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Saturation in Training


Regardless of modest improvements in patient care, more needs to be done, and Wachter’s (2004; 2010) reports are now a renewed call for action and a move away from the often sporadic and incomplete manner in which we are preparing our health care teams. This article will discuss how those involved in patient safety and, specifically, in simulation-based instruction, can improve upon their methods and results.
Saturation in Training
On Jun 12, 2013
This article discusses how those involved in patient safety and, specifically, in simulation-based
instruction, can improve upon their methods and results.
Cite this article: Clapper, T. C. (2013, Spring). Saturation in Training. Patient Safety InSight.
by Timothy C. Clapper, PhD
Earlier this year, patient safety leader and advocate Bob Wachter wrote a post on his health
care blog, Wachter’s World, that caused many of us in the patient safety community to take
notice of our progress and shortcomings for making patient care much safer. Asking “Is the
Patient Safety Movement in Danger of Flickering Out?” he noted that the health care industry
has seen lower infection rates, fewer falls, fewer medication errors, fewer readmissions, better-
trained clinicians, and even better systems. Since the initial 1999 IOM report, To Err is Human
(Kohn, et al. 2000), and Wachter’s follow-up report (Wachter 2004), modest improvements
have been made, although they have been difficult to measure “because of our rudimentary
measurement capacity in safety” (Wachter 2010). Regardless of modest improvements, more
needs to be done, and Wachter’s (2004; 2010) reports are now a renewed call for action and a
move away from the often sporadic and incomplete manner in which we are preparing our
health care teams. This article will discuss how those involved in patient safety and, specifically,
in simulation-based instruction, can improve upon their methods and results.
TeamSTEPPS® and simulation
As noted by the Agency for Healthcare Research and Quality (AHRQ 2012), patient safety was a
fairly new field at the time that the groundbreaking IOM report emerged. AHRQ began to look
at systematic factors affecting patient safety, along with potential solutions that needed to be
implemented to address issues that caused unsafe practices. In 2006, two major AHRQ
initiatives unfolded that would have the potential to significantly address clinical error: Team
Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) and the
Improving Patient Safety through Simulation Research Grants program.
TeamSTEPPS provides a comprehensive training program to improve the teamwork and
communication of clinical teams. It evolved from older Crew Resource Management concepts
and uses evidence-based teamwork and communication tools to address human factor and
other environmental issues affecting patient care (Clapper & Kong 2012). The Simulation
Research Grants program, still active today, encourages health care organizations to create an
environment for providers to acquire proficiency in clinical skills, particularly those procedures
where there is the high potential for error, including central venous catheter (CVC) infection
and complication and obstetric emergencies that can lead to poor patient care, injury, death,
and substantial cost to the health care system (AHRQ 2012; AHRQ 2013).
Seven Years Later
Over the past seven years, TeamSTEPPS has been adopted by many hospitals and health care
organizations, and some patient safety officers have made great progress in educating their
workers in the four competencies (leadership, communication, situational awareness, and
mutual support) that can be used to improve team performance (Clapper & Kong 2012).
Likewise, the simulation community has witnessed ongoing growth in the use of simulation to
prepare health care workers. Membership in organizations such as the Society for Simulation in
Healthcare has steadily increased as clinical educators adopt this training modality. Simulation
is certainly not new, but, in part because of innovative companies that are continually
improving the fidelity or realism of simulation equipment, health care educators are feeling
more comfortable about replacing a great deal of bedside teaching with simulation-based
Health care organizations such as AHRQ require evidence to support the human and fiscal
resources that go into efforts to improve patient care and reduce medical error through these
two major initiatives (AHRQ 2013). In turn, the leaders of health care organizations, including
patient safety officers, will turn to simulation educators and TeamSTEPPS trainers and ask them
to show resultsnot in terms of number of learners trained, but rather, results in patient care.
