intensive care nurse perception: "training increases awareness of clinical practice and acknowledges the importance of structured work in teams". Three generic categories were found: "realistic training contributes to safe care", "reflection and openness motivates learning" and "finding a common understanding of team performance".

CONCLUSIONS

Simulation-based team training makes intensive care nurses more prepared to care for severely ill patients. Team training creates a common understanding of how to work in teams with regard to patient safety.

Current assessment of patient safety education

The purpose of this literature review was to examine current evidence on how student nurses and nursing faculty members perceived the integration of patient safety education in preregistration/undergraduate nursing training. Databases searched from January 2000 to April 2011 included CINAHL, PsycINFO, British Nursing Index, PubMed, AMED, Academic Science, Midline, Cochrane Library Database, Web of Knowledge, Ovid Nursing Database, Wiley Online Library and Science Direct. In total, 77 articles were initially found, although only 15 were included in the author's review. Of these, 5 papers were research-based articles that examined aspects of patient safety education in undergraduate/pre-registration nursing training, and 9 papers were literature review and discussion based, which provided insight into the experience, assessment, evaluation or implementation of patient safety education curriculum in nursing education. The author's literature review highlights the continuing lack of research on patient safety education in undergraduate/preregistration nursing training and, in particular, outlines areas in nursing education which need to be addressed to develop patient-safety-friendly nursing curricula.

Investigating the safety of medication administration in adult critical care settings

BACKGROUND

Medication errors are recognized causes of patient morbidity and mortality in hospital settings, and can occur at any stage of the medication management process. Medication administration errors are reported to occur more frequently in critical care settings, and can be associated with severe consequences. However, patient safety research tends to focus on accident causations rather than organizational factors which enhance patient safety and health care resilience to unsafe practice. The Organizational Safety Space Model was developed for high-risk industries to investigate factors that influence organizational safety. Its application in health care settings may offer a unique approach to understand organizational safety in the health care context, particularly in investigating the safety of medication administration in adult critical care settings.

PURPOSE

This literature review explores the development and use of the Organizational Safety Space Model in the industrial context, and considers its application in investigating the safety of medication administration in adult critical care settings. SEARCH STRATEGIES (INCLUSION AND EXCLUSION CRITERIA): CINAHL, Medline, British Nursing Index (BNI) and PsychInfo databases were searched for peer-reviewed papers, published in English, from 1970 to 2011 with relevance to organizational safety and medication administration in critical care, using the key words: organization, safety, nurse, critical care and medication administration. Archaeological searching, including grey literature and governmental documents, was also carried out. From the identified 766 articles, 51 studies were considered relevant.

CONCLUSION

The Organizational Safety Space Model offers a productive, conceptual system framework to critically analyse the wider organizational issues, which may influence the safety of medication administration and organizational resilience to accidents. However, the model needs to be evaluated for its application in health care settings in general and critical care in particular. Nurses would offer a valuable insight in explaining how the Organizational Safety Space Model can be used to analyse the organizational contributions towards medication administration in adult critical care settings.

Characterizing the structure of operating room staffing using social network analysis

BACKGROUND

: Very little research has been focused on the interdisciplinary staffing characteristics of the operating room team, an essential component of providing safe patient care in a high-risk setting.

OBJECTIVES

: The aim of this study was to determine how the operating room staffing of two surgical specialties compares in terms of social network variables.

METHODS

: Staffing data from all general and neurosurgical procedures performed at a large Midwestern hospital were analyzed using Social Network Analysis methods. Network variables include centrality, team coreness, and the core/periphery network structure. Multidimensional scaling, correlation, and descriptive statistics were used for the analysis.

RESULTS

: The core/periphery network structure was characteristic of both surgical services. Team coreness, a measure of how often the team worked together, was associated with the length of the case (p < .001). Procedure start time predicts the team coreness measure, with cases starting later in the day less likely to be staffed with a high core team (p < .001). Registered nurses constitute the majority of core interdisciplinary team members in both groups.

DISCUSSION

: Analysis of the core/periphery structure of specialty team staffing networks indicates that many procedures are staffed with individuals who are associated peripherally with the specialty. Registered nurses as core group members are in a position to take a leadership role in the communication of norms and process variations to noncore members. The effect of having late starting cases staffed with a lower core team should be studied further because it pertains to patient outcomes. Future work should strive to account for the complex and dynamic nature of team development.

Review article: Crisis resource management in emergency medicine

Effective team management is a core element of expert practice in emergency medicine. Thus far, training in emergency medicine has focussed predominantly on proficiency in medical and technical skills, with emergency physicians acquiring these 'non-technical' skills in an ad hoc manner or by trial and error with varying levels of success. This paper describes a set of behaviours that, when practised in conjunction with medical and technical expertise, can reduce the incidence of clinical error and contribute to effective teamwork and the smooth running of an ED. Teaching and practice of these behaviours is now a core element of training and skills maintenance in other high-risk areas, such as aviation, and is becoming part of the routine training for anaesthetists. They address areas, such as communication, leadership, knowledge of environment, anticipation and planning, obtaining timely assistance, attention allocation and workload distribution. We outline the application of these behaviours in the speciality of emergency medicine, and suggest that the teaching and practice of crisis resource management principles should become part of the curriculum for training and credentialing of emergency medicine specialists.

