TeamSTEPPS makes strides for better communication

WHEN A TRAUMA PATIENT has significant pain, an order for morphine is yelled out during the chaos. An RN on orientation watches as her mentor, the charge nurse, administers 10 mg of I.V. morphine. Although the new nurse thinks that the dose is too high, she doesn't want to question the more experienced RN. The patient's respirations decrease to 6/minute, necessitating rapid endotracheal intubation to maintain the patient's airway. The healthcare provider asks the charge nurse how much morphine she's administered. She says, “10 mg, just as you ordered.” The healthcare provider berates her, saying that he prescribed 2 mg morphine. The nurse on orientation watches in horror, wishing she'd followed her instincts and spoken up earlier. Because she was intimidated, she'd kept quiet. This situation exemplifies how ineffective communication and teamwork can lead to serious medical errors. This article addresses how Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) can be used to improve communication and enhance patient safety. Root of errors The Institute of Medicine's classic 1999 report, To Err Is Human, detailed the number of preventable deaths that occur in hospitals. It concluded that medical errors cause up to 98,000 deaths annually.1 In healthcare, communication issues are considered the leading cause of medical errors. The good news? Clear and concise communication can prevent them.2 But the person speaking needs to establish that the other person heard and understood what was said. Communication and teamwork can fail for many reasons. For instance, nurses may be asked to do more with less, forcing multitasking and shortcuts and exacerbating fatigue, which can all lead to errors. Some may defend certain familiar but unsafe practices because “this is the way we've always done it.” A common but mistaken belief is that embedded practices need to remain in place, even though better, safer, and more effective practices can be used. As in the scenario just presented, team members may fear speaking up. They're afraid they'll be embarrassed or, even worse, berated, due to their place in the hierarchy of the healthcare setting. Mutual respect is vital to patient safety: All team members should feel they're equal and have the opportunity to voice concerns openly and honestly. Cultivating relationships with interprofessional healthcare teams improves care and decreases medical errors and negative outcomes.2 Every team needs to fill established roles, including a leadership role, to ensure that all team members are providing mutual support and communicating effectively. In another example, because an orthopedic surgeon is focused on a lower extremity fracture and the emergency medicine healthcare provider is monitoring the patient's airway, the team leader is responsible for overseeing the patient's vital signs, ensuring external bleeding is controlled, monitoring the patient's mental status, and following up to confirm all interventions have been completed and reassessed. Improving communication and teamwork The Department of Defense and the Agency for Healthcare Research and Quality developed TeamSTEPPS as a systematic approach to integrate teamwork into practice, as well as improve the quality, safety, and efficiency of healthcare. This approach was based on 25 years of research related to teamwork, team training, and culture change.3 Healthcare followed the lead of the aviation industry, modifying its principles, such as those developed from Crew Resource Management, to prevent medical errors and reduce negative outcomes. (See Lessons from aviation.) In TeamSTEPPS, many techniques are used to facilitate teamwork and communication, including situational awareness and mutual support. When working as part of a team, someone—the leader—must be aware of every aspect of the team and situation as well as what changes affect the team's work. This technique is called situational awareness. Team members focused on their own tasks may lose sight of the big picture. In contrast, the leader is responsible for the whole scenario. His or her role is to continuously monitor the room and remain aware of what's happening at all times. Team members need mutual support to ensure all members have a backup and resources are readily available to complete the task at hand. Each person receives the message, “Hey, I've got your back.” When someone feels overwhelmed, it's understood and expected that he or she can ask for and receive assistance. This also lets all members feel they're on equal ground and have the right to speak up when they have concerns. A shared mental model confirms that all members are “on the same page” by ensuring that everyone shares all knowledge and relevant facts, as well as the common goal. With a team that knows, understands, and agrees on the common goal, the focus is clear, and all members are working toward the same objective.3 Communication tools Effective communication is the backbone of all successful teams. Some common communication tools include the following: Situation, Background, Assessment, Recommendation and Request, and Questions (SBARQ) is used in many organizations, especially during patient hand-offs. It provides a systematic way to convey patient information, which is essential during high-stress situations. Call outs are used to broadcast information, such as vital signs, to all team members at the same time. Check backs are based on the idea of closed-loop communication to restate what the person said and verify understanding. This is critical when administering medications. An example is calling back, “Two-mg Versed I.V. Two-mg Versed I.V. given.” This tells the prescriber that the information relayed was understood.3 The two-challenge rule allows a team member to voice his or her concerns twice, and if they're still ignored, go up the chain of command. Because all team members should feel they're equal and have the right to speak up about safety concerns, everyone must be empowered to “stop the line” for any safety violations, questions, or concerns. “CUS” words mean “I'm Concerned; I'm Uncomfortable; I don't feel like this is Safe!” Using these words is another way to stop the line. If any team member uses these techniques, everything should stop and the situation should be reassessed.3 New approach Now let's get back to the situation described in the beginning of this article, which exemplified a lack of leadership and a breakdown in communication. Because no leadership had been established, no single person had situational awareness. Still, if the charge nurse had used call-backs, the medication error might have been avoided and the patient might not have experienced respiratory depression. And if mutual support had been in place, the nurse on orientation would have felt empowered to speak up. Effective communication, good teamwork skills, equalized hierarchies, and clear leadership are vital for improving patient care and limiting negative outcomes. TeamSTEPPS can play an integral role in establishing a culture of safety in the healthcare setting. Lessons from aviation In the mid-1900s, the aviation industry continued to experience errors based on communication and teamwork dysfunction. Crew Resource Management, based on the idea that people make mistakes, was established.4 In aviation as in healthcare, if mistakes are made, people can die. In the 1970s, several aviation disasters led to a cultural shift in regard to safety. For example, in the Canary Islands, two 747s collided on the runway, killing 583 people. The crash was caused by miscommunication between the flight crew and air traffic control. Despite their concerns, the flight crews wouldn't speak up due to the culture of the industry. The pilot was considered the captain of the ship, with ultimate authority, wisdom, and knowledge. The flight crews wouldn't cross this line, even if it resulted in their own deaths. With the implementation of Crew Resource Management and six generations of training, these incidents have drastically decreased. Aircraft crews are now encouraged to speak up when something is “not quite right.” This is a result of team training that stresses effective communication.5