Nonlinear effects of team tenure on team psychological safety climate and climate strength: Implications for average team member performance.

PubMed

Koopmann, Jaclyn; Lanaj, Klodiana; Wang, Mo; Zhou, Le; Shi, Junqi

2016-07-01

The teams literature suggests that team tenure improves team psychological safety climate and climate strength in a linear fashion, but the empirical findings to date have been mixed. Alternatively, theories of group formation suggest that new and longer tenured teams experience greater team psychological safety climate than moderately tenured teams. Adopting this second perspective, we used a sample of 115 research and development teams and found that team tenure had a curvilinear relationship with team psychological safety climate and climate strength. Supporting group formation theories, team psychological safety climate and climate strength were higher in new and longer tenured teams compared with moderately tenured teams. Moreover, we found a curvilinear relationship between team tenure and average team member creative performance as partially mediated by team psychological safety climate. Team psychological safety climate improved average team member task performance only when team psychological safety climate was strong. Likewise, team tenure influenced average team member task performance in a curvilinear manner via team psychological safety climate only when team psychological safety climate was strong. We discuss theoretical and practical implications and offer several directions for future research. (PsycINFO Database Record (c) 2016 APA, all rights reserved).

Implementations of the Navy Coupled Ocean Data Assimilation System at the Naval Oceanographic Office

DTIC Science & Technology

2010-06-01

Clim ( GDEM ) +−2std = 95.4% GDEM POE at Depth MODAS Synthetic Profile T,S with Sat SST Local OI of Nearby Valid Data Global3D Analysis Fig. 3. NCODA...observation (Obs), NCODA analysis (Anal), RNCOM nowcast (NCST) for today, RNCOM 24–hour forecast (FCST) from yesterday, GDEM climatology (Clim), and the

Spectral Variability of Airborne Ocean Color Data Linked to Variations in Lidar Backscattering Profiles

DTIC Science & Technology

2009-01-01

1008.3 r <•-• ADOR/Director NCST E. R. Franchi , 7000 Public Affairs (Unclassified/ Unlimited Only), Code 703Q 4 ’𔃻 iJL:,. iUn’i i’-"Vt... global ocean color sensors (e.g., MODIS). Also, this resolution roughly matches the swath of MicroSAS radiometric measurements in the visible range

Anomalous Upwelling in Nan Wan: July 2008

DTIC Science & Technology

2009-12-01

Head Ruth H. Preller 7300 Security, Code 1226 Office of Couns sl.Code 1008.3 ADOR/Director NCST E. R. Franchi , 7000 Public Affairs (Unclassified...State University (OSU) tidal forcing drives the tidal currents. A global weather forecast model (Navy Operational Global Atmospheric Prediction...system derives its open ocean boundary conditions from NRL global NCOM (Navy Co- astal Ocean Model) (Rhodes et al. 2002) that operates daily

Integrated Modeling of the Battlespace Environment

DTIC Science & Technology

2010-10-01

Office of Counsel.Code 1008.3 ADOR/Director NCST E. R. Franchi , 7000 Public Affairs (Unclassified/ Unlimited Only). Code 7030 4 Division, Code...ESMF: the Hakamada- Akasofu-Fry version 2 (HAFv2) solar wind model and the global assimilation of ionospheric mea- surements (GAIM1) forecast...ground-truth measurements for comparison with the solar wind predictions. Global Assimilation of Ionospheric Measurements The GAIMv2.3 effort

Evaluation of the combined effects of reclaimed asphalt pavement (RAP), reclaimed asphalt shingles (RAS), and different virgin binder sources on the performance of blended binders for mixes with higher percentages of RAP and RAS : a research report from t

DOT National Transportation Integrated Search

2015-11-01

This report summarizes the main findings from a project funded by the National Center for : Sustainable Transportation (NCST) to investigate the use of higher percentages of reclaimed : asphalt pavement (RAP) and reclaimed asphalt shingles (RAS) as a...

Evaluation of the combined effects of reclaimed asphalt pavement (RAP), reclaimed asphalt shingles (RAS), and different virgin binder sources on the performance of blended binders for mixes with higher percentages of RAP and RAS : a national center for su

DOT National Transportation Integrated Search

2015-11-01

This report summarizes the main findings from a project funded by the National Center for : Sustainable Transportation (NCST) to investigate the use of higher percentages of reclaimed : asphalt pavement (RAP) and reclaimed asphalt shingles (RAS) as a...

Bio-Physical Ocean Modeling in the Gulf of Mexico

DTIC Science & Technology

2009-01-01

up to 1 20-hour forecasts for the region. In this configuration, the model receives (initial) boundary information from the operational 1/8" Global ...NCOM, and it is forced by 3-hourly 1/2° momentum and heat fluxes from the Naval Operational Global Prediction System (NOGAPS). The NCOMGOM model...H. Preller, 7300 Security, Code 1226 Office of Counsel,Code 1008.3 ADOR/Director NCST E. R. Franchi , 7000 Public Affairs (Unclassified

A Note on NCOM Temperature Forecast Error Calibration Using the Ensemble Transform

DTIC Science & Technology

2009-01-01

Division Head Ruth H. Preller, 7300 Security, Code 1226 Office of Counsel,Code 1008.3 ADOR/Director NCST E. R. Franchi , 7000 Public Affairs...problem, local unbiased (correlation) and persistent errors (bias) of the Navy Coastal Ocean Modeling (NCOM) System nested in global ocean domains, are...system were made available in real-time without performing local data assimilation, though remote sensing and global data was assimilated on the