While progress has been made in each of these areas, many educators and administrators are
using ineffective approaches to put these initiatives into practice (Clapper & Ng 2012). The
following sections highlight three significant changes that will need to be made: truly move
away from outdated teaching methodologies, standardize curriculum content, and apply the
theory of Saturation in Training (Clapper & Ng 2012).
Fully immerse learners in standardized curriculum
Simulation educators must move away from outdated, ineffective learning methodologies. For
example, some simulation centers conduct summertime “simulation boot camps” in airway
management and CVC placement for new residents where groups of residents rotate through
skill stations. I have observed that the teaching methods in these circumstances are similar to
the “see one, do one, teach one” method: only one of the residents had an opportunity to have
hands-on practice of the procedure while the rest of the group observed before rotating to the
next station. As a result, many of the learners would not have the opportunity to learn by
working through the experience, and by making errors that are sometimes a part of the
learning process. To make an analogy, this is akin to fitting an old engine into a new car. If it
continues, while simulation is a potentially powerful resource, it will not be used to its fullest
Another needed change involves simulation educators teaching from a standardized, research-
based curriculum because of the variance in skill and knowledge among both educators and
learners. The curriculum needs to be based on research and “best-practices,” include detailed
information to assist the learners with understanding the content, and be facilitated in a
standardized, student-centered manner that is conducive to good curriculum and instruction
design principles. For example, when developing simulation-based instruction for multiple
public hospitals in New York City, I used the four-phase, brain-based lesson plan developed by
Williams and Dunn (2008) that allowed learners to inquire, gather, process, and apply the
content being learned in the classroom. The four phases mirror the way the brain prefers to
process information for long-term retention and application. In addition, the instructional
content was thoroughly researched to include the latest information, and all learners were
required to practice and apply the procedures. The facilitator was prepared to facilitate this
course, provided a detailed demonstration with explanation, and made few assumptions
concerning the level of knowledge of the learner. We always have to ask ourselves “how do
they know it?” and “where/how did they learn it?” Many educators themselves may not have
learned all of the declarative or procedural knowledge in their own learning process, and when
teaching others, some will leave out important information (Crispen 2010; Sullivan et al. 2008).
Saturation in training
As a researcher-educator, I have led simulation courses that were supported by research and
best practices and packaged according to the four-phase lesson plan that I introduced to the
simulation community. However, my team encountered problems with the central venous
catheter (CVC) course, the first standardized course that we introduced. Essentially, the
problem was the same one that many simulation educators have today, and the impetus
behind this very article: training was sporadic across departments and, as a result, it was
relatively ineffective for making any real difference (Clapper & Ng 2012).
As I expressed to my supervisor at the time, if we continued to train small groups of people
over a longer period of time, most likely those people would revert back to the practice existing
in the department. Instead, we put into practice my theory of Saturation in Training (Clapper &
Ng 2012), with the goal of changing culture. The Saturation in Training theory holds that if we
train the greatest number of people in the shortest period of time we can change the practice
and culture of a department. And in our case, it worked.
After we trained an entire emergency department in CVC placement in just a couple of weeks,
the ED director observed the practice of his attending physicians and reported that they were
using the CVC bundle “correctly” (my emphasis) and, using the ultrasound, achieving one-stick
placement. Using the ultrasound during CVC placement allowed the provider to align the
needle with the vein and visualize the needle as it moved into its proper place in the center of
the vein. Relying on landmarks alone could cause the provider to blindly stick multiple times,
increasing the risk of complication, and providing multiple sites for infection.
TeamSTEPPS was also added to every course I developed and facilitated, and the adjunct
instructors I trained were shown how to apply it to that particular topic. Learners practiced the
CVC procedure with one another and learned that lost guide wires occurred even as a second
person looked on. They learned how to speak up, be supportive, and use CUS (I’m Concerned,
Uncomfortable…for Safety reasons, I am Stopping the line) if necessary to prevent an error
from occurring. These were not “show and tell” courses, but rather complete 4-hour courses
where the learner was immersed in the declarative and procedural knowledge in a student-
centered environment. Another part of the saturation process is making the time to facilitate
the training the right way, the first time.
