Dunn Edward J, Mills Peter D, Neily Julia, Crittenden Michael D, Carmack Amy L, Bagian James P
Department of Veterans Affairs National Center for Patient Safety, Ann Arbor, MI, USA.
Jt Comm J Qual Patient Saf. 2007 Jun;33(6):317-25. doi: 10.1016/s1553-7250(07)33036-5.
Communication failure, a leading source of adverse events in health care, was involved in approximately 75% of more than 7,000 root cause analysis reports to the Department of Veterans Affairs (VA) National Center for Patient Safety (NCPS).
The VA NCPS Medical Team Training (MTT) program, which is based on aviation principles of crew resource management (CRM), is intended to improve outcomes of patient care by enhancing communication between health care professionals. Unique features of MTT include a full-day interactive learning session (facilitated entirely by clinical peers in a health care context), administration of pre-and postintervention safety attitudes questionnaires, and follow-up semistructured interviews with reports of program activities and lessons learned.
Examples of projects in these facilities include intensive care unit (ICU) teams' patient-centered multidisciplinary rounds, surgical teams' preoperative briefings and debriefings, an entire operating room (OR) unit's adoption of "Rules of Conduct" for expected staff behavior, and an ICU team's use of the model for daily administrative briefings.
An MTT program based on applied CRM principles was successfully developed and implemented in 43 VA medical centers from September 2003 to May 2007.
沟通失误是医疗保健中不良事件的主要来源，在向退伍军人事务部（VA）国家患者安全中心（NCPS）提交的7000多份根本原因分析报告中，约75%涉及沟通失误。
VA NCPS医疗团队培训（MTT）计划基于机组资源管理（CRM）的航空原则，旨在通过加强医疗保健专业人员之间的沟通来改善患者护理结果。MTT的独特之处包括全天互动学习课程（完全由医疗保健环境中的临床同行推动）、干预前后安全态度问卷的管理，以及对项目活动报告和经验教训的后续半结构化访谈。
这些机构中的项目示例包括重症监护病房（ICU）团队以患者为中心的多学科查房、手术团队的术前简报和术后总结、整个手术室（OR）单元采用预期员工行为的“行为准则”，以及ICU团队将该模式用于日常行政简报。
2003年9月至2007年5月，在43个VA医疗中心成功开发并实施了基于应用CRM原则的MTT计划。