Patterns of Indian Ocean Sea-Level Change in a Warming Climate

DTIC Science & Technology

2010-08-01

distribution is unlimited. 13. SUPPLEMENTARY NOTES 20110415461 14 ABSTRACT Global sea level has risen during the past decades as a result of thermal...expansion of the warming ocean and freshwater addition from melting continental icel However, sea-level rise is not globally uniforml, 2, 3, 4, 5...7320 Division Head Ruth H. Preller, 7300 Security. Code 1226 Office of Counsel,Code 1008.3 ADOR/Director NCST E. R. Franchi , 7000 Public

The content of the message matters: The differential effects of promotive and prohibitive team voice on team productivity and safety performance gains.

PubMed

Li, Alex Ning; Liao, Hui; Tangirala, Subrahmaniam; Firth, Brady M

2017-08-01

We propose that it is important to take the content of team voice into account when examining its impact on team processes and outcomes. Drawing on regulatory focus theory (Higgins, 1997), we argue that promotive team voice and prohibitive team voice help teams achieve distinct collective outcomes-that is, team productivity performance gains and team safety performance gains, respectively. Further, we identify mechanisms through which promotive and prohibitive team voices uniquely influence team outcomes as well as boundary conditions for such influences. In data collected from 88 production teams, we found that promotive team voice had a positive association with team productivity performance gains. By contrast, prohibitive team voice had a positive association with team safety performance gains. The relationship between promotive team voice and team productivity performance gains was mediated by team innovation, and the relationship between prohibitive team voice and team safety performance gains was mediated by team monitoring. In addition, the indirect effect of prohibitive team voice on team safety performance gains via team monitoring was stronger when prior team safety performance was lower. We discuss the theoretical and practical implications of these findings. (PsycINFO Database Record (c) 2017 APA, all rights reserved).

Team safety and innovation by learning from errors in long-term care settings.

PubMed

Buljac-Samardžić, Martina; van Woerkom, Marianne; Paauwe, Jaap

2012-01-01

Team safety and team innovation are underexplored in the context of long-term care. Understanding the issues requires attention to how teams cope with error. Team managers could have an important role in developing a team's error orientation and managing team membership instabilities. The aim of this study was to examine the impact of team member stability, team coaching, and a team's error orientation on team safety and innovation. A cross-sectional survey method was employed within 2 long-term care organizations. Team members and team managers received a survey that measured safety and innovation. Team members assessed member stability, team coaching, and team error orientation (i.e., problem-solving and blaming approach). The final sample included 933 respondents from 152 teams. Stable teams and teams with managers who take on the role of coach are more likely to adopt a problem-solving approach and less likely to adopt a blaming approach toward errors. Both error orientations are related to team member ratings of safety and innovation, but only the blaming approach is (negatively) related to manager ratings of innovation. Differences between members' and managers' ratings of safety are greater in teams with relatively high scores for the blaming approach and relatively low scores for the problem-solving approach. Team coaching was found to be positively related to innovation, especially in unstable teams. Long-term care organizations that wish to enhance team safety and innovation should encourage a problem-solving approach and discourage a blaming approach. Team managers can play a crucial role in this by coaching team members to see errors as sources of learning and improvement and ensuring that individuals will not be blamed for errors.

Beyond the First Optical Depth: Fusing Optical Data From Ocean Color Imagery and Gliders

DTIC Science & Technology

2009-01-01

34*/ Office of Counsel,Code 1008.3 U •• "*-<-, ADOR/Director NCST E. R. Franchi , 7000 %. Public Affairs (Unclassified/ Unlimited Only). Code -rn...extreme weather (e.g., hurricanes) becoming a safe and efficient alternative to shipboard surveys3. Despite these benefits , data streams provided by...ECO-triplet poke, WetLabs). Unlike other glider types (e.g., spray, seaglider), the use of Slocums was especially advantageous in the WAP region to

77 FR 33016 - Agency Information Collection Activities: Requests for Comments; Clearance of New Approval of...

Federal Register 2010, 2011, 2012, 2013, 2014

2012-06-04

... Safety Team Safety Enhancements AGENCY: Federal Aviation Administration (FAA), DOT. ACTION: Notice and... Aviation Safety Team (CAST) safety enhancements (SEs) from certificate holders conducting operations under... . SUPPLEMENTARY INFORMATION: OMB Control Number: 2120-XXXX. Title: Commercial Aviation Safety Team Safety...

Reaping the benefits of task conflict in teams: the critical role of team psychological safety climate.

PubMed

Bradley, Bret H; Postlethwaite, Bennett E; Klotz, Anthony C; Hamdani, Maria R; Brown, Kenneth G

2012-01-01

Past research suggests that task conflict may improve team performance under certain conditions; however, we know little about these specific conditions. On the basis of prior theory and research on conflict in teams, we argue that a climate of psychological safety is one specific context under which task conflict will improve team performance. Using evidence from 117 project teams, the present research found that psychological safety climate moderates the relationship between task conflict and performance. Specifically, task conflict and team performance were positively associated under conditions of high psychological safety. The results support the conclusion that psychological safety facilitates the performance benefits of task conflict in teams. Theoretical implications and suggestions for future research are discussed.

