LEARNING IN A CULTURE OF SAFETY

Creating a culture of safety and developing teamwork have been broadly addressed in previous Institute of Medicine (IOM) reports, namely the Quality Chasm series (IOM, 2000, 2003, 2004). The committee builds on those earlier reports, focusing attention on adopting strategies for teamwork development and error reporting to better serve the educational needs of residents while fostering safe patient care.

REDUCING ERRORS BY IMPROVING HANDOVERS

Handovers, or transitions in patient care are an area of medical practice that is considered a substantial source of errors and risks to patients, but one that can benefit from immediate attention through processes improvement. More commonly referred to as “handoffs,” “transfers,” or “sign-out” in the United States, the committee chose the term “handover” for this report because it better encompasses the goal of these pivotal moments, suggesting that they are intended as a handing over of responsibility for a patient from one healthcare provider to another and not simply a quick transcription of patient information at the end of one’s time on duty. Continuity of care as described in Chapter 4 refers primarily to relationship building between physician and patient, and gaining thorough knowledge of a patient’s condition in order to provide the best treatment. A resident’s familiarity with a patient and his/her care is important, and discontinuity of care due to handing cases over to other residents has been shown to result in increased levels of preventable adverse events (Laine, 1993; Petersen, 1994).

However, to achieve stronger patient-physician relationships and serve its educational purpose, continuity of care relies heavily on the continuity of information itself. Information transferred during handovers may include a patient’s name, bed location, blood pressure, diagnosis, and other critical data on patient status or treatment plan. A service that must be available 24 hours daily, such as health care, requires transferring this information and responsibility of tasks from one team member to another at some point or points during the day. In a hospital setting, for example, where teams of physicians, nurses, and residents are all responsible for a single patient, continuity of care involves a comprehensive handover of patient information from one provider or team to another so that clinical care can be maintained successfully among a healthcare team. Handovers take place among teams of nurses, teams of physicians, and teams of residents, as well as between those teams and between integrated care teams consisting of various types of clini cians. Handovers occur between emergency departments, different inpatient settings from surgical to postoperative care, and different hospitals, not to mention transitions out of hospitals to nursing homes or home care settings (Patterson et al., 2004). The act of transferring responsibility for patient care is not inherently a negative practice. However with each additional handover per patient, there is more opportunity for dilution or omission of information, which can lead to inaccuracies that affect patient care and outcomes (Arora et al., 2005, 2007; Horwitz et al., 2008; Petersen, 1994). Such communication breakdowns result in information gaps that intensify discontinuity of patient care and the potential for errors. These factors make them pivotal moments in the care continuum and an important aspect of preventing medical errors and ensuring patient safety (Saultz, 2003). For residents, these exchanges are also opportunities for professional interaction, learning how to assess patient care situations, and problem solving.

The next several sections discuss the role handovers play in the continuity of patient care, the impact they have on patient safety and resident education, how they are affected by the regulation of duty hours, and suggestions for redesigning handover processes to optimize patient safety and resident education.

HANDOVER INTERVENTIONS

The attention that handovers have received as a target area to improve patient safety is exemplified by the Joint Commission’s decision to issue a “Patient Safety Goal” (effective January 1, 2006) requiring hospitals to standardize their handover approaches and communications as components of improving continuity of care (see Box 8-1) (Joint Commission, 2007). It is generally believed that providing some structure for handover procedures is the appropriate solution for improving outcomes. Other industries in high-risk or high-reliability environments have already identified aspects of handover processes, and several of their lessons or techniques are applicable to hospital settings (Patterson et al., 2004). Examples from such industries were indeed drawn upon to help formulate the Joint Commission requirements for these procedures.

BOX 8-1

National Patient Safety Goal 2: Improve the Effectiveness of Communication Among Caregivers. Requirement 2E Implement a standardized approach to “hand off” communications, including an opportunity to ask and respond to questions.

Improving handovers provides an opportunity to restructure the way residents learn, possibly leading them to greater collaboration with peers and supervisors and helping them to build new skills that promote quality care. One-size-fits-all interventions or complete standardization of the process across all settings, however, is not feasible in a highly variable and complex system such as health care; therefore flexibility in adopting any suggested handover method would be crucial to its success (Patterson, 2008). Application of core components should be evaluated for each setting and care scenario to ensure that they are not used superfluously and do not hinder existing effective transfer methods (Patterson, 2008; Perry et al., 2008). It is expected that handover practices would be tailored somewhat to accommodate the differing needs of intensive care units compared to emergency rooms, surgical and internal medicine disciplines (Arora and Johnson, 2006), or outpatient and inpatient settings, but that core components would be instituted within a basic framework with consistent principles. Therefore, the basic elements that may help improve current medical handover processes presented in the following section are general suggestions. Limited data are available on the implementation of handover guidelines or their effectiveness, but the existing evidence suggests that following a somewhat structured protocol does improve resident communication (Chung and Ahmed, 2007) and patient outcomes (Catchpole et al., 2007).

TRAINING DOCTORS AND ERROR REPORTING

In addition to the latest, evidence-based best practices for patient care and structured handover procedures, new physicians must also learn and practice safety and quality improvement principles and methods. Throughout medical centers or hospitals there should be encouragement for residents to participate in ongoing quality improvement efforts and support for them to learn from constructive feedback. As part of its six core competencies the Accreditation Council for Graduate Medical Education (ACGME) requires residency programs to teach about quality improvement practices and produce residents who can “systematically analyze practice using quality improvement methods, and implement changes with the goal of practice improvement,” and “participate in identifying system errors and implementing potential systems solutions,” to improve care based on an understanding of resource allocation and integration of care delivery systems as well as individual patients’ clinical needs (ACGME, 2007, pp. 1, 3). Some health researchers are finding that educating residents on quality improvement methods for patient care can have a beneficial effect on the outcomes of patients that they treat during training (Stevens et al., 2008; Warm et al., 2008). If the quality of education that residents receive during training affects the quality of care they give to future patients once they are working independently, then learning from their mistakes or those of others as part of that education can be valuable for future patient safety.

