How teamwork, trust and improved communication reduce mistakes in the ER

It's so easy to think you've communicated a message clearly. After all, you understand the instructions, so it only stands to reason that the person receiving them must also understand what you meant.

And though most misunderstandings can be cleared up quickly in everyday situations, studies show that they pose a significant danger for patients when signals get crossed. In fact, an estimated 80 percent of the most serious medical errors in hospitals are linked to miscommunications.

To combat miscommunication in the emergency room, one Sheridan Healthcare physician is leading an effort to practice communication drills with his teams at Baptist Hospital of Miami. The program, based on the aviation industry's crisis or crew resource management, uses checklists and specific protocols to promote teamwork and communication.

I recently had a chance to talk to David Mishkin, M.D., and Paula Barrass, an assistant nurse manager, about the program at Baptist Hospital and how it dramatically improved teamwork and collaboration after team members received just a few hours of training.

Mishkin (pictured right) said there wasn't a particular incident that led to his decision to become involved in the program. But he noted during medical codes that there was definitely a need for ED team members to communicate better. Fortunately, he said, the nurse leaders at the hospital had the same vision and senior leaders at the hospital were quick to lend their support.

The hospital actually opened a patient safety simulation lab in 2011 and over the past two years all members of the ER team have received training. Although it's always difficult to engage physicians, Mishkin said that one physician was immediately interested and his enthusiasm spread throughout the department.

The training takes three hours and staff complete it on their own time. The scenarios vary and may include how to manage a patient experiencing an acute myocardial infarction or stroke. Staff use the scenarios to learn how to communicate with one another and improve hand offs in care.

"We find the biggest improvement has been in code situations," Barrass told me. "Before the environment was sometimes too chaotic with people doing their own thing and if the physician asked for something, maybe two nurses would leave to get the same thing. This helped us improve communication during code and now the room is much more quiet and controlled because we use the principles we learned in simulation in real life."

The training has helped the team effectively distribute workload as well and created an atmosphere where all team members are comfortable to speak up if they notice a problem, according to Mishkin.

"It established role clarity. And usually people think of the physician as the team leader but that may not always be the case," he said. "The physician may be preoccupied with the procedure on a patient and can't be the full eyes of the room and may pass leadership to another staff person."

Sometimes, he said, the leader may be a person in an administrative role who is gathering information. "We've even had an ER tech serve as the leader when the physician was intubating the patient," Barrass said.

Although the team hasn't collected hard data about a drop in medical mistakes since they launched the program, Mishkin said that anecdotally the department has seen improvement. "My relationships with my colleagues, our nurses and techs are stronger and more trusting. By stepping outside of the real work environment and doing the training, it caused me to slow down and talk through things and bring it back to the clinical setting."

Even if a hospital ER doesn't have the luxury of simulation training, Mishkin said he encourages all organizations to do what they can to help build trust and comradery. "It will only make a more successful emergency department environment and much safer patient care. I enjoy the relationships I've developed and being on the same page when we work together," he said.  --Ilene (@FierceHealth)

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