Salt Transport in the Near-Surface Layer in the Monsoon-Influenced Indian Ocean Using HYCOM

DTIC Science & Technology

2010-08-04

A copy is filed in this office. Office of Counsel,Code 1008.3 ADOR/Director NCST E. R. Franchi , 7000 .^SLjdM/fc^- */?//<» Public Affairs...mechanisms for the transport of salt in the Indian Ocean are not fully understood. Global HYCOM simulated SSS data, validated with in situ observations...included in the HYCOM SSS simulations. 2. Data and Methods [6] This study uses the 4 year period (2003-2006) monthly SSS from the global HYbrid

Combining Satellite Ocean Color Imagery and Circulation Modeling to Forecast Bio-Optical Properties: Comparison of Models and Advection Schemes

DTIC Science & Technology

2008-10-01

Director NCST E. R. Franchi , 7000 ^^M^4^k ro£— 4// 2^/s y Public Affairs (Unclassified/ Unlimited Only), Code 7030 4 Division, Code Author, Code...from the Navy Operational Global Atmospheric Prediction System (NOGAPS, Hogan and Rosmond, 1991) and assimilates data via the Navy Coupled Ocean...forecasts using Global , Atlantic, Gulf of Mexico, and northern Gulf of Mexico configurations of HYCOM. Proceedings, Ocean Optics XIX, Castelvecchio Pascoli

A Model-Coupling Framework for Nearshore Waves, Currents, Sediment Transport, and Seabed Morphology

DTIC Science & Technology

2009-01-01

1008.3 ADOR/Director NCST E. R. Franchi , 7000 1. Paper or abstract was released 2. A copy is filed in this office. WfcfeF Public Affairs...have been developed to simulate and predict their behaviors in the past few decades. For example, models have been designed to forecast global ...Smedstad LF. Rhodes RC Validation of interannual simulations from the 1/8° global Navy Coastal Ocean Model (NCOM). Ocean Model 2006;11:376-98. |5| Van

Uncertainties of Optical Parameters and Their Propagations in an Analytical Ocean Color Inversion Algorithm

DTIC Science & Technology

2010-01-20

34’/ Office of Counsel,Code 1008.3 .( 41 «, • ADOR/Director NCST E. R. Franchi , 7000 Public Affairs (Unclassified/ Unlimited Only), Code 703o...satellite remote sensors are indispensable. To meet this requirement, systematic observations of the biogeochemical prop- erties of global oceans through...average a(550)qAA of each group) for the various a(550) groups. For O(550)QAA < 0.1 m" 1, which covers ~95% of global waters (Bryan Franz, personal com

Establishing Baseline Subsurface Light Fields for the Flower Garden Banks National Marine Sancturay

DTIC Science & Technology

2011-04-12

Code 1226 Office of Counsel,Code 1008.3 ADOR/Director NCST E. R. Franchi , 7000 Public Affairs (Unclassified/ Unlimited Only). Code 7030 4...deRada et al., 2009), which receives boundary information from the operational Global NCOM system (Kara et al., 2006; http://www7320.nrlssc.navy.mil...Gulf of Mexico. OCEANS 2009, MTS/IEEE Biloxi - Marine Technology for Our Future: Global and Local Challenges, ISBN: 978-1-4244-4960-6, pp. 1-7, 26-29

Evaluation of Assimilative SST Forecasts in the Okinawa Trough and Gulf of Mexico

DTIC Science & Technology

2012-12-06

Ruth H. Preller, 7300 Socurily, Code -- 1231 Office of 1008.3 ADOR/Director NCST E. R. Franchi , 7000 Public Affairs (Unclassified/ Unlimited Only...E. R. Franchi , 7000 Pubii<: Aifaini iiJneia5s;ii$(iF. · - Unlimited Only), Code 7030•4 0 ·-5 -J·z_...operational global ocean model GOFS 2.6. The SST level 2 data assimilated in these studies is provided by NAVOCEANO and introduced into NCODA via its OCNQC

Impacts of Freshwater on the Seasonal Variations of Surface Salinity in the Caspian Sea

DTIC Science & Technology

2010-01-01

Counsel.Code 1008.3 ADOR/Director NCST E. R. Franchi , 7000 Public Affairs (Unclassified/ Unlimited Only). Code 7030 4 " 7-? o* c •> 1...component of a global ocean system. It is included neither in high resolution eddy resolving ocean models nor in existing operational models. Examples of...601153N as part of the NRL 6.1 Global Remote Littoral Forcing via Deep Water Pathways project. This is contribution NRL/JA/7320/08/8235 and has been

Republished: Building a culture of safety through team training and engagement.

PubMed

Thomas, Lily; Galla, Catherine

2013-07-01

Medical errors continue to occur despite multiple strategies devised for their prevention. Although many safety initiatives lead to improvement, they are often short lived and unsustainable. Our goal was to build a culture of patient safety within a structure that optimised teamwork and ongoing engagement of the healthcare team. Teamwork impacts the effectiveness of care, patient safety and clinical outcomes, and team training has been identified as a strategy for enhancing teamwork, reducing medical errors and building a culture of safety in healthcare. Therefore, we implemented Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS), an evidence-based framework which was used for team training to create transformational and/or incremental changes; facilitating transformation of organisational culture, or solving specific problems. To date, TeamSTEPPS (TS) has been implemented in 14 hospitals, two Long Term Care Facilities, and outpatient areas across the North Shore LIJ Health System. 32 150 members of the healthcare team have been trained. TeamSTEPPS was piloted at a community hospital within the framework of the health system's organisational care delivery model, the Collaborative Care Model to facilitate sustainment. AHRQ's Hospital Survey on Patient Safety Culture, (HSOPSC), was administered before and after implementation of TeamSTEPPS, comparing the perception of patient safety by the heathcare team. Pilot hospital results of HSOPSC show significant improvement from 2007 (pre-TeamSTEPPS) to 2010. System-wide results of HSOPSC show similar trends to those seen in the pilot hospital. Valuable lessons for organisational success from the pilot hospital enabled rapid spread of TeamSTEPPS across the rest of the health system.