Teaching hospitals typically have error-reporting systems (as ACGME states they should in its competency requirements), but residents are often not fully integrated into the hospital’s culture of safety and either do not know how to report errors or do not see the value of doing so. A serious barrier is that residents, regardless of whether they see the value of reporting errors, are often reluctant to report them because they fear retribution for asking questions, displaying ignorance, or facing legal consequences (Hines et al., 2008; Kaldjian et al., 2008).

The Joint Commission recently issued a Sentinel Event Alert concerning “intimidating and disruptive behaviors [that] can foster medical errors … and preventable adverse outcomes” that indicates that such disruptive behavior is not unusual (Joint Commission, 2008, p. 1). The Joint Commission mentioned examples of intimidating behavior, such as “reluctance or refusal to answer questions, return phone calls or pages; condescending language or voice intonation; and impatience with questions. Overt and passive behaviors undermine team effectiveness …” (Joint Commission, 2008, p. 1). The alert states that several surveys have found that a majority of healthcare workers have seen or experienced such behavior and one study found that “40 percent of clinicians have kept quiet or remained passive during patient care events rather than question a known intimidator” (Joint Commission, 2008, p. 1). Likewise, an AHRQ database comprised of voluntary survey responses by hospital staff on the efforts to create a patient safety culture in their institutions revealed that only 44 percent of respondents agreed that their hospital had a nonpunitive response to errors (AHRQ, 2008).

Among the core concepts of HROs is a perception of errors or near misses not as an occasion to point blame, but as an opportunity to improve system design and performance to achieve an even safer environment (Hines et al., 2008). This leads to creating a blame-free environment through a systemic response to errors, which could help reform the punitive culture often observed in healthcare settings that tend to inhibit open communication and, thus, learning. The careful design of an error-reporting system, analyses resulting from it, and feedback to those involved and to others who can learn from error-related events are critical to the success of the system (Kaplan and Rabin Fastman, 2003). An understanding of the errors in a system is the foundation for building a strong culture of safety. Information from error reporting and root-cause analyses of critical cases could also contribute significantly to residents’ education.

Since the focus of most hospital error-reporting programs has been on system-wide problems rather than on the individual, and they frequently guarantee confidentiality, they often do not note characteristics of the individual who was involved in the event, such as profession, discipline, and training status. Without data on error patterns—including what type of caregiver was involved, at what training level, and whether there were errors of omission, commission, misdiagnosis, or work-around—it is more difficult to address educational deficiencies (Battles and Shea, 2001). However, if data were available on when during a work period the event occurred, it might show that events happened most frequently at the end of an extended work period and were possibly an indication of decreased attention due to fatigue. Error reports indicating the time and other specific circumstances of events might reveal patterns related to work shifts of individuals or teams, the transitions from team to team, and whether fatigue or communications failures were a significant factor. Currently, reporting does not capture such information in hospitals for use in residency programs.

While most individual institution reporting systems would have a limited volume of reports and insufficient power to draw statistically valid conclusions about certain events, they could be valuable to management and educators by identifying any problem. Just one report of a near miss could identify a critical situation in need of redesign and lead to significant quality improvement. Residents in particular can play an important role in improving health systems in this regard. Acting as the “spackle” in the busy training settings of the health profession, they know where gaps exist in the system, and helping to identify them can be an asset in any care setting as well. Not only would residents be a part of the solution to these problems, they would benefit from the educational benefits these systems can provide.

If more hospitals had robust error-reporting systems with sufficiently detailed data reported, and an atmosphere that encouraged all workers to participate, and if such data were consistently recorded from hospital to hospital and could be aggregated to a national level, or if there were an effective national reporting program in place, it might have been possible for this committee to assess whether errors by residents were a serious threat to patients and to what extent those errors could be attributed to fatigue and long work hours. However, data at that level do not currently exist.

The issues surrounding error-reporting systems are not new and are of much broader relevance than just the training of physicians. In fact, earlier IOM reports, including many in the Quality Chasm series, contain extensive discussions of these issues and recommendations on how to develop an effective error-reporting and learning system. This report does not repeat those discussions, but rather turns the focus toward residents. Healthcare organizations have been responding to these reports and pressures from the Joint Commission and public bodies. Both the public and healthcare professionals are growing more aware of the importance of identifying errors in understanding how to improve the quality of services and the safety of patients and workers. However, progress in reporting and reducing errors has not been uniform (ACGME, 2008; Hines et al., 2008; Kaldjian et al., 2008).

At the hospital level, to learn from mistakes in patient care involving residents and to prevent similar events in the future requires an error-reporting system with a common set of data standards and a broader definition of what information should be collected that could, perhaps, contribute to the training of doctors. The error-reporting system would have to include training for all residents in what should be reported, how to report incidents, who should report, and how to analyze the reported errors to understand the root causes of the error and the changes needed to prevent future harm to patients (Garbutt et al., 2008). Support and encouragement from executive leadership, methods for reporting errors anonymously, and a feedback loop to the residents, caregivers, and especially the graduate medical faculty are all important elements of the reporting system for promoting its use. Knowledge that the reported information will be used to enhance patient care is critical to motivate doctors and other caregivers to make the effort to report an incident. The perception that there is no follow-up can be a deterrent to reporting (Evans et al., 2006). The use of such reported information to enhance resident training would also be a benefit.

Recommendation 8-2: Graduate medical education-sponsoring institu tions should fully involve residents in their safety reporting, learning, and quality improvement systems, and this should become an impor tant part of the residents’ educational experience.