The Saturation in Training approach was applied to other courses, including the Shoulder
Dystocia Teamwork and Skills course, the Cardiac Code Team course, and the Advanced Airway
Course. We trained entire OB, emergency, and medicine departments in 6 to 8 weeks, with
physicians, physician assistants, midwives, and nurses training together in their particular
course. In addition, learners received an overview of the TeamSTEPPS competencies and were
able to practice them in the context of their particular clinical setting. As with the CVC course,
we began to receive immediate, positive results, especially testimonials from department leads
who observed a definite change in individual and team skills at the departmental level.
As noted by Wachter (2013), we are in danger of looking at the time after the 1999 IOM report
as a “Golden Era of Patient Safety.” We cannot adopt this view because, while we have made
some improvement, we have not yet made our mark in patient safety, nor fully justified the
costs associated with the major health care initiatives. If we apply Kirkpatrick’s (1994) four
levels of education outcomes (reaction, learning, transfer of the new behavior, and results) to
patient safety, we know that instruction can lead to: 1) greater efficacy by the health care
provider to perform a skill or apply knowledge; 2) a change in knowledge, as perhaps measured
by a course pre/posttest; 3) an observed change in the practice in the healthcare setting; or 4)
at the highest level, a noted change in direct patient care, which may be measured in numerous
ways including reduced rates of litigation, infection, and complications.
We do not need more research to assess whether nurses or residents are more confident after
simulation-based instruction or whether they can work as a part of an interprofessional team.
There is already an abundance of this Level 12 research and even studies showing that brain-
based learning can be effective for changing the knowledge and skill level of health care
workers (Clapper et al., 2012). Simulation can be used to improve the skills, communication,
and teamwork of our health care workers, but patient safety will not be fully realized unless
simulation educators can show improvement at the highest levels of education outcomes
changes in the actual department and direct patient care (Kirkpatrick’s levels 3–4). If a
difference is going to be made for patient safety, the Saturation in Training theory must be
applied to practice.
Wachter (2013) saw two major forces slackening the response to patient safety: clinician
burnout and strategic repositioning of health care resources to deal with the Affordable Care
Act. I see a third one, and that is the reliance on ineffective and status quo facilitation practices
for TeamSTEPPS and simulation-based instruction. Our health care workers and our patients
deserve better, and we can change our facilitation methods to achieve the best learning
Timothy C. Clapper, PhD, is adjunct professor with the University of Colorado at Colorado
Springs and Education and Simulation Consultant with TC Curriculum & Instructional Design,
LLC. Contact him at
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Copyright © 2013 All Rights Reserved Patient Safety InSight is Published by National Patient
Safety Foundation | ISSN 2326-0467
... When cardiac emergencies occur, clinical teams can be caught off-guard. As a result, many people respond when a code is called, but only a few people are able to immediately begin all the life-saving steps effectively (Clapper, 2013;Clapper & Ng, 2013). Herbers and Heaser (2016) conducted mock codes in-situ, or in the natural clinical setting, as part of a quality improvement program. ...
... However, dedicated code team training must include opportunities for teams and individual learners to learn best practices in teamwork and communication in addition to the individual clinical skills. In addition, if only a few of the team members receive the training, the team may not perform as effectively as they could (Clapper, 2013;Clapper & Ng, 2013). ...
... A debriefing following each case and the end of the course to assist learners with reflecting on what they learned and what they will apply or transfer to their clinical settings. We used the saturation in training model (Clapper, 2013;Clapper & Ng, 2013), training the greatest number of people in the shortest period. Our goal was to train more than 90% of the entire clinical floor to ensure that enough members of the teams would have the individual and teambased skills necessary to respond properly to cardiac emergencies. ...