Building a culture of safety through team training and engagement.

PubMed

Thomas, Lily; Galla, Catherine

2013-05-01

Medical errors continue to occur despite multiple strategies devised for their prevention. Although many safety initiatives lead to improvement, they are often short lived and unsustainable. Our goal was to build a culture of patient safety within a structure that optimised teamwork and ongoing engagement of the healthcare team. Teamwork impacts the effectiveness of care, patient safety and clinical outcomes, and team training has been identified as a strategy for enhancing teamwork, reducing medical errors and building a culture of safety in healthcare. Therefore, we implemented Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS), an evidence-based framework which was used for team training to create transformational and/or incremental changes; facilitating transformation of organisational culture, or solving specific problems. To date, TeamSTEPPS (TS) has been implemented in 14 hospitals, two Long Term Care Facilities, and outpatient areas across the North Shore LIJ Health System. 32 150 members of the healthcare team have been trained. TeamSTEPPS was piloted at a community hospital within the framework of the health system's organisational care delivery model, the Collaborative Care Model to facilitate sustainment. AHRQ's Hospital Survey on Patient Safety Culture, (HSOPSC), was administered before and after implementation of TeamSTEPPS, comparing the perception of patient safety by the heathcare team. Pilot hospital results of HSOPSC show significant improvement from 2007 (pre-TeamSTEPPS) to 2010. System-wide results of HSOPSC show similar trends to those seen in the pilot hospital. Valuable lessons for organisational success from the pilot hospital enabled rapid spread of TeamSTEPPS across the rest of the health system.

Relationship among team dynamics, care coordination and perception of safety culture in primary care.

PubMed

Blumenthal, Karen J; Chien, Alyna T; Singer, Sara J

2018-05-18

There remains a need to improve patient safety in primary care settings. Studies have demonstrated that creating high-performing teams can improve patient safety and encourage a safety culture within hospital settings, but little is known about this relationship in primary care. To examine how team dynamics relate to perceptions of safety culture in primary care and whether care coordination plays an intermediating role. This is a cross-sectional survey study with 63% response (n = 1082). The study participants were attending clinicians, resident physicians and other staff who interacted with patients from 19 primary care practices affiliated with Harvard Medical School. Three domains corresponding with our main measures: team dynamics, care coordination and safety culture. All items were measured on a 5-point Likert scale. We used linear regression clustered by practice site to assess the relationship between team dynamics and perceptions of safety culture. We also performed a mediation analysis to determine the extent to which care coordination explains the relationship between perceptions of team dynamics and of safety culture. For every 1-point increase in overall team dynamics, there was a 0.76-point increase in perception of safety culture [95% confidence interval (CI) 0.70-0.82, P < 0.001]. Care coordination mediated the relationship between team dynamics and the perception of safety culture. Our findings suggest there is a relationship between team dynamics, care coordination and perceptions of patient safety in a primary care setting. To make patients safer, we may need to pay more attention to how primary care providers work together to coordinate care.

76 FR 47287 - Agency Information Collection Activities: Requests for Comments; Clearance of a New Information...

Federal Register 2010, 2011, 2012, 2013, 2014

2011-08-04

... Activities: Requests for Comments; Clearance of a New Information Collection: Commercial Aviation Safety Team... Commercial Aviation Safety Team (CAST) safety enhancements (SEs) from certificate holders conducting....gov . SUPPLEMENTARY INFORMATION: OMB Control Number: 2120-XXXX. Title: Commercial Aviation Safety Team...

15 CFR 270.102 - Conditions for establishment and deployment of a Team.

Code of Federal Regulations, 2010 CFR

2010-01-01

... deployment of a Team. 270.102 Section 270.102 Commerce and Foreign Trade Regulations Relating to Commerce and... SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Establishment and Deployment of Teams § 270.102 Conditions for establishment and deployment of a Team. (a) The Director may establish a Team for deployment...

15 CFR 270.102 - Conditions for establishment and deployment of a Team.

Code of Federal Regulations, 2014 CFR

2014-01-01

... deployment of a Team. 270.102 Section 270.102 Commerce and Foreign Trade Regulations Relating to Commerce and... SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Establishment and Deployment of Teams § 270.102 Conditions for establishment and deployment of a Team. (a) The Director may establish a Team for deployment...

15 CFR 270.102 - Conditions for establishment and deployment of a Team.

Code of Federal Regulations, 2013 CFR

2013-01-01

... deployment of a Team. 270.102 Section 270.102 Commerce and Foreign Trade Regulations Relating to Commerce and... SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Establishment and Deployment of Teams § 270.102 Conditions for establishment and deployment of a Team. (a) The Director may establish a Team for deployment...