DEVELOPING A TEAM CULTURE

It has been recognized that healthcare structures are complex, “characterized by competing responsibilities and an evolving perception of patient care as a collective responsibility” (Park et al., 2007, p. 111). Residents are increasingly trained and expected to practice in models of integrated care, which rely on the coordination of different services, clinicians, and teams all working together to provide comprehensive care for patients. Facilitating this coordination requires effective communication skills and strategies across and among all units—a fundamental trait of teams and teamwork. A team is defined as a distinguishable set of two or more people interacting toward a common goal with specific roles and boundaries on tasks that are interdependent and are completed within a larger organizational context (Kozlowski and Bell, 2003; Salas et al., 1992). The tasks that teams work on tend to require (1) dynamic exchange of team member resources (including information), (2) coordination of activities, (3) adaptability to task demands, and (4) an organizational structure that coordinates members (Salas et al., 1992; Swezey et al., 1994).

Team-based work is an effective strategy not only for combating errors, but also for mitigating the negative impact of high workloads, fatigue, and stress, especially when team members become aware of their own responsibilities in addition to the responsibilities of others (Salas and Cannon-Bowers, 2000b; Salas et al., 2005; Smith-Jentsch et al., 1996). Using a team-based approach for resident work and patient care could suitably address concerns of both continuity and fatigue, reducing potential threats to patient safety.

A study by Singh and colleagues, analyzing malpractice claims in which residents were identified as playing a role in harming patients, concluded that residents “are particularly vulnerable to medical errors owing to teamwork failures” (Singh et al., 2007, p. 2030). From among 240 cases resulting in patient injury, teamwork breakdowns were a factor in 70 percent of them (errors in judgment were a factor in 72 percent and lack of technical competence was a factor in 58 percent) (Singh et al., 2007). It was also found that “lack of supervision and handoff problems were the most prevalent types of teamwork problems [in the malpractice cases], and both were disproportionately more common among errors that involved trainees than those that did not” (respectively, 54 percent vs. 7 percent, p = .001, and 20 percent vs. 12 percent, p = .009) (Singh et al., 2007, p. 2032). Such data suggest that residents could greatly benefit from a reinforced team structure and training in communication and team practices to prevent patient harm, where supervision is readily available to provide necessary guidance.

Teamwork and Task Performance

The focus of teamwork for residents is individual performance in a team environment; helping each resident perform to his or her fullest capacity, most effectively and efficiently, while creating more learning opportunities. Teamwork is defined as a set of interrelated behaviors, cognitions (thoughts), and attitudes (feelings) held by each team member that combine to facilitate adaptive, coordinated performance (Morgan et al., 1986; Salas et al., 2004). Learning and using the five core components of teamwork—specifically, leadership, mutual performance modeling, backup behavior, adaptability, and team orientation (Box 8-2)—can lead to more effective work processes.

BOX 8-2

The Five Core Components of Teamwork. Team leadership: The ability to direct and coordinate the activities of other team members; assess team performance; assign tasks; develop team knowledge, skills, and abilities; motivate team members; plan and organize; (more...)

Research by Jung and colleagues has demonstrated that as teams work together applying these components, they can increase their productivity and build shared ideas of how to accomplish a task (Jung et al., 2002). Teamwork depends on each team member’s ability and willingness to cooperate toward achieving shared goals. For residents, these goals are providing effective patient care, maximizing learning, and minimizing errors.

An example of using team efforts to achieve these goals is a general medicine residency program that recently developed a team-based teaching program to determine the effects of reducing workload and providing more supervision and teaching upon the quality of resident education and patient care. This was accomplished by creating integrated teams of two attendings (one a primary care physician and the other a hospitalist or subspecialist), two residents, three interns, and two medical students. The team remained together for 2 weeks or more at a time completing daily work and teaching schedules with a cap of 15 patients at any time, who were divided equitably among the interns. Compared to the traditional general medicine resident team, patients treated by the integrated team had a lower mortality rate (1.4 percent vs. 2.4 percent, p = .053) and significantly shorter length of stays (LOSs) (4.2 vs. 4.7 days, p < .01) (McMahon, 2008). The quality of discharge communications was also higher for the integrated team, and members managed to double their amount of time spent in educational sessions (McMahon, 2008), demonstrating that improved patient care and resident learning can both be facilitated by team structures. Other efforts incorporating interdisciplinary or multidisciplinary team rounds had very similar results of reduced LOS and improved core knowledge and team skills (Curley et al., 1998; O’Mahoney et al., 2007).

Training Residents in Effective Teamwork Strategies

Teamwork skills often need to be learned and numerous reports and publications highlight the importance of team training in realizing goals to enhance patient safety and clinical communication (Barach and Small, 2000; Barach and Weingart, 2004; Jeffcott and Mackenzie, 2008; Leonard et al., 2004). The skills acquired through resident team training can be taught using various techniques (Klein et al., 2009; Rosen et al., 2008; Salas and Cannon-Bowers, 2000a, 2001; Salas et al., 2008; Smith-Jentsch et al., 1998), including simulation strategies that can measure team competency (Zheng et al., 2008), and are valuable because they are applicable to many facets of resident work.

Since there are multiple forms of team structures and methods in which teams can be trained, a straightforward way of introducing team-centered activity and skills into healthcare settings is by training residents as a team around completing specific tasks. Also referred to as “task-tailored train ing,” this type of training can be effective for several processes that take place in hospitals (e.g., surgical procedures, handovers, clinical rounds). For example, a study by Chung et al. (2007) applied a task-tailored team approach to the rounding process (a substantial part of some handover processes) performed by general surgical residents, specifically morning rounds. The strategy focused residents’ work during their rounds on three distinct tasks: detecting postoperative complications early or conducting orderly preoperative workup; informing patients of the agenda for the day; and answering patient questions and complaints. In addition to having them focus exclusively on these tasks, the members of the rounding team (nine members: one PGY-5 and eight PGY-1 to PGY-4s) were assigned specific roles. With this direction, residents’ work became more purposeful and efficient, and they completed rounds and associated work in 1 hour (Chung and Ahmed, 2007). After a year of implementation, attendings on duty observed substantial increases in resident professionalism and communication, demonstrating the positive effects of team structure and culture, not only on workload but on general attitude as well. Such structure also automated team continuity of care, increasing patient awareness of the resident team and satisfaction with care received (Chung and Ahmed, 2007).

