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a) The ability to rehearse procedures together, like a choir or a sports team.
b) Stable membership; that is, they have the same people on the team from day-to-day.
c) Effective two-way communication (effective communication techniques)
d) The ability to achieve good results without strong communication.
a) Less costly health care
b) More effective handoffs
c) Fewer delays in care
d) Elimination of waste in the system
a) Less costly health care
b) Safer care
c) Fewer delays in care
d) Elimination of waste in the system
a) Not a single complaint about unprofessional behavior has been filed by clinic members over the past year.
b) The providers work in rotating shifts and rarely need to transmit information from one shift to the next.
c) The team routinely takes a moment to discuss the plan and voice concerns before doing a procedure.
d) All of the above.
a) Effective teams reduce the risk of errors by providing a “safety net” for individual caregivers.
b) Effective teams limit the number of caregivers patients have to speak with, reducing confusion among patients and families.
c) Teams rely less on technology and more on human capabilities, thus leading to better care.
d) All of the above
When considering your role within a health care team, it is important to keep in mind that:
a) No matter what profession you belong to, you will be a member of the team and must work intentionally toward making that team effective.
b) You may be part of a team, but will likely be able to work autonomously without much input or help from others.
c) Teamwork skills will come naturally to you, because we all learn them in other settings.
d) You will need to be a good team member until you become an expert in your field, at which point you probably won’t need teamwork skills
Effective team leaders:
(A) Have multiple degrees.
(B) Are usually physicians.
(C) Seek input from all members of the team.
(D) Know the correct answer in any given situation.
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You are a pharmacy student, and this month you are doing a clinical rotation in a pharmacy located just outside of town. This is a very different experience from working in a hospital pharmacy, and you are enjoying the time immensely. However, you notice that your preceptor (instructor), whom you respect and who has been practicing and teaching for many years, has been losing his train of thought unusually often when talking with patients. And while filling a prescription recently, he grabbed the wrong strength of pills — and then he barked at the pharmacy technician who corrected him. As he begins to fill another order this morning, you see that once again, he seems to be using the wrong pills.
Which of the following is a factor that might make it difficult for you to say something to this pharmacist?
(A) You’re just a student, and health care is hierarchical by design.
(B) The pharmacist got annoyed when someone corrected him earlier.
(C) You do not have time to say anything today.
(D) A and B
Why should you tell the pharmacist about your concern?
(A) So that the pharmacist will think well of you when completing your evaluation at the end of the rotation
(B) So that you can make your knowledge and eye for details apparent
(C) So that the patient does not experience an adverse event
(D) So that the pharmacist gets some extra training
You decide to speak with the pharmacist while he is filling the order. What would be the most appropriate thing to say?
(A) “Did you check the bottle from which you’re dispensing that medication?”
(B) “I am concerned there is a safety issue here.”
(C) “What are you doing? Can I help?”
(D) “Stop filling that prescription right now or I will be forced to call the manager.”
After you speak up, which of the following responses by the pharmacist would best indicate that this pharmacy has a culture of safety?
(A) “Thanks! I’ll tell your supervisor that you helped me today.”
(B) “If you know what’s good for you, you won’t tell anyone about this.”
(C) “Thanks! But in the future, please correct me in private, when others aren’t around.”
(D) “Thanks! I appreciate that. But don’t ever say something like that to the other pharmacist here. He’s got quite a temper.”
What is a culture of safety?
(A) A place where errors never happen
(B) A place where errors are always caught
(C) A place where all staff can talk freely about safety problems without fear
(D) A place where all staff feel comfortable reporting errors only if they’re guaranteed anonymity
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What is SBAR?
(A) A system for delivering information
(B) A system for identifying areas for improvement
(C) A system for confirming receipt of information
(D) A system for assessing patient values
Linda, a pharmacist at an outpatient pharmacy for a medium-sized medical group, receives a call from John, a nurse practitioner in the cardiology clinic. John tells Linda he needs to call in a new prescription for hydrochlorothiazide at 50 mg once a day for Ms. Krane. At the end of the conversation Linda says to John, “Okay, so you want Ms. Joanne Krane to have a new prescription for hydrochlorothiazide at 50 mg by mouth once a day. Thirty pills and six refills.”
What has Linda just done?
(A) Increased the likelihood of error by repeating an order
(B) Provided a read back
(C) Used SBAR in communication
(D) B and C
You are a member of an intensive care unit team in a regional hospital. This morning, a patient had an unexpected severe allergic reaction (anaphylaxis) after being given a penicillin derivative. There was a significant delay in getting the physician involved and beginning treatment for this life-threatening condition. Fortunately, the patient is now stable and does not seem to be experiencing any lasting effects.
At this point, what would an effective team leader do?