Physician communication in the operating room: expanding application of face-negotiation theory to the health communication context

Communication variables that are associated with face-negotiation theory were examined in a sample of operating-room physicians. A survey was administered to anesthesiologists and surgeons at a teaching hospital in the southwestern United States to measure three variables commonly associated with face-negotiation theory: conflict-management style, face concern, and self-construal. The survey instrument that was administered to physicians includes items that measured these three variables in previous face-negotiation research with slight modification of item wording for relevance in the medical setting. The physician data were analyzed using confirmatory factor analysis, Pearson's correlations, and t-tests. Results of this initial investigation showed that variables associated with face-negotiation theory were evident in the sample physician population. In addition, the correlations were similar among variables in the medical sample as those found in previous face-negotiation research. Finally, t-tests suggest variance between anesthesiologists and surgeons on specific communication variables. These findings suggest three implications that warrant further investigation with expanded sample size: (1) An intercultural communication theory and instrument can be utilized for health communication research; (2) as applied in a medical context, face-negotiation theory can be expanded beyond traditional intercultural communication boundaries; and (3) theoretically based communication structures applied in a medical context could help explain physician miscommunication in the operating room to assist future design of communication training programs for operating-room physicians.

Diffusing aviation innovations in a hospital in The Netherlands

BACKGROUND

Many authors have advocated the diffusion of innovations from other high-risk industries into health care to improve safety. The aviation industry is comparable to health care because of its similarities in (a) the use of technology, (b) the requirement of highly specialized professional teams, and (c) the existence of risk and uncertainties. For almost 20 years, The Rotterdam Eye Hospital (Rotterdam, the Netherlands) has been engaged in diffusing several innovations adapted from aviation.

METHODS

A case-study methodology was used to assess the application of innovations in the hospital, with a focus on the context and the detailed mechanism for each innovation. Data on hospital performance outcomes were abstracted from the hospital information data management system, quality and safety reports, and the incident reporting system. Information on the innovations was obtained from a document search; observations; and semistructured, face-to-face interviews.

INNOVATIONS

Aviation industry-based innovations diffused into patient care processes were as follows: patient planning and booking system, taxi service/valet parking, risk analysis (as applied to wrong-site surgery), time-out procedure (also for wrong-site surgery), Crew Resource Management training, and black box. Observations indicated that the innovations had a positive effect on quality and safety in the hospital: Waiting times were reduced, work processes became more standardized, the number of wrong-site surgeries decreased, and awareness of patient safety was heightened.

CONCLUSION

A near-20-year experience with aviation-based innovation suggests that hospitals start with relatively simple innovations and use a systematic approach toward the goal of improving safety.

Examining communication and team performance during clinical handover in a complex environment: the private sector post-anaesthetic care unit

Threats to patient safety during clinical handover have been identified as an ongoing problem in health care delivery. In complex handover situations, organisational, cultural, behavioural and environmental factors associated with team performance can affect patient safety by undermining the stability of team functioning and the effectiveness of interprofessional communication. We present a practical framework for promoting systematic, comprehensive measurement of the factors involved in clinical handover. The framework can be used to develop viable solutions to the problems of clinical handover. The framework was devised and used in a recent project examining interprofessional communication and team performance during clinical handover in post-anaesthetic care units. The framework combines five key concepts: clinical governance, clinician engagement, ecological validity, safety culture and team climate, and sustainability. We believe that use of this framework will help overcome the limitations of previous research that has not taken into account the complex and multifaceted influences on clinical handover and interprofessional communication.

Medication administration process assessment: applying lessons learned from commercial aviation

Medication administration is a major safety issue for patients and providers. The authors describe a commercial aviation-based system safety assessment conducted on the medication administration process for a community teaching hospital in the northeast United States. Processes on 2 medical units and 1 surgical unit were assessed. A sampling of qualitative outcomes is presented in a risk prioritization framework, along with practical recommendations predicated on the valuable lessons learned in commercial aviation.

Primer on risk management for the gynaecological laparoscopist

The gynaecologist practising operative laparoscopy should be seen as part of a team that actively promotes patient safety, minimizing risks and optimizing outcomes. Building a culture of safety which focuses on proactive initiatives to manage risk and remove individual 'blame' should be an integral part of any operative laparoscopy unit. Thus, when adverse clinical incidents or outcomes occur, reporting of such events is encouraged and seen to be acceptable behaviour within the framework of complete patient care. By recognizing and analysing adverse outcomes, the team can develop strategies to prevent or manage a recurrence of such events. Implementing systems or solutions to prevent harm to patients is the cornerstone of any risk management programme. In this review, we discuss the development and implementation of risk management strategies in the clinical setting, and in particular how this applies to operative laparoscopy.