November 10, 2011 | By: Calevir
The November AHRQ newsletter has two examples about the positive influence of team training on medical workers and its effect on patient safety. Dr. Robert Wachter, Editor of AHRQ WebM&M, spoke with Dr. Eduardo Salas, a professor of Psychology at the University of Central Florida who served in the Navy for 15 years, about applying lessons learned from military team work training to medical teams. “Those who know about teamwork do better.†Read the interview and listen to a perspective piece online.
A second article draws attention to the lessons learned from the VA’s team training program referenced by Dr. Salas. After the VA implemented Medical Team Training at 74 sites, the results were astounding: Mortality rates declined by 17% versus 7% from sites that had not yet been trained. The study’s findings confirm Dr. Salas’ point about the importance of culture in promoting and sustaining teamwork. The article explains why studying near misses is actually more effective than adverse events and can even eliminate adverse events. Review the spotlight case Near Miss with Bedside Medications.
Another case examines the issue of patient flow management and its effect on patient safety, as well as the challenge to implement operations management tools to maximize patient throughput while reducing waiting times. Review The Case for Patient Flow Management.
A recent Pennsylvania case shows how courts narrowly interpret the PSQIA, ignoring the D & A pathway and the clear language of the Final Rule. (Ungurian v. Beyzman, et al., 2020 PA Super 105). The cour
The Center for Patient Safety wants to share this important harm-prevention advice from The Joint Commission and its Sentinel Event Alert: Managing the Risks of Direct Oral Anticoagulants. The Joint Commis
Issue: A number of events reported co CPS’ Patient Safety Organization (PSO) demonstrate poor handoff communication about the patients’ infectious disease status Examples include: Patient with
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