(A) Report this adverse event in the anonymous reporting system so that it can be investigated
(B) Ask administrators to launch an investigation immediately to find out who was responsible for this adverse event
(C) Add this medication to the patient’s allergy list
(D) Conduct a debriefing
You are a member of an intensive care unit team in a regional hospital. This morning, a patient had an unexpected severe allergic reaction (anaphylaxis) after being given a penicillin derivative. There was a significant delay in getting the physician involved and beginning treatment for this life-threatening condition. Fortunately, the patient is now stable and does not seem to be experiencing any lasting effects.
The unit leaders are trying to figure out what changes they should make to prevent this treatment delay from happening again. Given what you know about the incident, what change would you recommend?
(A) Implement mandatory debriefings after the team works together on a patient.
(B) Fire the physician who failed to respond in a timely way.
(C) Stop using nursing assistants in the ICU.
(D) Implement the use of critical language in the ICU.
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On the unit where you work, nurses “sign out” at the end of a shift by tape recording their change of shift reports. The nurses who are starting their shifts then listen to the reports after the other nurses have left. (Not on my IHI)
Which of the following is a possible negative consequence of this type of patient handoff?
a) Information may be confusing because it is transmitted verbally.
b) Information may be miscommunicated because there is no opportunity to ask questions.
c) Information may be miscommunicated because the nurse who records the report does not use a checklist.
d) There is no possible negative consequence; this is an excellent handoff technique.
When you arrived at the unit today and listened to the change of shift report, you heard about a patient named Jane W. According to the tape-recorded signout, Jane “is a 57-year-old woman with abdominal pain and vomiting. She has pain medications ordered p.r.n. [as needed].” During your shift, Jane does not request pain medications. Near the end of your shift, however, you get a call from Jane’s daughter. Distraught, she asks why nobody is treating her mother’s pain. When you explain that Jane has not requested any pain medications, her daughter exclaims, “But she’s had a stroke! She can’t use the call light! What kind of place are you running over there?”
How might the handoff have contributed to this situation?
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a) The handoff was too brief and failed to include important information.
b) The handoff was hard to understand.
c) You weren’t paying close attention to the information you were being given.
d) You had no opportunity for verbal repeat back.
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a) In a hallway, where others can quickly find you if they have questions.
b) In the cafeteria, where you can both grab something to eat between shifts.
c) In a back room, where you are not likely to be easily interrupted.
d) Over the phone, so you can both be wherever is most convenient.
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a) Between physicians
b) Between a doctor and a nurse
c) Between two health care organizations
d) All of the above
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a) The sender gives a great deal of detailed information to the receiver, making sure not to leave anything out.
b) The receiver responds to all information, even if it is only with an “okay” or “uh-huh,” to acknowledge that he has heard the sender.
c) The receiver repeats to the sender what he has heard.
d) None of the above is essential.
On a particular busy night in the emergency department, a patient comes in with chest pain. The triage nurse, who has been on the job only two days, follows protocol and brings the patient in immediately. An electrocardiogram is done within five minutes and shows a possible heart attack. The cardiologist is called immediately, and 25 minutes after arriving in the emergency department, the patient is in the cardiac catheterization lab.
The efficient care in this case is an example of:
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a) Commitment to quality by a fabulous triage nurse.
b) The excellence that’s only possible at an academic medical center.
c) The benefits of having a clear plan for emergencies.
d) The need to publically report patient outcomes.
On a particularly busy night in the emergency department, a patient comes in with chest pain. The triage nurse, who’s been on the job only two days, takes the patient’s information, fills out the form, and puts the patient’s chart on the rack so he’ll be seen in the order in which he arrived. She mentions to a passing nurse, “There’s a patient here who has pain – he’s waiting to be seen.” Thirty minutes later, still waiting to be seen, the patient collapses in the waiting room.
What likely contributed to this outcome?
a) The lack of a shared plan for patients with chest pain resulted in a failure to act quickly.
b) The high patient volume caused a long delay in caring for a patient with a critical condition.
c) A new nurse was placed in triage, which was not safe.
d) No clear standard of care exists for chest pain patients, so the nurse couldn’t have known what to do.
a) Prevent patient emergencies such as a reaction to a new drug.
b) Allow an institution to better respond to unsafe behavior by employees.
c) Save money.
d) Diffuse responsibility for sharing information among multiple caregivers.
a) Tell team members exactly what to do.
b) Specify who is responsible for carrying out each part of the plan.
c) Provide a comprehensive evaluation of likely patient outcomes.
d) Are not needed for experienced teams.
a) Must be initiated by the team leader.
b) Includes SBAR, briefings, and debriefings.
c) Is more important for nurses than for physicians.
d) Includes email, text messaging, and debriefings.
a) The team will be able to accomplish its work with fewer people.
b) Crucial patient information will be lost.
c) There will be fewer lawsuits.
d) The team will be more adaptable to change.
Effective communication techniques.
Effective health care teams have a shared goal and effective two-way communication. The membership of the team may change frequently (Answer B), and it’s quite possible for a health care team to consist of people who have never worked together before (Answer A). That makes strong, two-way communication a critical part of delivering safe care.
