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Lessons from aviation: teamwork to improve patient safety.

Executive Summary

* Medical errors may contribute to as many as 44,000 to 98,000 deaths per year.

* Effective teamwork may serve to avoid and manage error and also address increasing staff shortages, the growing need for cost reduction, and increasing patient expectations.

* The Institute of Medicine and others have encouraged health care providers to look to the aviation industry because of its long history of measuring and improving teamwork to prevent and mitigate errors.

MOST HEALTH CARE PROVIDERS now recognize that medical errors t are a significant problem. Errors are frequent, costly, and may lead to adverse events. Errors may contribute to as many as 44,000 (Thomas et al., 1999) to 98,000 (Leape, Lawthers, Brennan, & Johnson, 1993) deaths per year, according to estimates by the Institute of Medicine (IOM) (Kohn, Corrigan, & Donaldson, 1999). With prompting from groups such as the IOM, Joint Commission for Accreditation of Healthcare Organizations, The Leapfrog Group, The Agency for Healthcare Research and Quality, and others, providers are mobilizing to reduce errors and improve patient safety.

Experts recommend a variety of methods to improve patient safety such as computerized physician order entry, bar coding, and incident reporting systems. In addition, The Institute of Medicine Report suggested that health care organizations "promote effective team functioning" as one of its five principals for creating safe systems of care delivery (Kohn et al., 1999).

Effective teamwork may serve to avoid and manage error and also address increasing staff shortages, the growing need for cost reduction, and increasing patient expectations. This emphasis on teamwork resonates with the experience of the aviation industry (Helmreich & Merrit, 1998) and health care providers (Sexton, Thomas, & Helmreich, 2000) and is supported by research on measuring and improving teamwork during trauma resuscitations (Risser et al., 1999) and in the operating room (Gaba et al., 1998; Helmreich & Schaefer, 1994).

Here we discuss how health care providers might promote effective team function by translating lessons from aviation. We use the word translating with purpose; health care is very different from aviation and methods used to improve safety in aviation cannot just be directly applied to health care. We also highlight how the existing nursing paradigm of Relationship-Centered Care has many similarities to principles of Crew Resource Management, one method used in aviation to improve teamwork. Finally, recent examples of activities that may improve teamwork in health care are highlighted.

The Aviation-Health Care Link

The Institute of Medicine and others have encouraged health care providers to look to the aviation industry because of its long history of measuring and improving teamwork to prevent and mitigate errors (Helmreich & Merrit, 1998; Odegard, 2000). This effort began after recognition that airplane crashes were more often caused by problems with the human component than by mechanical problems or bad weather (Helmreich & Foushee, 1993) Helmreich and colleagues developed surveys to collect data on pilot attitudes about teamwork and their perceptions of the safety practices and culture of the organization. Individuals' attitudes (as opposed to personalities) are relatively malleable to training interventions and predict performance, making it critical to understand and assess attitudes as a beginning measure (Helmreich et al., 1986).

The aviation industry subsequently developed a successful training concept called Crew Resource Management that addresses specific teamwork-related attitudes and behaviors, and elicits positive changes in performance and aviation safety (Helmreich et al., 1990; Helmreich & Foushee, 1993). This path taken by the aviation industry provides guidance for health care. However, there are important differences between health care and aviation (Thomas & Helmreich, 2002). Aircraft accidents are infrequent, highly visible, involve massive loss of life and are followed by exhaustive investigations into causal factors. Medical errors and adverse events happen to individual patients, seldom receive national publicity, and there is no standardized method of investigation. Furthermore, medical and nursing training is longer and involves more on-the-job learning. In contrast, aviation relies upon simulation to train and maintain skills. Pilot's professional skills (now including teamwork as well as technical skills) are re-evaluated more frequently than health care providers' skills. Continuing qualification is contingent on successful performance evaluations both in simulators and in normal flight operations. Further, patients are more complex than airplanes, and their health is influenced by numerous factors like socioeconomic status, access to health care, and genetic determinants. Rapid advances in the information needed to care for patients add to the complexity. New technologies appear and are implemented more rapidly in medicine than aviation.

Finally, a cockpit crew is an easily defined team with a well-defined hierarchy of authority for decisions made during a flight that has a clear beginning and end. A health care team may include social workers, lab technicians, nurses, students, doctors, and others who are working from disparate locations to care for a patient over days, months, or even years, thus increasing the complexity of communication.

Despite these differences, health care can learn from aviation's rich history of measuring and improving teamwork. Team training models from other industries may also prove beneficial (Brannick, Salas, & Prince, 1997). In health care, the hope lies in the future rather than in what has already been accomplished. We are gaining more research experience in how to measure and improve teamwork but clear evidence to guide our actions remains scarce (Shojania et al., 2001).

Examples of Teamwork Research in Health Care

In this section, a very small amount of the research on teamwork in health care is highlighted. Similar to the aviation research model, we have conducted surveys of providers. Results show that critical care physicians and nurses have discrepant attitudes about the teamwork they experience with each other (Thomas, Sexton, & Helmreich, 2003). Overall, physicians appear more satisfied with physician-nurse collaboration than nurses. Nurses did not reciprocate the high ratings of collaboration and communication attributed to them by physicians. These data suggest this different global rating of teamwork may be due to several specific issues. Relative to physicians, nurses reported that it is difficult to speak up, disagreements are not appropriately resolved, more input into decision making is needed, and nurse input is not well received.