Background and Objectives. The code team course is a 3-hour, interactive course that follows a 4-phase brain-based lesson plan for simulation. Interprofessional teams receive instruction and practice in evidence-based teamwork, communication, and individual skills. Methods. This quantitative research included a pre-test and post-test design in an urban Department of Medicine. Sixteen groups (n=109) participated in the course over a period of eight weeks. Classroom metrics included pre- and post-course High-Quality cardiopulmonary resuscitation (CPR) and code team didactic knowledge assessed by Wilcoxon rank-sum tests. In addition, four in-situ mock code simulations were conducted to provide the researchers with baseline and post-intervention data. Code team performance assessment scores were tallied and compared between baseline and post-intervention by Fisher’s Exact Test. Results. The classroom metrics produced significant results. High-Quality CPR scores were higher post-training than pre-training (median score 4 vs. 3, respectively; p=0.006). Didactic knowledge test scores were also significantly higher (median score 90 vs. 70, respectively; p <0.001). In-situ team performance improved in several areas. There was a significant improvement in the area of cardiac code management in the day shift group. The percent “done well” improved from 25% (5/20) to 100% (20/20) (p= <0.001). Conclusion. The results of this pilot study suggest that code team training using the 4-phase BBL plan for simulation is associated with improvements in interprofessional team knowledge and performance during cardiac emergencies. It is equally important that the training is conducted over a short period in order to ensure that all team members are properly prepared.
... The Saturation in Training Model (Clapper, 2013;Clapper & Ng, 2013) would be an appropriate strategy for addressing the implementation of WC across the mesosystem. The Saturation in Training Model proposes that training the greatest number of people in the shortest period of time can wield the greatest effect (Clapper, 2013;Clapper & Ng, 2013). ...
... The Saturation in Training Model (Clapper, 2013;Clapper & Ng, 2013) would be an appropriate strategy for addressing the implementation of WC across the mesosystem. The Saturation in Training Model proposes that training the greatest number of people in the shortest period of time can wield the greatest effect (Clapper, 2013;Clapper & Ng, 2013). This training model was used to rapidly and effectively change behaviors across multiple-cultural, public healthcare organizations worldwide by training large numbers of learners in each department or domain in a short period (Clapper, 2013;Clapper & Ng, 2013). ...
... The Saturation in Training Model proposes that training the greatest number of people in the shortest period of time can wield the greatest effect (Clapper, 2013;Clapper & Ng, 2013). This training model was used to rapidly and effectively change behaviors across multiple-cultural, public healthcare organizations worldwide by training large numbers of learners in each department or domain in a short period (Clapper, 2013;Clapper & Ng, 2013). The reasoning behind the saturation theory is that we can train a few people to employ a skill or procedure effectively, but upon returning to their organization, if nobody else is using that skill or does not understand it, those people we trained are likely to give up on it themselves. ...
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Purpose. The purpose of this article is to propose a solution for conflict resolution in a bioecological system. Background. In 1979, Bronfenbrenner introduced his bioecological theory of human development which suggested that children are immersed in four integrated systems that affect student behavior and success in public schools. More than thirty years later, the bioecological system has experienced several changes, most notably in the structure of the family and changes in the culture. Conflict can lead to tragedy but intervention programs have seen some success when any one of the four systems is positively affected. Winning Colors® can be an effective tool to teach conflict resolution and communication leading to situational leadership, team building, conflict resolution, and improved communication in any inter-personal situation. Winning Colors® uses four color cards with corresponding behavior strengths that can be understood by children and adults in a short period. Aim. In this article, we explain how Winning Colors® program that has been used to teach conflict resolution and communication to thousands of learners. Conclusion. Winning Colors® can be implemented to teach conflict resolution and communication across the bioecological system.
... As no one acquired or processed the experiences in the same manner (Lederman, 1992), learners enter the learning environment with frames of references that are very unique to them. Augmenting this uniqueness is the lack of standardization in health care education and inadequate learning experiences that affect patient safety and learning itself (Barnsteiner, 2011;Clapper, 2013Clapper, , 2014Davies & Tales, 2005). As Dewey posited long ago, a problem that we must face is not a lack of experience, but a lack of quality experiences. ...