15 CFR 270.102 - Conditions for establishment and deployment of a Team.

Code of Federal Regulations, 2012 CFR

2012-01-01

... deployment of a Team. 270.102 Section 270.102 Commerce and Foreign Trade Regulations Relating to Commerce and... SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Establishment and Deployment of Teams § 270.102 Conditions for establishment and deployment of a Team. (a) The Director may establish a Team for deployment...

15 CFR 270.105 - Duties of a Team.

Code of Federal Regulations, 2014 CFR

2014-01-01

... 15 Commerce and Foreign Trade 1 2014-01-01 2014-01-01 false Duties of a Team. 270.105 Section 270... OF STANDARDS AND TECHNOLOGY, DEPARTMENT OF COMMERCE NATIONAL CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Establishment and Deployment of Teams § 270.105 Duties of a Team. (a) A Team's Lead...

15 CFR 270.105 - Duties of a Team.

Code of Federal Regulations, 2012 CFR

2012-01-01

... 15 Commerce and Foreign Trade 1 2012-01-01 2012-01-01 false Duties of a Team. 270.105 Section 270... OF STANDARDS AND TECHNOLOGY, DEPARTMENT OF COMMERCE NATIONAL CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Establishment and Deployment of Teams § 270.105 Duties of a Team. (a) A Team's Lead...

15 CFR 270.105 - Duties of a Team.

Code of Federal Regulations, 2013 CFR

2013-01-01

... 15 Commerce and Foreign Trade 1 2013-01-01 2013-01-01 false Duties of a Team. 270.105 Section 270... OF STANDARDS AND TECHNOLOGY, DEPARTMENT OF COMMERCE NATIONAL CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Establishment and Deployment of Teams § 270.105 Duties of a Team. (a) A Team's Lead...

15 CFR 270.105 - Duties of a Team.

Code of Federal Regulations, 2010 CFR

2010-01-01

... 15 Commerce and Foreign Trade 1 2010-01-01 2010-01-01 false Duties of a Team. 270.105 Section 270... OF STANDARDS AND TECHNOLOGY, DEPARTMENT OF COMMERCE NATIONAL CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Establishment and Deployment of Teams § 270.105 Duties of a Team. (a) A Team's Lead...

15 CFR 270.105 - Duties of a Team.

Code of Federal Regulations, 2011 CFR

2011-01-01

... 15 Commerce and Foreign Trade 1 2011-01-01 2011-01-01 false Duties of a Team. 270.105 Section 270... OF STANDARDS AND TECHNOLOGY, DEPARTMENT OF COMMERCE NATIONAL CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Establishment and Deployment of Teams § 270.105 Duties of a Team. (a) A Team's Lead...

15 CFR 270.102 - Conditions for establishment and deployment of a Team.

Code of Federal Regulations, 2011 CFR

2011-01-01

... deployment of a Team. 270.102 Section 270.102 Commerce and Foreign Trade Regulations Relating to Commerce and... SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Establishment and Deployment of Teams § 270.102 Conditions for establishment and deployment of a Team. (a) The Director may establish a Team for deployment...

Multi-Model Validation in the Chesapeake Bay Region in June 2010

DTIC Science & Technology

2013-05-31

ADOR/Director NCST E. R. Franchi , 7000 Public Affairs (Unclassified/ Unlimited Only), Code 7030_4 X no ---~~~~~~~~~~~~~~~-~-~~-~------------ thor...US Navy at global , regional and coastal scales (Rowley 2008, 2010). The NCOM model in the Chesapeake Bay region for this exercise is configured in...derived from the NRL DBDB2 global bathymetry database. Boundary forcing and initial conditions were extracted from the East Coast NCOM which has a 3-km

15 CFR 270.352 - Public safety information.

Code of Federal Regulations, 2012 CFR

2012-01-01

... INSTITUTE OF STANDARDS AND TECHNOLOGY, DEPARTMENT OF COMMERCE NATIONAL CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Collection and Preservation of Evidence; Information Created Pursuant to an... Team, NIST, and any other investigation participant will not publicly release any information it...

15 CFR 270.352 - Public safety information.

Code of Federal Regulations, 2011 CFR

2011-01-01

... INSTITUTE OF STANDARDS AND TECHNOLOGY, DEPARTMENT OF COMMERCE NATIONAL CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Collection and Preservation of Evidence; Information Created Pursuant to an... Team, NIST, and any other investigation participant will not publicly release any information it...

15 CFR 270.352 - Public safety information.

Code of Federal Regulations, 2010 CFR

2010-01-01

... INSTITUTE OF STANDARDS AND TECHNOLOGY, DEPARTMENT OF COMMERCE NATIONAL CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Collection and Preservation of Evidence; Information Created Pursuant to an... Team, NIST, and any other investigation participant will not publicly release any information it...

15 CFR 270.352 - Public safety information.

Code of Federal Regulations, 2013 CFR

2013-01-01

... INSTITUTE OF STANDARDS AND TECHNOLOGY, DEPARTMENT OF COMMERCE NATIONAL CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Collection and Preservation of Evidence; Information Created Pursuant to an... Team, NIST, and any other investigation participant will not publicly release any information it...

15 CFR 270.106 - Conflicts of interest related to service on a Team.

Code of Federal Regulations, 2012 CFR

2012-01-01

... service on a Team. 270.106 Section 270.106 Commerce and Foreign Trade Regulations Relating to Commerce and... SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Establishment and Deployment of Teams § 270.106 Conflicts of interest related to service on a Team. (a) Team members who are not Federal employees will be...