To follow up the survey research, we are conducting focus groups with physicians and nurses from different clinical areas to better understand which factors influence the way providers work together. We are also videotaping providers during resuscitation of preterm infants to identify specific team-related behaviors that improve patient care. These research activities, funded by The Agency for Healthcare Research and Quality (1 PO1 HS11544-01 and U18 HS11164 01), should allow us to develop situation-appropriate and data-driven interventions to improve teamwork. We also expect that these research methods derived from commercial aviation will provide data to complement the significant amount of existing knowledge about teams in health care settings (Fried, Topping, & Rundall, 2O00).

Teamwork and Relationship Centered Care

Our preliminary survey, focus group, and observational research suggest that health care providers may benefit from a type of training similar to aviation's Crew Resource Management (CRM). As part of CRM, pilots learn skills such as assertion, inquiry, briefings, vigilance, workload distribution, and conflict resolution. We believe this general approach and these specific skills fit well into existing models within nursing (Sherwood, Thomas, Simmons, & Lewis, 2002).

In medicine, for example, Relationship-Centered Care is a patient care delivery model and philosophy that unites the entire health care team in a partnership with the patient and family to promote quality patient care. A major focus is practitioner-to-practitioner relationships within and between disciplines. Relationship-centered care focuses on the concepts of connectedness, accountability, reverence, and exchange of knowledge to avoid practicing in silos. Shared documentation is an essential tool in coordinating care in a partnership of the team and the patient/family. Critical care environments employing relationship-centered care demonstrate better hand-offs, enhanced communication, and less duplicative activities such as three professionals asking the same questions and repeating the same assessments (Malloch, Moore, & Sluyter, 2000). Maximally effective training in medicine should provide specific instruction for each discipline (for example, surgeons and scrub nurses) followed by joint training that addresses issues in communications, conflict, and decision making at the interface between disciplines. As in aviation, role playing and simulation are valuable modes for instruction and practice. Training methods to implement such approaches are needed if we are to answer the challenges posed in the IOM report. Clearly the status quo will not yield the outcomes desired.

What to Do Now

Health care professionals are acting to improve teamwork. Uhlig and colleagues (2001) report a successful teamwork project that reshaped patterns of interaction and communication in an open heart surgery program. A structured communications protocol to include all providers in care of the patient, the Collaborative Communication Cycle, allowed team building, planning and briefing, execution, and review of the plan with modification. The intervention improved patient satisfaction, and providers noted better communication of patient information that improved job performance.

Several investigators have reported success with structured participation of clinical pharmacists with rounds in intensive care units. For example, with a clinical pharmacist as a team member in a medical ICU, there was a 66% reduction in adverse drug events caused by prescribing errors (Leape et at., 1999).

Finally, several institutions are instituting safety briefings. This idea is derived from the pre and post-flight briefings that are routinely conducted by pilots. In health care, surgical teams have used briefings with some success before and after surgical procedures. The preoperative briefing provides an opportunity to discuss various issues that may lead to problems during the procedure. These may include a patient's co-morbid illnesses, lack of operating room personnel, provider fatigue, or expected technical difficulties associated with a complex procedure. The postoperative briefing may include a discussion of problems encountered during the procedure and how the team handled them. Briefings may also be used by nonsurgical providers. For example, safety issues can be discussed during nurse shift changes on pediatric or adult medicine wards.


Medical errors lead to significant human and economic concern exacting a toll in unnecessary patient suffering, provider morale, and institutional costs. The experience of the aviation industry provides some direction for improving patient safety, especially regarding how teamwork can be improve.


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ABOUT THE NATIONAL PATIENT SAFETY FOUNDATION: The National Patient Safety Foundation (NPSF) was founded in 1996 by the American Medical Association. CNA HealthPro, 3M, and contributions from the Schering-Plough Corporation. The NPSF is an independent, nonprofit research and education organization. It is an unprecedented partnership of health care practitioners, institutional providers, health product providers, health product manufacturers, researchers, legal advisors, patient/consumer advocates, regulators, and policy makers committed to making health care safer for patients. Through leadership, research support, and education, the NPSF is committed to making patient safety a national priority. For more information, visit For information on Six Sigma training for health care, contact the NPSF at (312) 464-4154.

ERIC J. THOMAS, MD, MPH, is an Associate Professor, The Division of General Medicine, Department of Medicine, at The University of Texas--Houston Medical School, Houston, TX.

GWEN D. SHERWOOD, PhD, RN, FAAN, is a Professor, The University of Texas Health Science Center, School of Nursing, Houston, TX.

ROBERT L. HELMREICH, PhD, is a Professor, Department of Psychology. The University of Texas at Austin, Austin, TX.
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Title Annotation:Patient Safety
Author:Thomas, Eric J.; Sherwood, Gwen D.; Helmreich, Robert L.
Publication:Nursing Economics
Geographic Code:1USA
Date:Sep 1, 2003
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