Safer care
The best answer is that care will be safer. For example, according to The Joint Commission, an estimated 80 percent of serious medical errors can be linked to miscommunication between caregivers when patients are transferred or “handed-over.” One of the hallmarks of effective health care teams is frequent, two-way communication — a characteristic that would likely have an immediate and positive effect on care transitions and safety. While better teamwork can lead to fewer delays, elimination of waste, and even less costly care, these results would likely be secondary to an increase in safety.
The team routinely takes a moment to discuss the plan and voice concerns before doing a procedure.
One of the main characteristics of strong health care teams is effective and frequent communication. The absence of unprofessional behavior (Answer A) does not necessarily mean the team is effective. And the failure to share information during shift changes is risky for patients (Answer B).
Effective teams reduce the risk of errors by providing a “safety net” for individual caregivers.
Effective teams — teams whose members communicate often and reciprocally — act as a kind of “safety net” that can help prevent errors resulting from one member’s fatigue or distraction, for instance. Effective teams may still use technology often, and it’s likely that patients and families will encounter many members of the team.
No matter what profession you belong to, you will be a member of the team and must work intentionally toward making that team effective.
If you’re entering any field in which you’ll be caring for patients, it’s a certainty that you will be a member of a team; in fact, you may be a member of multiple teams. As such, you’ll have the responsibility to communicate effectively, value the contributions of other members, and keep building your team’s ability to provide excellent care. Teamwork skills don’t come naturally to everyone (Answer C), but anyone can learn and practice them.
A and B
The best answer is A and B. While challenging authority figures requires courage in any field, the hierarchical nature of health care can make speaking up particularly difficult. This is especially true when senior practitioners get upset with junior staff who voice concerns about safety. Other reasons it may be hard to say something in this case include your respect for the pharmacist, concern that you are mistaken, and fear of being yelled at or mistreated. For learners, there’s the additional worry that your evaluations and grades may be affected. However, it is always your place to speak up where safety is concerned, even if you’re not certain you’re right.
So that the patient does not experience an adverse event
Speaking up about safety concerns should be a patient-centered act. Your goal in voicing your concern is simply to ensure the patient receives safe and effective care — in this case, the correct medication. Voicing your concern should not be about displaying your knowledge, currying favor, or getting someone in trouble.
“I am concerned there is a safety issue here.”
When speaking up, it is important to use clear, direct language. Words like “safety” or “concerned” can get people’s attention. Hinting at a problem, such as in Answer A, is not sufficient. Likewise, using threats, as in Answer D, is not professional behavior. Answer C is the vaguest option, and it’s least likely to result in a solution to the problem.
“Thanks! I’ll tell your supervisor that you helped me today.”
In a culture of safety, all individuals value safety. Those who help prevent errors should be rewarded, not punished or told not to repeat their behavior. If this were an especially strong culture of safety, the pharmacist would also suggest sharing his error with the rest of the staff and changing the system to make medication mix-ups less likely. Answer B is threatening and Answer C is likely to be confusing to the learner. Answer D shows that although this pharmacist may value safety, the rest of the group does not.
A place where all staff can talk freely about safety problems without fear
Humans, even humans using technology, are fallible. In health care, there will always be errors and near-misses. In a culture of safety, however, people feel comfortable discussing errors and are rewarded for their focus on patient safety. Although an anonymous reporting system may be useful, the fact that it needs to be anonymous may indicate that people don’t feel comfortable discussing errors openly.
A system for delivering information
SBAR, which stands for “Situation-Background-Assessment-Recommendation,” is a system for delivering information. It is an adaptation of a US Navy communication technique and can be an effective means to communicate urgent patient care issues.
Provided a read back
This is a read back, which is used to confirm receipt of information (SBAR is a system for delivering information). The pharmacist went through the step of verbally verifying the order from the nurse practitioner by repeating it back to him, which can catch mistakes. The additional time that a read back requires is not a waste. In fact, it may make work more efficient by decreasing the need for later calls for clarification.
Conduct a debriefing
Debriefings occur after events to find out what happened and what could be done better next time. The most effective debriefings happen soon after the event, while memories are fresh. However, the first priority is the patient’s health – so debriefings should only occur after the patient is stabilized.
Implement the use of critical language in the ICU.
Critical language (such as “I need some clarity”) is an agreed-upon phrase or set of words that indicates to all members of a patient care team that there is a problem. It helps individuals who need to call attention to a problem but don’t know what to say, especially if the patient is awake and listening; and it also serves as a red flag to team members that they need to stop and pay attention. Critical language might have helped the nursing assistant speak up more quickly when he observed problems with the patient’s breathing. Debriefings, which occur after the event, would be a valuable source of learning, but they would not be sufficient to prevent an event like this one in the future.
Seek input from all members of the team.
Effective team leaders are not necessarily the ones with the most training, the most degrees, or the highest salary. And they don’t always have all the answers. They do, however, seek feedback from all team members, recognizing that one person can’t provide safe care alone.
