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Dr Goffman is the Director, Quality, Patient Safety & Simulation and Associate Professor, Department of Obstetrics & Gynecology and Women's Health, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York.
Simulation training can prepare an obstetrical team for emergencies and provide a way to effectively review performance.
The dialogue you've just read is from a simulation used to train an obstetric team in managing shoulder dystocia. This scenario is commonly used for simulation team training because it happens infrequently, but has a high potential for morbidity.
Incidence of shoulder dystocia ranges from 0.2% to 3.0%1 in vaginal deliveries of fetuses in the vertex presentation, making it relatively rare, yet lawsuits involving brachial plexus injuries after shoulder dystocia are now the second most common type of lawsuit in obstetrics.2
A 1999 Institute of Medicine (IOM) landmark report on medical error and patient safety stated: "The committee [Committee on Quality of Health Care in America] believes that healthcare organizations should establish team training programs for personnel in critical care areas...using proven methods such as crew resource management techniques employed in aviation, including simulation."3
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) released a Sentinel Alert in 2004. In the cases studied, communication failures topped the list of identified root causes (72%). The JCAHO report states: "Since the majority of perinatal death and injury cases reported root causes related to problems with organizational culture and with communication among caregivers, it is recommended that organizations, 1) conduct team training in perinatal areas to teach staff to work together and communicate more effectively, and 2) for high-risk events, such as shoulder dystocia, emergency cesarean delivery, maternal hemorrhage and neonatal resuscitation, conduct clinical drills to help staff prepare for when such events actually occur, and conduct debriefings to evaluate team performance and identify areas for improvement."4
Team training and simulation are not new or untested in healthcare, and many well-established programs exist across the United States.5,6 To really understand why the concept works so well, it is important to understand how and why it started.
Team training originated in the commercial and military sectors of the aviation industry. Crew resource management (CRM) was conceived in a National Aeronautics and Space Administration workshop in 1979 and developed to focus on the skills of communication, leadership, and decision-making of flight crews.7
CRM has since been adopted by other high-risk industries and organizations such as nuclear power and air traffic control.8 The work environments of the aviation and healthcare industries share characteristics of complexity, intense stress, time sensitivity, multiple players, and a requirement that teams function consistently at high levels in environments in which human error can be devastating.7
A well-known team-training program for the healthcare industry is Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS). TeamSTEPPS was developed by the US Department of Defense's patient-safety program in collaboration with the Agency for Healthcare Research and Quality to extend the military's research on team performance to healthcare.9,10 The program identified essential team performance skills, including aspects of teamwork, leadership, performance monitoring, mutual support, and communication. (The TeamSTEPPS program includes a comprehensive multimedia kit of instructional modules available free to any institution at http://teamstepps.ahrq.gov/.)