15 CFR 270.106 - Conflicts of interest related to service on a Team.

Code of Federal Regulations, 2011 CFR

2011-01-01

... service on a Team. 270.106 Section 270.106 Commerce and Foreign Trade Regulations Relating to Commerce and... SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Establishment and Deployment of Teams § 270.106 Conflicts of interest related to service on a Team. (a) Team members who are not Federal employees will be...

15 CFR 270.106 - Conflicts of interest related to service on a Team.

Code of Federal Regulations, 2014 CFR

2014-01-01

... service on a Team. 270.106 Section 270.106 Commerce and Foreign Trade Regulations Relating to Commerce and... SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Establishment and Deployment of Teams § 270.106 Conflicts of interest related to service on a Team. (a) Team members who are not Federal employees will be...

15 CFR 270.106 - Conflicts of interest related to service on a Team.

Code of Federal Regulations, 2013 CFR

2013-01-01

... service on a Team. 270.106 Section 270.106 Commerce and Foreign Trade Regulations Relating to Commerce and... SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Establishment and Deployment of Teams § 270.106 Conflicts of interest related to service on a Team. (a) Team members who are not Federal employees will be...

15 CFR 270.106 - Conflicts of interest related to service on a Team.

Code of Federal Regulations, 2010 CFR

2010-01-01

... service on a Team. 270.106 Section 270.106 Commerce and Foreign Trade Regulations Relating to Commerce and... SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Establishment and Deployment of Teams § 270.106 Conflicts of interest related to service on a Team. (a) Team members who are not Federal employees will be...

15 CFR 270.103 - Publication in the Federal Register.

Code of Federal Regulations, 2012 CFR

2012-01-01

... NATIONAL INSTITUTE OF STANDARDS AND TECHNOLOGY, DEPARTMENT OF COMMERCE NATIONAL CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Establishment and Deployment of Teams § 270.103 Publication in the... of each Team. ...

15 CFR 270.103 - Publication in the Federal Register.

Code of Federal Regulations, 2011 CFR

2011-01-01

... NATIONAL INSTITUTE OF STANDARDS AND TECHNOLOGY, DEPARTMENT OF COMMERCE NATIONAL CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Establishment and Deployment of Teams § 270.103 Publication in the... of each Team. ...

15 CFR 270.103 - Publication in the Federal Register.

Code of Federal Regulations, 2014 CFR

2014-01-01

... NATIONAL INSTITUTE OF STANDARDS AND TECHNOLOGY, DEPARTMENT OF COMMERCE NATIONAL CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Establishment and Deployment of Teams § 270.103 Publication in the... of each Team. ...

15 CFR 270.103 - Publication in the Federal Register.

Code of Federal Regulations, 2010 CFR

2010-01-01

... NATIONAL INSTITUTE OF STANDARDS AND TECHNOLOGY, DEPARTMENT OF COMMERCE NATIONAL CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Establishment and Deployment of Teams § 270.103 Publication in the... of each Team. ...

15 CFR 270.103 - Publication in the Federal Register.

Code of Federal Regulations, 2013 CFR

2013-01-01

... NATIONAL INSTITUTE OF STANDARDS AND TECHNOLOGY, DEPARTMENT OF COMMERCE NATIONAL CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Establishment and Deployment of Teams § 270.103 Publication in the... of each Team. ...

Endoscopic non-technical skills team training: the next step in quality assurance of endoscopy training.

PubMed

Matharoo, Manmeet; Haycock, Adam; Sevdalis, Nick; Thomas-Gibson, Siwan

2014-12-14

To investigate whether novel, non-technical skills training for Bowel Cancer Screening (BCS) endoscopy teams enhanced patient safety knowledge and attitudes. A novel endoscopy team training intervention for BCS teams was developed and evaluated as a pre-post intervention study. Four multi-disciplinary BCS teams constituting BCS endoscopist(s), specialist screening practitioners, endoscopy nurses and administrative staff (A) from English BCS training centres participated. No patients were involved in this study. Expert multidisciplinary faculty delivered a single day's training utilising real clinical examples. Pre and post-course evaluation comprised participants' patient safety awareness, attitudes, and knowledge. Global course evaluations were also collected. Twenty-three participants attended and their patient safety knowledge improved significantly from 43%-55% (P ≤ 0.001) following the training intervention. 12/41 (29%) of the safety attitudes items significantly improved in the areas of perceived patient safety knowledge and awareness. The remaining safety attitude items: perceived influence on patient safety, attitudes towards error management, error management actions and personal views following an error were unchanged following training. Both qualitative and quantitative global course evaluations were positive: 21/23 (91%) participants strongly agreed/agreed that they were satisfied with the course. Qualitative evaluation included mandating such training for endoscopy teams outside BCS and incorporating team training within wider endoscopy training. Limitations of the study include no measure of increased patient safety in clinical practice following training. A novel comprehensive training package addressing patient safety, non-technical skills and adverse event analysis was successful in improving multi-disciplinary teams' knowledge and safety attitudes.