Whichever methods of handover intervention or error reporting are used, residents will have to be trained in the team components of coordination, communication, and cooperation to conduct them most effectively and efficiently. In some facilities, faculty or supervisors may also have to be trained in these matters in order to ensure their organizational adoption and most effective implementation.

CONCLUSION

Redesigning any part of the resident learning process is a challenge. To eliminate preventable adverse events and intercept other errors before they harm the patient, it is important to have in place an environment that is both mindful of errors and nonpunitive, as well as leaders willing to consider redesign of the institutions’ systems and processes as necessary to reduce risks. The emphasis on handovers, blame-free error reporting, and teamwork does not mean that individual residents are not expected to develop a sense of loyalty or personal responsibility for individual patient care, but it helps ensure that the best information is available at all times for patient care given that a resident or any caregiver cannot be at the bedside 24 hours a day, 7 days week. It may not be possible to eliminate discontinuity altogether in healthcare settings, but the training system can strive to minimize its effects by enhancing the quality of handovers and error reporting, promoting patient-centered approaches, and improving physician relationships by facilitating communication through team struc tures. Suggestions for these areas of the system are ones that the committee believes deserve immediate attention and can bear positive results if effectively applied.

REFERENCES

• ACGME (Accreditation Council for Graduate Medical Education). 2007. Common pro gram requirements: General competencies . http://www​.acgme.org​/outcome/comp/GeneralCompetenciesStandards21307.pdf (accessed March 17, 2008).
• ———. 2008. The ACGME duty hour standards: One element for promoting good learning, safe patient care and resident well-being: Data on compliance and effect. Presentation by Ingrid Philibert and Thomas Nasca to the Committee on Optimizing Graduate Medical Trainee (Resident) Hours and Work Schedules to Improve Patient Safety, March 4, 2008, Irvine, CA.
• Afessa, B., C. C. Kennedy, K. W. Klarich, T. R. Aksamit, J. C. Kolars, and R. D. Hubmayr. 2005. Introduction of a 14-hour work shift model for housestaff in the medical ICU. Chest 128(6):3910-3915. [PubMed: 16354863]
• Afrin, L. B., G. W. Arana, F. J. Medio, A. F. Ybarra, and H. S. Clarke, Jr. 2006. Improving oversight of the graduate medical education enterprise: One institution’s strategies and tools. Academic Medicine 81(5):419-425. [PubMed: 16639192]
• AHRQ (Agency for Healthcare Research and Quality). 2008. Hospital survey on patient safety culture: 2008 comparative database report . Rockville, MD: Agency for Healthcare Research and Quality.
• Alvarado, K., R. Lee, E. Christoffersen, N. Fram, S. Boblin, N. Poole, J. Lucas, and S. Forsyth. 2006. Transfer of accountability: Transforming shift handover to enhance patient safety. Healthcare Quarterly 9(Supp):75-79. [PubMed: 17087173]
• Arora, V. M., and J. M. Farnan. 2008. Care transitions for hospitalized patients. Medical Clinics of North America 92(2):315-324. [PubMed: 18298981]
• Arora, V., and J. Johnson. 2006. A model for building a standardized hand-off protocol. Joint Commission Journal on Quality & Patient Safety 32(11):646-655. [PubMed: 17120925]
• Arora, V., J. Johnson, D. Lovinger, H. J. Humphrey, and D. O. Meltzer. 2005. Communication failures in patient sign-out and suggestions for improvement: A critical incident analysis. Quality and Safety in Health Care 14(6):401-407. [PMC free article: PMC1744089] [PubMed: 16326783]
• Arora, V., J. Kao, D. Lovinger, S. C. Seiden, and D. Meltzer. 2007. Medication discrepancies in resident sign-outs and their potential to harm. Journal of General Internal Medicine 22(12):1751-1755. [PMC free article: PMC2219840] [PubMed: 17963009]
• Arora, V. M., J. K. Johnson, D. O. Meltzer, and H. J. Humphrey. 2008. A theoretical framework and competency-based approach to improving handoffs. Quality and Safety in Health Care 17(1):11-14. [PubMed: 18245213]
• Ash, J. S., D. F. Sittig, E. G. Poon, K. Guappone, E. Campbell, and R. H. Dykstra. 2007. The extent and importance of unintended consequences related to computerized provider order entry. Journal of the American Medical Informatics Association 14(4):415-423. [PMC free article: PMC2244906] [PubMed: 17460127]
• Barach, P., and S. D. Small. 2000. Reporting and preventing medical mishaps: Lessons from non-medical near miss reporting systems. BMJ 320(7237):759-763. [PMC free article: PMC1117768] [PubMed: 10720361]
• Barach, P., and M. Weingart. 2004. Trauma team performance. In Trauma: Resuscitation, anesthesia, surgery, and critical care, edited by W. Wilson, editor; , C. Grande, editor; , and D. Hoyt, editor. . New York: Dekker Inc.
• Bates, D. W., L. L. Leape, D. J. Cullen, N. Laird, L. A. Petersen, J. M. Teich, E. Burdick, M. Hickey, S. Kleefield, B. Shea, M. Vander Vliet, and D. L. Seger. 1998. Effect of computerized physician order entry and a team intervention on prevention of serious medication errors. JAMA 280(15):1311-1316. [PubMed: 9794308]