... Furthermore, individual-focused education may contribute to the lack of teamwork and communication that exists in the health care community (Clapper & Kong, 2012). A breakdown in communication is still recognized as a leading factor in the high rate of medical error that has not improved much in the last 25 years, especially during patient handoffs (Clapper, 2013;Clapper & Kong, 2012;Wachter, 2013). ...
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Purpose. The purpose of this article is to introduce cooperative-based learning and Vygotsky’s zone of proximal development (ZPD) to the simulation literature as two important mutually supportive learning theories that may enhance the effectiveness of simulation-based instruction. Design/Methodology/Approach. A brief literature review of cooperative-based learning and Vygotsky’s zone of proximal development (ZPD) is presented, along with a description of how these two important learning theories may be applied to improve simulation-based instruction. Findings. When learning new material or skills, learners sometimes need to be assisted with moving through the disequilibrium process that can occur when the new information contrasts with their existing frames of reference or ways of knowing. Cooperative-based learning and the zone of proximal development (ZPD) can be used to assist the learner with working through the disequilibrium process, including accommodating and assimilating the new skills and information into their own practice. Limitations/Implications. Gaps in the simulation literature, including ways to implement both theories into practice, can lead to incomplete or ineffective simulation-based instruction practices. Originality/Value. Many organizations have implemented simulation into their patient safety program, but have not considered how the zone of proximal development (ZPD) and cooperative-based learning can be used to improve educational outcomes.
... J. Gross, personal communication, 2010). We find very little research showing simulation in health care moving past the first two levels of Kirkpatrick's (1994) educational outcomes to create an observable change in practice in the health care setting or notable changes in direct patient care (Clapper, 2013). This may result from poor instructional design or a deficiency in understanding of how learning occurs. ...
... This may result from poor instructional design or a deficiency in understanding of how learning occurs. We must always consider where our learners acquired the information and skills that they have and how they were taught (Clapper, 2013). This statement can apply to simulation facilitators and their instructional practices as well. ...
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The education reformer, Horace Mann once suggested that trying to teach a learner without creating interest is like hammering cold iron. All too often, health care educators begin an instructional session while the mind of the learner is focused on places other than on the subject to be learned. Regardless of specialization, understanding situational interest and ways to nurture it in the facilitation process is important for educators. However, it is especially important for the health care community as it helps us to develop best practices in instructional design and facilitation that can improve simulation-based instruction. This article defines situational interest and explains how instructional design can generate such interest with the use of advance organizers, active learning strategies, and the practices of effective reflection-in-action and reflection-on-action. Developing situational interest may lead to an individual interest or passion for the subject, foster lifelong learning, and encourage learners to return for additional simulation-based learning experiences
... The first reason to use the two-team training approach is to make the best use of valuable training time. Changes in the behaviors and practice of entire units and organizations can be achieved with the saturation in training model (Clapper, 2013;Clapper & Ng, 2013), which has been used in several research-based interventions Clapper, Rajwani, et al., 2018; et al., 2019). With the Saturation in Training model, the facilitator's goal is to train the greatest number of people (usually more than 90%) in the shortest period to see the greatest effect. ...
Most clinical cases involve more than one nurse and one profession in the patient care plan, and so it can be stated that health care is very often a team event. In this article, I describe a two-team training approach that is very effective for maximizing learning and preparing high-performing teams in several team-based courses. This strategy exemplifies the power of vicarious learning and learning through imitation. Benefits of the two-team training approach in simulation-based education may include: (1) improved use of training time; (2) increased training volume; (3) recognition, correction, and immediate application of desired behaviors; (4) an improved simulation do-over process; (5) improvement in self-efficacy; and (6) applicable use of research and evidence-based educational practices. The two-team approach is an educational strategy that is supported by research and sound educational learning theories and should be considered for inclusion in organizational continuing education training plans. [J Contin Educ Nurs. 2021;52(9):417-422.].
