Using an Interprofessional Lens to Analyze Serious Adverse Events in a Teaching Hospital: An Analysis with the TeamSTEPPS® Framework

This paper explores the contribution of teamwork skills in serious adverse events, using the TeamSTEPPS® framework. Adverse events are the undesirable events that are not due to the natural course of a disease;they are considered serious when they prolong a hospital stay, lead to a physical disability or to death. Failures in teamwork, particularly with interprofessional teams, can lead to potential risks to patient safety. Using a dataset of de-identified reports of serious adverse events in 2016 in a tertiary teaching hospital, we explored the contribution of teamwork skills according to the TeamSTEPPS® framework to these adverse events. We found that 61% of the 41 analyzed events involved failures in teamwork skills, with 80% of these involving communication, 52% in situation monitoring and team structure, 44% in mutual support and 40% in leadership. Sixty-four percent of the events involved more than one teamwork component. Our findings emphasize the need to improve teamwork training in healthcare, focusing not only on communication, but also on other teamwork skills as they often contribute together in adverse events. Future analyses of serious adverse events should include a focus on teamwork competencies, to guide the development of future quality and safety training programs.

Benefits of multidisciplinary collaborative care team-based nursing services in treating pressure injury wounds in cerebral infarction patients

BACKGROUND Cerebral infarction patients need to be bedridden for long periods of time often resulting in pressure injuries,which may represent a serious threat to patients'life and health.An effective nursing program should be adopted for timely intervention in patients with pressure wounds.AIM To explore the value of nursing services based on a multidisciplinary collaborative treatment team in patients with pressure injury wounds following cerebral infarction.METHODS Patients with cerebral infarction pressure injury wounds in our hospital from December 2016 to January 2021 were selected and divided into one study group and one control group based on the simple random number table method.The control group was treated with conventional nursing care(CNC),and the study group was treated with care services based on multidisciplinary collaborative care(MDCC).The Pressure Ulcer Scale for Healing(PUSH),healing effect,Self-Perceived Burden Score(SPBS),and satisfaction with the intervention were calculated before and after 2 and 4 wk of intervention in both groups.RESULTS Sixty-two patients were enrolled,and 31 patients were assigned to each group.The results of the interventions were as follows:(1)There was no significant difference between the PUSH scores of the MDCC group(11.19±2.46)and CNC group(12.01±2.79)before the intervention(P>0.05),and the PUSH scores were lower after 2 and 4 wk of intervention in the MDCC group(6.63±1.97 and 3.11±1.04)than in the CNC group(8.78±2.13 and 4.96±1.35 points)(P<0.05);(2)The rate of wound healing in the MDCC group(96.77%)was higher than that in the CNC group(80.65%)(P<0.05);(3)There was no significant difference between the SPBS scores of emotional factors(21.15±3.11),economic factors(9.88±2.15),and physical factors(8.19±2.23)in the two groups before the intervention.The scores of emotional factors(13.51±1.88),economic factors(6.38±1.44),and physical factors(5.37±1.08)were lower in the MDCC group than in the CNC group(16.89±2.05,7.99±1.68 and 7.06±1.19)after 4 wk of intervention(P<0.05);and(4)Satisfaction with the intervention was higher in the MDCC group(93.55%)than in the CNC group(74.19%)(P<0.05).CONCLUSION Interventions for patients with cerebral infarction pressure wounds based on an MDCC treatment team can effectively reduce patients'self-perceived burden,improve pressure wound conditions,facilitate wound healing,and increase patient satisfaction with the intervention.