• Battles, J. B., and C. E. Shea. 2001. A system of analyzing medical errors to improve GME curricula and programs. Academic Medicine 76(2):125-133. [PubMed: 11158830]
• Beach, C., P. Croskerry, and M. Shapiro. 2003. Profiles in patient safety: Emergency care transitions. Academic Emergency Medicine 10(4):364-367. [PubMed: 12670851]
• Behara, R., R. L. Wears, and S. J. Perry. 2005. A conceptual framework for studying the safety of transitions in emergency care. In Advances in patient safety: From research to imple mentation, Vol. 2 , Concepts and Methodology. Rockville, MD: Agency for Healthcare Research and Quality. Pp.309-321.
• Borowitz, S. M., L. A. Waggoner-Fountain, E. J. Bass, and R. M. Sledd. 2008. Adequacy of information transferred at resident sign-out (in hospital handover of care): A prospective survey. Quality and Safety in Health Care 17(1):6-10. [PubMed: 18245212]
• Campbell, E. M., D. F. Sittig, J. S. Ash, K. P. Guappone, and R. H. Dykstra. 2006. Types of unintended consequences related to computerized provider order entry. Journal of the American Medical Informatics Association 13(5):547-556. [PMC free article: PMC1561794] [PubMed: 16799128]
• Care Transitions Program. 2008. The care transitions program: Improving quality and safety during care hand-offs . http:​//caretransitions.org/overview.asp (accessed July 21, 2008).
• Carpenter, D. 2008. 2008 innovators. Healthcare’s Most Wired Magazine, http://www​.hhnmostwired​.com/hhnmostwired_app​/jsp/articledisplay​.jsp?dcrpath=HHNMOSTWIRED​/Article/data​/Summer2008/08SUM_MW​_FEA_Innovators&domain= (accessed October 20, 2008).
• Carroll, J. S., and M. A. Quijada. 2004. Redirecting traditional professional values to support safety: Changing organisational culture in health care. Quality and Safety in Health Care 13(Suppl II):ii16-ii21. [PMC free article: PMC1765803] [PubMed: 15576686]
• Catchpole, K. R., M. R. De Leval, A. McEwan, N. Pigott, M. J. Elliott, A. McQuillan, C. Macdonald, and A. J. Goldman. 2007. Patient handover from surgery to intensive care: Using Formula 1 pit-stop and aviation models to improve safety and quality. Pediatric Anesthesia 17(5):470-478. [PubMed: 17474955]
• Chung, R. S., and N. Ahmed. 2007. How surgical residents spend their training time: The effect of a goal-oriented work style on efficiency and work satisfaction. Archives of Surgery 142(3):249-252. [PubMed: 17372049]
• Coleman, E. A., and R. A. Berenson. 2004. Lost in transition: Challenges and opportunities for improving the quality of transitional care. Annals of Internal Medicine 141(7):533-536. [PubMed: 15466770]
• Curley, C. M. D. M. S., J. E. M. D. McEachern, and T. P. Speroff. 1998. A firm trial of interdisciplinary rounds on the inpatient medical wards: An intervention designed using continuous quality improvement. Medical Care 36(8 Suppl):AS4-AS12. [PubMed: 9708578]
• Evans, S. M., J. G. Berry, B. J. Smith, A. Esterman, P. Selim, J. O’Shaughnessy, and M. DeWit. 2006. Attitudes and barriers to incident reporting: A collaborative hospital study. Quality and Safety in Health Care 15(1):39-43. [PMC free article: PMC2563993] [PubMed: 16456208]
• Fletcher, K. E., S. Saint, and R. S. Mangrulkar. 2005. Balancing continuity of care with residents’ limited work hours: Defining the implications. Academic Medicine 80(1):39-43. [PubMed: 15618090]
• Forster, A. J., H. J. Murff, J. F. Peterson, T. K. Gandhi, and D. W. Bates. 2003. The incidence and severity of adverse events affecting patients after discharge from the hospital. Annals of Internal Medicine 138(3):161-167. [PubMed: 12558354]
• Gandhi, T. K. 2005. Fumbled handoffs: One dropped ball after another. Annals of Internal Medicine 142(5):352-358. [PubMed: 15738454]
• Gandhi, T. K., A. Kachalia, E. J. Thomas, A. L. Puopolo, C. Yoon, T. A. Brennan, and D. M. Studdert. 2006. Missed and delayed diagnoses in the ambulatory setting: A study of closed malpractice claims. Annals of Internal Medicine 145(7):488-496. [PubMed: 17015866]
• Garbutt, J., A. D. Waterman, J. M. Kapp, W. C. Dunagan, W. Levinson, V. Fraser, and T. H. Gallagher. 2008. Lost opportunities: How physicians communicate about medical errors. Health Affairs 27(1):246-255. [PubMed: 18180501]
• Garg, A. X., N. K. Adhikari, H. McDonald, M. P. Rosas-Arellano, P. J. Devereaux, J. Beyene, J. Sam, and R. B. Haynes. 2005. Effects of computerized clinical decision support systems on practitioner performance and patient outcomes: A systematic review. JAMA 293(10):1223-1238. [PubMed: 15755945]
• Goldstein, M. J., E. Kim, W. D. Widmann, and M. A. Hardy. 2004. A 360 degrees evaluation of a night-float system for general surgery: A response to mandated work-hours reduction. Current Surgery 61(5):445-451. [PubMed: 15475093]
• Halasyamani, L., S. Kripalani, E. Coleman, J. Schnipper, C. van Walraven, J. Nagamine, P. Torcson, T. Bookwalter, T. Budnitz, and D. Manning. 2006. Transition of care for hospitalized elderly patients—Development of a discharge checklist for hospitalists. Journal of Hospital Medicine (Online) 1(6):354-360. [PubMed: 17219528]
