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Peter J. Pronovost, Christine A. Goeschel, Kyle L. Olsen, Julius C. Pham, Marlene R. Miller, Sean M. Berenholtz, J. Bryan Sexton, Jill A. Marsteller, Laura L. Morlock, Albert W. Wu, Jerod M. Loeb, and Carolyn M. Clancy Reducing Health Care Hazards: Lessons From The Commercial Aviation Safety Team Health Affairs, May/June 2009; 28(3): w479-w489. [Abstract] [Full Text] [PDF] [Appendix Figure 1] [Reprints & Permissions]

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Crew Resource Management And Medical Team Training

Charles P. Clericuzio   ( 15 April 2009 )

Patient Safety: The Authors Respond

Peter J. Pronovost, Christine A. Goeschel, Kyle L. Olsen, Julius C. Pham, Marlene R. Miller, Sean M. Berenholtz, J. Bryan Sexton, Jill A. Marsteller, Laura L. Morlock, Albert W. Wu, Jerod M. Loeb, and Carolyn M. Clancy   ( 23 April 2009 )

Crew Resource Management And Medical Team Training 15 April 2009
Charles P. Clericuzio, Chief, Surgical Service VAMC, Jackson, MS. Send comment to journal: Re: Crew Resource Management And Medical Team Training Charles.Clericuzio{at}va.gov Charles P. Clericuzio	The Department of Veterans Health Affairs currently has an ongoing robust program of medical team training modeled on crew resource management. This program is supported by monthly conference calls from the VA National Center for Patient Safety. Arguably, the VA's model could be used as a template for the P5S.
Patient Safety: The Authors Respond 23 April 2009
Peter J. Pronovost, Professor The Johns Hopkins University, Christine A. Goeschel, Kyle L. Olsen, Julius C. Pham, Marlene R. Miller, Sean M. Berenholtz, J. Bryan Sexton, Jill A. Marsteller, Laura L. Morlock, Albert W. Wu, Jerod M. Loeb, and Carolyn M. Clancy Send comment to journal: Re: Patient Safety: The Authors Respond ppronovo{at}jhmi.edu Peter J. Pronovost, et al.	We appreciate the thoughtful comments from Dr. Clericuzio. The Department of Veterans Affairs is a leader in patient safety, and undoubtedly P5S and the entire country can learn much from them. Team training is important and long overdue in health care, and P5S will certainly build upon the VA experiences. We hope to mimic the success the VA has had working as a large and networked entity in influencing health care trends (e.g., in EMR). However, P5S will also employ other methods, such as product and process redesigns in our efforts to substantially reduce the risk of error and subsequent patient harm on a broad scale.[1] Toward that end, we can and hope to learn from many organizations. For example, the Anesthesia Patient Safety Foundation (APSF) has worked diligently for decades to design safe anesthesia equipment.[2] If we are to reduce preventable harm, safe product design needs to be coupled with a safe culture that ensures and rewards effective teamwork, including measurement, feedback, and continuous opportunities for learning, participation, and improvement. At a recent U.S. Senate quality of care hearing, Senator Hagen stated, “I cannot stick a diesel fuel pump into my gas powered car because it does not fit. I am protected from making this mistake. Yet caregivers can connect an epidural to an intravenous catheter and harm patients. How can that be?” It is unlikely that health care provider organizations working alone will make substantial or comprehensive progress in improving patient safety. It is equally unlikely that telling nurses and doctors to be more careful will be an effective or efficient method to comprehensively improve safety. Rather, we need to partner with a variety of stakeholders and manufacturers, identify specific hazards, and design interventions that reduce risks to all patients. Our hope is that comprehensive approaches such as P5S will complement and expand upon previous efforts such that health care is safer because we have redesigned it to make it harder to make mistakes. NOTES 1. Pronovost PJ et al. “Reducing Health Care Hazards: Lessons from the Commercial Aviation Safety Team,” Health Affairs Web Exclusive, April 7, 2009. 2. See the Anesthesia Patient Safety Foundation home page, http://www.apsf.org