15 CFR 270.204 - Provision of additional resources and services needed by a Team.

Code of Federal Regulations, 2013 CFR

2013-01-01

... services needed by a Team. 270.204 Section 270.204 Commerce and Foreign Trade Regulations Relating to... CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Investigations § 270.204 Provision of additional resources and services needed by a Team. The Director will determine the appropriate resources that a Team...

15 CFR 270.204 - Provision of additional resources and services needed by a Team.

Code of Federal Regulations, 2014 CFR

2014-01-01

... services needed by a Team. 270.204 Section 270.204 Commerce and Foreign Trade Regulations Relating to... CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Investigations § 270.204 Provision of additional resources and services needed by a Team. The Director will determine the appropriate resources that a Team...

15 CFR 270.204 - Provision of additional resources and services needed by a Team.

Code of Federal Regulations, 2012 CFR

2012-01-01

... services needed by a Team. 270.204 Section 270.204 Commerce and Foreign Trade Regulations Relating to... CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Investigations § 270.204 Provision of additional resources and services needed by a Team. The Director will determine the appropriate resources that a Team...

15 CFR 270.204 - Provision of additional resources and services needed by a Team.

Code of Federal Regulations, 2010 CFR

2010-01-01

... services needed by a Team. 270.204 Section 270.204 Commerce and Foreign Trade Regulations Relating to... CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Investigations § 270.204 Provision of additional resources and services needed by a Team. The Director will determine the appropriate resources that a Team...

15 CFR 270.204 - Provision of additional resources and services needed by a Team.

Code of Federal Regulations, 2011 CFR

2011-01-01

... services needed by a Team. 270.204 Section 270.204 Commerce and Foreign Trade Regulations Relating to... CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Investigations § 270.204 Provision of additional resources and services needed by a Team. The Director will determine the appropriate resources that a Team...

Ares I Integrated Vehicle System Safety Team

NASA Technical Reports Server (NTRS)

Wetherholt, Jon; McNairy, Lisa; Shackelford, Carla

2009-01-01

Complex systems require integrated analysis teams which sometimes are divided into subsystem teams. Proper division of the analysis in to subsystem teams is important. Safety analysis is one of the most difficult aspects of integration.

Team Psychological Safety and Team Learning: A Cultural Perspective

ERIC Educational Resources Information Center

Cauwelier, Peter; Ribière, Vincent M.; Bennet, Alex

2016-01-01

Purpose: The purpose of this paper was to evaluate if the concept of team psychological safety, a key driver of team learning and originally studied in the West, can be applied in teams from different national cultures. The model originally validated for teams in the West is applied to teams in Thailand to evaluate its validity, and the views team…

15 CFR 270.320 - Entry and inspection of site where a building failure has occurred.

Code of Federal Regulations, 2013 CFR

2013-01-01

... CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Collection and Preservation of Evidence... deploys a Team, the Team members will be issued notices of inspection authority to enter and inspect the...

15 CFR 270.320 - Entry and inspection of site where a building failure has occurred.

Code of Federal Regulations, 2012 CFR

2012-01-01

... CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Collection and Preservation of Evidence... deploys a Team, the Team members will be issued notices of inspection authority to enter and inspect the...

15 CFR 270.320 - Entry and inspection of site where a building failure has occurred.

Code of Federal Regulations, 2010 CFR

2010-01-01

... CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Collection and Preservation of Evidence... deploys a Team, the Team members will be issued notices of inspection authority to enter and inspect the...

15 CFR 270.320 - Entry and inspection of site where a building failure has occurred.

Code of Federal Regulations, 2014 CFR

2014-01-01

... CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Collection and Preservation of Evidence... deploys a Team, the Team members will be issued notices of inspection authority to enter and inspect the...

15 CFR 270.320 - Entry and inspection of site where a building failure has occurred.

Code of Federal Regulations, 2011 CFR

2011-01-01

... CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Collection and Preservation of Evidence... deploys a Team, the Team members will be issued notices of inspection authority to enter and inspect the...

Leader humility and team creativity: The role of team information sharing, psychological safety, and power distance.

PubMed

Hu, Jia; Erdogan, Berrin; Jiang, Kaifeng; Bauer, Talya N; Liu, Songbo

2018-03-01

In this study, we identify leader humility, characterized by being open to admitting one's limitations, shortcomings, and mistakes, and showing appreciation and giving credit to followers, as a critical leader characteristic relevant for team creativity. Integrating the literatures on creativity and leadership, we explore the relationship between leader humility and team creativity, treating team psychological safety and team information sharing as mediators. Further, we hypothesize and examine team power distance as a moderator of the relationship. We tested our hypotheses using data gathered from 72 work teams and 354 individual members from 11 information and technology firms in China using a multiple-source, time-lagged research design. We found that the positive relationship between leader humility and team information sharing was significant and positive only within teams with a low power distance value. In addition, leader humility was negatively related to team psychological safety in teams with a high power distance value, whereas the relationship was positive yet nonsignificant in teams with low power distance. Furthermore, team information sharing and psychological safety were both significantly related to team creativity. We discuss theoretical and practical implications for leadership and work teams. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

15 CFR 270.1 - Description of rule; purpose; applicability.

Code of Federal Regulations, 2013 CFR

2013-01-01

... NATIONAL INSTITUTE OF STANDARDS AND TECHNOLOGY, DEPARTMENT OF COMMERCE NATIONAL CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS General § 270.1 Description of rule; purpose; applicability. (a) The National Construction Safety Team Act (the Act) (Pub. L. 107-231) provides for the establishment of...

