Using an Interprofessional Lens to Analyze Serious Adverse Events in a Teaching Hospital: An Analysis with the TeamSTEPPS^® Framework

Abstract

This paper explores the contribution of teamwork skills in serious adverse events, using the TeamSTEPPS ® framework. Adverse events are the undesirable events that are not due to the natural course of a disease; they are considered serious when they prolong a hospital stay, lead to a physical disability or to death. Failures in teamwork, particularly with interprofessional teams, can lead to potential risks to patient safety. Using a dataset of de-identified reports of serious adverse events in 2016 in a tertiary teaching hospital, we explored the contribution of teamwork skills according to the TeamSTEPPS ® framework to these adverse events. We found that 61% of the 41 analyzed events involved failures in teamwork skills, with 80% of these involving communication, 52% in situation monitoring and team structure, 44% in mutual support and 40% in leadership. Sixty-four percent of the events involved more than one teamwork component. Our findings emphasize the need to improve teamwork training in healthcare, focusing not only on communication, but also on other teamwork skills as they often contribute together in adverse events. Future analyses of serious adverse events should include a focus on teamwork competencies, to guide the development of future quality and safety training programs.