Grand Rounds: Lessons from the cockpit: How team training can reduce errors on L&D

January 1, 2006

Although many ob/gyns believe they already work on an interdisciplinary team, most don't really apply the principles of teamwork on labor and delivery. This Harvard team has discovered that applying the concepts used by military and commercial flight teams—an approach called Crew Resource Management—can improve patient safety and reduce the epidemic of lawsuits plaguing the specialty.

Preventable medical errors account for more deaths each year than breast cancer, automobile accidents, or drownings. Poor communication among health-care workers is the most common cause of these errors.1,2 This state of affairs is due in part to the fact that patient care is still provided by clinicians who are compartmentalized into separate disciplines, the so-called "silo approach" to health care. Changing this culture is going to require team training across disciplines, encompassing obstetricians, midwives, nurses, and anesthesia providers. And while this approach may meet some resistance, we're convinced by the data-and our own clinical experience-that it will provide a safety net that helps reduce preventable errors and medical malpractice suits.

The impact of preventable medical errors was recognized by the Institute of Medicine in its 1999 landmark report on patient safety, To Err is Human, which estimated that 45,000 to 98,000 Americans die annually and cost the nation about $29 billion.3 What many critics forget, however, is that these errors are often made by highly skilled professionals and are generally the result of system failures, not substandard individual performance. Unfortunately, despite our best intentions, errors occur, patients die, and the clinicians involved often become the "secondary victim."4

Currently, in most labor and delivery units, patient information is not shared in a coordinated way between providers. When there's a shift change, for instance, nurses sign out to nurses, obstetricians hand off patients to obstetricians-often by phone or e-mail-residents attend teaching rounds, and rarely are anesthesiologists and neonatologists included in any sign-out of important information regarding OB patients. Adding insult to injury, physicians, nurses, pharmacists, and ancillary staff all come from diverse educational and train-ing backgrounds, which means they speak a somewhat different language.

What's wrong with the current system?

It may seem obvious, but health-care professionals are interdependent and have to effectively communicate and coordinate their activities to provide efficient and safe patient care. With that in mind, the second IOM report in 2001, Crossing the Quality Chasm, recommended that health-care organizations establish interdisciplinary team training programs for clinicians to incorporate the proven team training strategies used in the aviation industry.7

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) noted in a Sentinel Alert issued in July 2004 that most cases of perinatal death and injury are caused by problems with an organization's culture and with communication among caregivers. That prompted the accrediting agency to recommend that organizations conduct team training in perinatal areas to teach staff to work together and communicate more effectively.2 Not coincidentally, communication is one of the six core competencies of Accreditation Council for Graduate Medical Education (ACGME) that requires residents to "demonstrate interpersonal and communication skills that result in effective information exchange and teaming with patients... and professional associates."8 With the advent of the resident 80-hour workweek and shorter shifts, these skills are even more important to improve hand-offs.

While most clinicians feel that they already work in teams, the plain truth is they often don't. Teamwork concepts are rarely taught in the curricula of most health-care professional training programs and are not yet commonplace in medical practice.9 Continuing educational forums rarely include obstetrics, anesthesia, and nursing in one room, despite the desperate need for precise communication between these providers.

Taking a lesson from aviation crews