• Hier, D. B., A. Rothschild, A. LeMaistre, and J. Keeler. 2005. Differing faculty and housestaff acceptance of an electronic health record. International Journal of Medical Informatics 74(7-8):657-662. [PubMed: 16043088]
• Hines, S., K. Luna, J. Lofthus, M. Marquart, and D. Stelmokas. 2008. Becoming a high reli ability organization: Operational advice for hospital leaders . Rockville, MD: Agency for Healthcare Research and Quality.
• Horwitz, L. I., H. M. Krumholz, M. L. Green, and S. J. Huot. 2006. Transfers of patient care between house staff on internal medicine wards: A national survey. Archives of Internal Medicine 166(11):1173-1177. [PubMed: 16772243]
• Horwitz, L., T. Moin, and M. Green. 2007. a. Development and implementation of an oral sign-out skills curriculum. Journal of General Internal Medicine 22(10):1470-1474. [PMC free article: PMC2305855] [PubMed: 17674110]
• Horwitz, L. I., M. Kosiborod, Z. Lin, and H. M. Krumholz. 2007. b. Changes in outcomes for internal medicine inpatients after work-hour regulations. Annals of Internal Medicine 147(2):97-103. [PubMed: 17548401]
• Horwitz, L. I., T. Moin, H. M. Krumholz, L. Wang, and E. H. Bradley. 2008. Consequences of inadequate sign-out for patient care. Archives of Internal Medicine 168(16):1755-1760. [PubMed: 18779462]
• IHI (Institute for Healthcare Improvement). 2007. Transforming care at the bedside—How- to guide: Creating an ideal transition home for patients with heart failure . Boston, MA: Institute for Healthcare Improvement.
• IOM (Institute of Medicine). 2000. To err is human: Building a safer health system. Washington, DC: National Academy Press. [PubMed: 25077248]
• ———. 2001. Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academy Press. [PubMed: 25057539]
• ———. 2003. Keeping patients safe: Transforming the work environment of nurses. Washington, DC: The National Academies Press. [PubMed: 25009849]
• ———. 2004. Patient safety: Achieving a new standard for care. Washington, DC: The National Academies Press. [PubMed: 25009854]
• ———. 2006. Preventing medication errors: Quality chasm series . Washington, DC: The National Academies Press.
• Jeffcott, S. A., and C. F. Mackenzie. 2008. Measuring team performance in healthcare: Review of research and implications for patient safety. Journal of Critical Care 23(2):188-196. [PubMed: 18538211]
• Joint Commission. 2007. National Patient Safety Goals: 2007 national patient safety goals hospital version manual chapter, including implementation expectations . http://www​.jointcommission​.org/PatientSafety​/NationalPatientSafetyGoals​/07_hap_cah_npsgs.htm (accessed February 26, 2008).
• ———. 2008. Behaviors that undermine a culture of safety. Sentinel Event Alert (Issue 40, July 9):1. http://www​.jointcommission​.org/SentinelEvents​/SentinelEventAlert/sea_40.htm (accessed July 25, 2008). [PubMed: 18686330]
• Joint Commission International Center for Patient Safety. 2006. Improving hand-off communications: Meeting national patient safety goal 2E. Patient Safety 6:9-15.
• Jung, D. I., J. J. Sosik, and K. B. Baik. 2002. Investigating work group characteristics and performance over time: A replication and cross-cultural extension. Group Dynamics 6(2):153-171.
• Kaldjian, L. C., E. W. Jones, B. J. Wu, V. L. Forman-Hoffman, B. H. Levi, and G. E. Rosenthal. 2008. Reporting medical errors to improve patient safety: A survey of physicians in teaching hospitals. Archives of Internal Medicine 168(1):40-46. [PubMed: 18195194]
• Kaplan, H. S., and B. Rabin Fastman. 2003. Organization of event reporting data for sense making and system improvement. Quality and Safety in Health Care 12(Suppl 2). [PMC free article: PMC1765770] [PubMed: 14645899]
• Keenan, C. R., H. H. Nguyen, and M. Srinivasan. 2006. Electronic medical records and their impact on resident and medical student education. Academic Psychiatry 30(6):522-527. [PubMed: 17139024]
• Klein, C., D. DiazGranados, E. Salas, H. Le, C. S. Burke, R. Lyons, and G. F. Goodwin. 2009. Does team building work? Small Group Research 40(2):181-222.
• Kozlowski, S. W. J., and B. S. Bell. 2003. Work groups and teams in organizations. In Hand book of physchology: Industrial and organizational psychology, Vol. 12 , edited by W. Borman, editor; , D. Igen, editor; , and R. Klimoski, editor. . London: Wiley. Pp.333-375.
• Kripalani, S. 2008. Care transition. http://webmm.ahrq.gov/printviewperspective.aspx? perspectiveID=52 (accessed April 16, 2008).
• Laine, C., L. Goldman, J. R. Soukup, and J. G. Hayes. 1993. The impact of a regulation restricting medical house staff working hours on the quality of patient care. JAMA 269(3):374-378. [PubMed: 8418344]
• Landrigan, C. P., J. M. Rothschild, J. W. Cronin, R. Kaushal, E. Burdick, J. T. Katz, C. M. Lilly, P. H. Stone, S. W. Lockley, D. W. Bates, and C. A. Czeisler. 2004. Effect of reducing interns’ work hours on serious medical errors in intensive care units. New England Journal of Medicine 351(18):1838-1848. [PubMed: 15509817]
• Leonard, M., S. Graham, and D. Bonacum. 2004. The human factor: The critical importance of effective teamwork and communication in providing safe care Quality and Safety in Health Care 13(Suppl 1):i85-i90. [PMC free article: PMC1765783] [PubMed: 15465961]
