HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS REGISTER		Author Keyword(s) Vol Page [Advanced]

This Article Full Text Full Text (PDF) Submit a response Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Citation Map Services Email this link to a friend Similar articles in this journal Similar articles in PubMed Add article to my folders Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Leonard, M Articles by Bonacum, D Search for Related Content PubMed PubMed Citation Articles by Leonard, M Articles by Bonacum, D

The human factor: the critical importance of effective teamwork and communication in providing safe care

¹ Colorado Permanente Medical Group, Denver, Colorado, OH, USA
² California Kaiser Permanente, Oakland, CA, USA
³ Kaiser Permanente, Oakland, CA, USA

Correspondence to:
Dr M Leonard
Physician Leader for Patient Safety, Patient Safety, One Kaiser Plaza, 22nd Floor, Oakland, CA 94612, USA; mmleonard{at}att.net Effective communication and teamwork is essential for the delivery of high quality, safe patient care. Communication failures are an extremely common cause of inadvertent patient harm. The complexity of medical care, coupled with the inherent limitations of human performance, make it critically important that clinicians have standardised communication tools, create an environment in which individuals can speak up and express concerns, and share common "critical language" to alert team members to unsafe situations. All too frequently, effective communication is situation or personality dependent. Other high reliability domains, such as commercial aviation, have shown that the adoption of standardised tools and behaviours is a very effective strategy in enhancing teamwork and reducing risk. We describe our ongoing patient safety implementation using this approach within Kaiser Permanente, a non-profit American healthcare system providing care for 8.3 million patients. We describe specific clinical experience in the application of surgical briefings, properties of high reliability perinatal care, the value of critical event training and simulation, and benefits of a standardised communication process in the care of patients transferred from hospitals to skilled nursing facilities. Additionally, lessons learned as to effective techniques in achieving cultural change, evidence of improving the quality of the work environment, practice transfer strategies, critical success factors, and the evolving methods of demonstrating the benefit of such work are described.

Abbreviations: CRM, crew resource management; OR, operating room; PIC, preferred intensity of care; SAQ, Safety Attitude Questionnaire

Keywords: communication; human factors; patient safety; teamwork

This article has been cited by other articles:

				V M Arora, J K Johnson, D O Meltzer, and H J Humphrey A theoretical framework and competency-based approach to improving handoffs Qual. Saf. Health Care, February 1, 2008; 17(1): 11 - 14. [Abstract] [Full Text] [PDF]

				P. C. Dykes, A. Hurley, M. Cashen, S. Bakken, and M. E. Duffy Development and Psychometric Evaluation of the Impact of Health Information Technology (I-HIT) Scale J. Am. Med. Inform. Assoc., July 1, 2007; 14(4): 507 - 514. [Abstract] [Full Text] [PDF]

				B. Parnes, D. Fernald, J. Quintela, R. Araya-Guerra, J. Westfall, D. Harris, and W. Pace Stopping the error cascade: a report on ameliorators from the ASIPS collaborative Qual. Saf. Health Care, February 1, 2007; 16(1): 12 - 16. [Abstract] [Full Text] [PDF]

				A N Healey, S Undre, and C A Vincent Defining the technical skills of teamwork in surgery. Qual. Saf. Health Care, August 1, 2006; 15(4): 231 - 234. [Abstract] [Full Text] [PDF]

				H Singh, L A Petersen, and E J Thomas Understanding diagnostic errors in medicine: a lesson from aviation. Qual. Saf. Health Care, June 1, 2006; 15(3): 159 - 164. [Abstract] [Full Text] [PDF]

				V Arora, J Johnson, D Lovinger, H J Humphrey, and D O Meltzer Communication failures in patient sign-out and suggestions for improvement: a critical incident analysis Qual. Saf. Health Care, December 1, 2005; 14(6): 401 - 407. [Abstract] [Full Text] [PDF]

				L Lingard, S Espin, B Rubin, S Whyte, M Colmenares, G R Baker, D Doran, E Grober, B Orser, J Bohnen, et al. Getting teams to talk: development and pilot implementation of a checklist to promote interprofessional communication in the OR Qual. Saf. Health Care, October 1, 2005; 14(5): 340 - 346. [Abstract] [Full Text] [PDF]

				B. P. Sachs A 38-Year-Old Woman With Fetal Loss and Hysterectomy JAMA, August 17, 2005; 294(7): 833 - 840. [Full Text] [PDF]