... Not to be seen as the "TeamSTEPPS® police," their goal should be to assess whether their TeamSTEPPS® program is working and where additional support and resources are needed. Following the saturation in training model (Clapper, 2013;Clapper & Ng, 2013), underscored by the value of learning from our social interactions (Bandura & Walters, 1963), health care workers will continue to learn from one another as each models the TeamSTEPPS® competencies in some form through their day-to-day complex interactions. Here lies a valuable opportunity for the implementation-turned observation team to assist workers with isolating particular behaviors as they occur and subsequently identify critical follow-on training. ...
Purpose The purpose of this article is to propose a strategy for ensuing simulation training following the implementation of a thorough Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS®) training initiative. The strategies include observing Teams in the workplace to facilitate the construction of organization-wide, follow-on simulation training. Design/methodology/approach A review of organizational change and instructional design practices is presented to facilitate TeamSTEPPS® to its fullest. This article serves as a continuation of steps to full implementation following an initial article introducing TeamSTEPPS® and a second article identifying the challenges and opportunities for success during preliminary organization-wide training. Findings TeamSTEPPS® is a patient safety tool developed by the U.S. Department of Defense that is based on four competencies. The TeamSTEPPS® competencies and simulation can be used to create a just culture, which is based on effective teamwork and communication. However, full implementation and facilitation of a just culture requires health care organizations to consider reinforcement and next steps in training, along with a new way of thinking about the use of observation and simulation to facilitate organizational change. Research limitations/implications The literature contains large gaps concerning full implementation of TeamSTEPPS®. Very little has been published on how to implement TeamSTEPPS® throughout a health care organization, particularly articles based on good instructional design and organizational change principles. These gaps can lead to piecemeal implementation of TeamSTEPPS® with few positive results for the organization. Originality/value Many organizations have implemented TeamSTEPPS®, but have not conducted follow-on training that uses direct observation, debriefing, and simulation to address or strengthen specific behaviors.
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Introduction: Although many organizations have reported successful outcomes as a result of Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS), implementation can be challenging, with its share of administrative obstacles and lack of research that shows observable change in practice. Methods: This quantitative, pretest/posttest design pilot research used a combination of classroom simulation-based instruction and in situ simulation in a Pediatrics department in an urban academic center. All personnel with direct patient care responsibilities (n = 547) were trained in TeamSTEPPS in an 8-week period. TeamSTEPPS course knowledge scores were compared pretraining to posttraining using the Wilcoxon rank-sum test. The performance of two-day and overnight shift teams, pre- and postintervention was assessed using the TeamSTEPPS Team Performance Observation Tool. Results: TeamSTEPPS course knowledge improved from the beginning of the course to completion with median scores of 16 and 19, respectively ( P < 0.001). Both day and evening postintervention groups demonstrated greater team performance scores than their control counterparts. Specifically, postintervention day shift team showed the greatest improvement and demonstrated more TeamSTEPPS behaviors. Conclusion: This pilot study involving 1 department in an urban hospital showed that TeamSTEPPS knowledge and performance could be improved to increase patient safety and reduce medical errors. However, teams need to be trained within a shorter period so they can apply a shared-model of teamwork and communication. Leaders and educators throughout the department must also reinforce the behaviors and include them in every education intervention.
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Airway management is a critical skill that emergency medicine (EM) residents must develop. Brain-based learning is a form of instruction that creates the best conditions for learning and retention. Used in conjunction with simula-tion-based instruction, the potential exists for reaching more learners. The purpose of this study was to assess the basic airway management skills of postgraduate year-one (PGY-1) EM residents before and after receiving training through a three-hour brain-based learning and simulation course in order to gauge the effectiveness of this teaching method. EM residents who completed a brain-based learning and simulation course in airway management in 2010 were evaluated be-fore and immediately after the course by using a multiple-choice quiz to assess knowledge and a standardized checklist to assess practical airway skills. Pretest and posttest assessments were identical and subjects were blinded to the practical assessment criteria. Mean pretest scores on the quizzes and practical skills assessments were calculated and compared with mean posttest scores using two-tailed paired t-tests. A total of 71 new EM residents participated in this study. Im-provements were observed in each practical airway management skill; mean total pretest score increased from 22.82/30 to a mean posttest score of 26.98/30 (p = 0.03). Improvements were also observed in knowledge assessments, from a mean pretest score of 5.97/10 to mean posttest score of 8.90/10 (p = 0.00). In conclusion, a three-hour brain-based learning and simulation course was effective at improving new EM residents’ knowledge and practical skills in basic airway management.
Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) is a patient safety tool developed by the defense industry and based on four competencies: leadership, communication, situational monitoring, and mutual support. Unfortunately, there are barriers that prevent TeamSTEPPS from reaching its full potential, including: (a) lack of administrative support and resources, (b) lack of training focus to address hierarchal differences and incivility at all levels of health care practice and administration, (c) inadequate TeamSTEPPS instruction and simulation practices, and (d) educators’ resistance to change from crew resource management concepts. Suggestions for improvement include providing command and health care agency emphasis for the TeamSTEPPS program, providing adequate material and personnel resources, designing training that is geared to trainer implementation at the departmental level, prioritizing and saturating training, and striving toward a just culture.
Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS®), crew resource management, and human factors, or ergonomics principles, have received the attention of many clinicians and administrators in health care today. For those conducting simulation or preparing an education initiative aimed at improving patient safety, these team-based concepts, directed toward improving system and team functioning for patient safety, can be overwhelming and confusing. This article explores the key components of crew resource management and human factor principles and how they fit into the more complete teamwork tool known as TeamSTEPPS®. In addition, barriers, especially the lack of leadership training in nursing and medicine, are identified, as are suggestions for incorporating the TeamSTEPPS® competencies through simulation.
December 1, 2009, marks the tenth anniversary of the Institute of Medicine report on medical errors, To Err Is Human, which arguably launched the modern patient-safety movement. Over the past decade, a variety of pressures (such as more robust accreditation standards and increasing error-reporting requirements) have created a stronger business case for hospitals to focus on patient safety. Relatively few health care systems have fully implemented information technology, and we are finally grappling with balancing "no blame" and accountability. The research pipeline is maturing, but funding remains inadequate. Our limited ability to measure progress in safety is a substantial impediment. Overall, I give our safety efforts a grade of B-, a modest improvement since 2004.
The Institute of Medicine's 1999 report on medical errors galvanized the public and health professionals. Before then, providers, health care organizations, and policymakers lacked the understanding and incentives to generate the changes in culture, systems, training, and technology to improve safety. Since 1999 there has been progress, but it has been insufficient. Stronger regulation has helped, as have some early improvements in information technology and in workforce organization and training. Error-reporting systems have had little impact, and scant progress has been made in improving accountability. Five years after the report's publication, we appear to be at "the end of the beginning".
The purpose of this study was to determine if a cognitive task analysis (CTA) could capture steps and decision points that were not articulated during traditional teaching of a colonoscopy. Three expert colorectal surgeons were videotaped performing a colonoscopy. After the videotapes were transcribed, the experts participated in a CTA. A 26-step procedural checklist and a 16-step cognitive demands table was created by using information obtained in the CTA. The videotape transcriptions were transposed onto the procedural checklist and cognitive demands table to identify steps and decision points that were omitted during traditional teaching. Surgeon A described 50% of "how-to" steps and 43% of decision points. Surgeon B described 30% of steps and 25% of decisions. Surgeon C described 26% of steps and 38% of cognitive decisions. By using CTA, we were able to identify relevant steps and decision points that were omitted during traditional teaching by all 3 experts.
Is the patient safety movement in danger of flickering out? Wachter's World
  • R M Wachter
Wachter RM. 2013. Is the patient safety movement in danger of flickering out? Wachter's World. Feb. 18, 2013. Retrieved April 18, 2013 from