• McMahon, G. 2008. Faulkner hospital: Integrated teaching unit—Progress report #3 . Boston, MA: Brigham and Women’s Hospital.
• Moore, C., J. Wisnivesky, S. Williams, and T. McGinn. 2003. Medical errors related to discontinuity of care from an inpatient to an outpatient setting. Journal of General Internal Medicine 18(8):646-651. [PMC free article: PMC1494907] [PubMed: 12911647]
• Morgan, B. B., A. S. Glickman, E. A. Woodard, A. S. Blaiwes, and E. Salas. 1986. Measure ment of team behavior in a Navy training environment . Orlando, FL: Naval Training Systems Center, Human Factors Division.
• Mukherjee, S. 2004. A precarious exchange. New England Journal of Medicine 351(18): 1822-1824. [PubMed: 15509813]
• O’Connell, R. T., C. Cho, N. Shah, K. Brown, and R. N. Shiffman. 2004. Take note(s): Differential EHR satisfaction with two implementations under one roof. Journal of the American Medical Informatics Association 11(1):43-49. [PMC free article: PMC305457] [PubMed: 14527978]
• Okie, S. 2007. An elusive balance—Residents’ work hours and the continuity of care. New England Journal of Medicine 356(26):2665-2667. [PubMed: 17596598]
• O’Mahony, S., E. Mazur, P. Charney, Y. Wang, and J. Fine. 2007. Use of multidisciplinary rounds to simultaneously improve quality outcomes, enhance resident education, and shorten length of stay. Journal of General Internal Medicine 22(8):1073-1079. [PMC free article: PMC2305734] [PubMed: 17486384]
• Park, J., S. I. Woodrow, R. K. Reznick, J. Beales, and H. M. MacRae. 2007. Patient care is a collective responsibility: Perceptions of professional responsibility in surgery. Surgery 142(1):111-118. [PubMed: 17630007]
• Parke, B., and A. Mishkin. 2005. Best practices in shift handover communication: Mars exploration rover surface operations. Paper read at European Space Agency (Special Publication), ESA SP, Nice, France.
• Patterson, E. S. 2007. Communication strategies from high-reliability organizations: Translation is hard work. Annals of Surgery 245(2):170-172. [PMC free article: PMC1876978] [PubMed: 17245167]
• ———. 2008. Structuring flexibility: The potential good, bad and ugly in standardisation of handovers. Quality and Safety in Health Care 17(1):4-5. [PubMed: 18245211]
• Patterson, E. S., E. M. Roth, D. D. Woods, R. Chow, and J. O. Gomes. 2004. Handoff strategies in settings with high consequences for failure: Lessons for health care operations. International Journal for Quality in Health Care 16(2):125-132. [PubMed: 15051706]
• Perry, S. J., R. L. Wears, and E. S. Patterson. 2008. (unpublished). High hanging fruit: Improv ing transitions in health care. Washington, DC: Department of Veterans Affairs.
• Petersen, L. A., T. A. Brennan, A. C. O’Neil, E. F. Cook, and T. H. Lee. 1994. Does housestaff discontinuity of care increase the risk for preventable adverse events? Annals of Internal Medicine 121(11):866. [PubMed: 7978700]
• Petersen, L. A., E. J. Orav, J. M. Teich, A. C. O’Neil, and T. A. Brennan. 1998. Using a computerized sign-out program to improve continuity of inpatient care and prevent adverse events. Joint Commission Journal on Quality Improvement 24(2):77-87. [PubMed: 9547682]
• Roberts, K. H., P. Madsen, V. Desai, and D. Van Stralen. 2005. A case of the birth and death of a high reliability healthcare organisation. Quality and Safety in Health Care 14(3):216-220. [PMC free article: PMC1744010] [PubMed: 15933321]
• Roberts, V., and M. M. Perryman. 2007. Creating a culture for health care quality and safety. Health Care Manager 26(2):155-158. [PubMed: 17464230]
• Rosen, M. A., E. Salas, T. S. Wu, S. Silvestri, E. H. Lazzara, R. Lyons, S. J. Weaver, and H. B. King. 2008. Promoting teamwork: An event-based approach to simulation-based teamwork training for emergency medicine residents. Academic Emergency Medicine 15:1-9. [PubMed: 18638035]
• Sabir, N., S. M. Yentis, and A. Holdcroft. 2006. A national survey of obstetric anaesthetic handovers. Anaesthesia 61(4):376-380. [PubMed: 16548959]
• Salas, E., and J. A. Cannon-Bowers. 2000. a. The anatomy of team training. In Training and retraining: A handbook for business, industry, government, and the military, edited by S. Tobias, editor; and J. D. Fletcher, editor. . New York: Macmillan Reference. Pp.312-335.
• ———. 2000. b. Designing training systems systematically. In The Blackwell handbook of principles of organizational behavior, edited by E. A. Locke, editor. . Malden, MA: Blackwell Publisher Ltd. Pp.43-59.
• ———. 2001. The science of training: A decade of progress. Annual Review of Psychology 52:471-499. [PubMed: 11148314]
• Salas, E., D. DiazGranados, C. Klein, C. Burke, K. Stagl, G. Goodwin, and S. Haplin. 2008. Does team training lead to improved team outcomes? A meta-analysis. Human Factors 50(6):903-933. [PubMed: 19292013]
• Salas, E., T. L. Dickinson, S. A. Converse, and S. I. Tannenbaum. 1992. Towards an understanding of team performance and training. In Teams: Their training and performance, edited by R. W. Swezey, editor; and E. Salas, editor. . Norwood, NJ: Ablex Publishing Corporation.
• Salas, E., E. Sims, and C. Klein. 2004. Cooperation and teamwork at work. In Encyclopedia of applied psychology , Vol. 1 , edited by C. D. Spielberger, editor. . San Diego, CA: Academic Press. Pp.497-505.
• Salas, E., D. E. Sims, and C. S. Burke. 2005. Is there a “Big Five” in teamwork? Small Group Research 36(5):555-599.
• Saultz, J. W. 2003. Defining and measuring interpersonal continuity of care. Annals of Family Medicine 1(3):134-143. [PMC free article: PMC1466595] [PubMed: 15043374]
• Shojania, K. G. 2005. Interpreting the patient safety literature . http://webmm​.ahrq.gov​/printviewperspective​.aspx?perspectiveID=5 (accessed April 15, 2008).
• Simmons, J., and J. Gonzalez del Rey. 2008. Family-centered rounds (FCRs): Building systems and skills for success at the bedside of the hospitalized child in a teaching hospital . Cincinnati, OH: Cincinnati Children’s Hospital Medical Center. PowerPoint presentation.
• Singer, J. I., and J. Dean. 2006. Emergency physician intershift handovers: An analysis of our transitional care. Pediatric Emergency Care 22(10):751-754. [PubMed: 17047478]
• Singer, S. J., D. M. Gaba, J. J. Geppert, A. D. Sinaiko, S. K. Howard, and K. C. Park. 2003. The culture of safety: Results of an organization-wide survey in 15 California hospitals. Quality and Safety in Health Care 12(2):112-118. [PMC free article: PMC1743680] [PubMed: 12679507]
• Singh, H., E. J. Thomas, L. A. Petersen, and D. M. Studdert. 2007. Medical errors involving trainees: A study of closed malpractice claims from 5 insurers. Archives of Internal Medicine 167(19):2030-2036. [PubMed: 17954795]
• Smith-Jentsch, K. A., E. Salas, and D. P. Baker. 1996. Training team performance-related assertiveness. Personnel Psychology 49(4):909-936.
• Smith-Jentsch, K., R. Zeisig, B. Acton, and J. McPherson. 1998. Team dimensional training: A strategy for guided team self-correction. In Making decisions under stress, edited by E. Salas, editor; and J. A. Cannon-Bowers, editor. . Washington, DC: American Psychological Association. Pp.271-297.
• Solet, D. J., J. M. Norvell, G. H. Rutan, and R. M. Frankel. 2005. Lost in translation: Challenges and opportunities in physician-to-physician communication during patient handoffs. Academic Medicine 80(12):1094-1099. [PubMed: 16306279]
• Stair, T. O., and J. M. Howell. 1995. Effect on medical education of computerized physician order entry. Academic Medicine 70(6):543. [PubMed: 7786378]
• Stevens, D. P., C. S. Sixta, E. Wagner, and J. L. Bowen. 2008. The evidence is at hand for improving care in settings where residents train. Journal of General Internal Medicine 23(7):1116-1117. [PMC free article: PMC2517951] [PubMed: 18612755]
• Sutcliffe, K. M., E. Lewton, and M. M. Rosenthal. 2004. Communication failures: An insidious contributor to medical mishaps. Academic Medicine 79(2):186-194. [PubMed: 14744724]
• Swezey, R. W., A. L. Meltzer, and E. Salas. 1994. Some issues involved in motivating teams. In Motivation: Theory and research, edited by H. F. O’Neil, Jr., editor; , and M. Drillings, editor. . Hillsdale, NJ: Lawrence Erlbaum Associates. Pp.141-169.
• TeamSTEPPS. 2007. Strategies and tools to enhance performance and patient safety: Essen tials course. Rockville, MD: Agency for Healthcare Research and Quality. PowerPoint presentation.
• Van Eaton, E. G., K. D. Horvath, W. B. Lober, A. J. Rossini, and C. A. Pellegrini. 2005. A randomized, controlled trial evaluating the impact of a computerized rounding and signout system on continuity of care and resident work hours. Journal of American College of Surgeons 200(4):538-545. [PubMed: 15804467]
• Vidyarthi, A. 2004. Fumbled handoff . http://webmm​.ahrq.gov/printview​.aspx?caseID=55 (accessed March 18, 2008).
• Vidyarthi, A. R., V. Arora, J. L. Schnipper, S. D. Wall, and R. M. Wachter. 2006. Managing discontinuity in academic medical centers: Strategies for a safe and effective resident sign-out. Journal of Hospital Medicine 1(4):257-266. [PubMed: 17219508]
• Volpp, K. G., and C. P. Landrigan. 2008. Building physician work hour regulations from first principles and best evidence. JAMA 300(10):1197-1199. [PubMed: 18780848]
• Wachter, R. M. 2008. Chapter 8: Transition and handoff errors. In Understanding patient safety, edited by J. Shanahan, editor; and K. Edmanson, editor. . New York: The McGraw-Hill Companies, Inc.
• Wachter, R. M., K. G. Shojania, A. J. Markowitz, M. Smith, and S. Saint. 2006. Quality grand rounds: The case for patient safety. Annals of Internal Medicine 145(8):629-630. [PubMed: 17043345]
• Warm, E., D. Schauer, T. Diers, B. Mathis, Y. Neirouz, J. Boex, and G. Rouan. 2008. The ambulatory long-block: An Accreditation Council for Graduate Medical Education (ACGME) Educational Innovations Project (EIP). Journal of General Internal Medicine 23(7):921-926. [PMC free article: PMC2517908] [PubMed: 18612718]
• Weick, K. E., editor; , and K. M. Sutcliffe, editor. , eds. 2001. Managing the unexpected: Assuring high perfor mance in an age of complexity. San Francisco: Jossey-Bass.
• Zheng, B., P. Denk, D. Martinec, P. Gatta, M. Whiteford, and L. Swanström. 2008. Building an efficient surgical team using a bench model simulation: Construct validity of the legacy inanimate system for endoscopic team training (LISETT). Surgical Endoscopy 22(4):930-937. [PubMed: 17710491]