15 CFR 270.1 - Description of rule; purpose; applicability.

Code of Federal Regulations, 2012 CFR

2012-01-01

... NATIONAL INSTITUTE OF STANDARDS AND TECHNOLOGY, DEPARTMENT OF COMMERCE NATIONAL CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS General § 270.1 Description of rule; purpose; applicability. (a) The National Construction Safety Team Act (the Act) (Pub. L. 107-231) provides for the establishment of...

15 CFR 270.1 - Description of rule; purpose; applicability.

Code of Federal Regulations, 2014 CFR

2014-01-01

... NATIONAL INSTITUTE OF STANDARDS AND TECHNOLOGY, DEPARTMENT OF COMMERCE NATIONAL CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS General § 270.1 Description of rule; purpose; applicability. (a) The National Construction Safety Team Act (the Act) (Pub. L. 107-231) provides for the establishment of...

15 CFR 270.1 - Description of rule; purpose; applicability.

Code of Federal Regulations, 2010 CFR

2010-01-01

... NATIONAL INSTITUTE OF STANDARDS AND TECHNOLOGY, DEPARTMENT OF COMMERCE NATIONAL CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS General § 270.1 Description of rule; purpose; applicability. (a) The National Construction Safety Team Act (the Act) (Pub. L. 107-231) provides for the establishment of...

15 CFR 270.1 - Description of rule; purpose; applicability.

Code of Federal Regulations, 2011 CFR

2011-01-01

... NATIONAL INSTITUTE OF STANDARDS AND TECHNOLOGY, DEPARTMENT OF COMMERCE NATIONAL CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS General § 270.1 Description of rule; purpose; applicability. (a) The National Construction Safety Team Act (the Act) (Pub. L. 107-231) provides for the establishment of...

15 CFR 270.104 - Size and composition of a Team.

Code of Federal Regulations, 2012 CFR

2012-01-01

... 15 Commerce and Foreign Trade 1 2012-01-01 2012-01-01 false Size and composition of a Team. 270... NATIONAL INSTITUTE OF STANDARDS AND TECHNOLOGY, DEPARTMENT OF COMMERCE NATIONAL CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Establishment and Deployment of Teams § 270.104 Size and composition of...

15 CFR 270.104 - Size and composition of a Team.

Code of Federal Regulations, 2013 CFR

2013-01-01

... 15 Commerce and Foreign Trade 1 2013-01-01 2013-01-01 false Size and composition of a Team. 270... NATIONAL INSTITUTE OF STANDARDS AND TECHNOLOGY, DEPARTMENT OF COMMERCE NATIONAL CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Establishment and Deployment of Teams § 270.104 Size and composition of...

15 CFR 270.104 - Size and composition of a Team.

Code of Federal Regulations, 2011 CFR

2011-01-01

... 15 Commerce and Foreign Trade 1 2011-01-01 2011-01-01 false Size and composition of a Team. 270... NATIONAL INSTITUTE OF STANDARDS AND TECHNOLOGY, DEPARTMENT OF COMMERCE NATIONAL CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Establishment and Deployment of Teams § 270.104 Size and composition of...

15 CFR 270.104 - Size and composition of a Team.

Code of Federal Regulations, 2014 CFR

2014-01-01

... 15 Commerce and Foreign Trade 1 2014-01-01 2014-01-01 false Size and composition of a Team. 270... NATIONAL INSTITUTE OF STANDARDS AND TECHNOLOGY, DEPARTMENT OF COMMERCE NATIONAL CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Establishment and Deployment of Teams § 270.104 Size and composition of...

TeamSTEPPS Improves Operating Room Efficiency and Patient Safety.

PubMed

Weld, Lancaster R; Stringer, Matthew T; Ebertowski, James S; Baumgartner, Timothy S; Kasprenski, Matthew C; Kelley, Jeremy C; Cho, Doug S; Tieva, Erwin A; Novak, Thomas E

2016-09-01

The objective was to evaluate the effect of TeamSTEPPS on operating room efficiency and patient safety. TeamSTEPPS consisted of briefings attended by all health care personnel assigned to the specific operating room to discuss issues unique to each case scheduled for that day. The operative times, on-time start rates, and turnover times of all cases performed by the urology service during the initial year with TeamSTEPPS were compared to the prior year. Patient safety issues identified during postoperative briefings were analyzed. The mean case time was 12.7 minutes less with TeamSTEPPS (P < .001). The on-time first-start rate improved by 21% with TeamSTEPPS (P < .001). The mean room turnover time did not change. Patient safety issues declined from an initial rate of 16% to 6% at midyear and remained stable (P < 0.001). TeamSTEPPS was associated with improved operating room efficiency and diminished patient safety issues in the operating room. © The Author(s) 2015.

A theory-driven, longitudinal evaluation of the impact of team training on safety culture in 24 hospitals.

PubMed

Jones, Katherine J; Skinner, Anne M; High, Robin; Reiter-Palmon, Roni

2013-05-01

Effective teamwork facilitates collective learning, which is integral to safety culture. There are no rigorous evaluations of the impact of team training on the four components of safety culture-reporting, just, flexible and learning cultures. We evaluated the impact of a year-long team training programme on safety culture in 24 hospitals using two theoretical frameworks. We used two quasi-experimental designs: a cross-sectional comparison of hospital survey on patient safety culture (HSOPS) results from an intervention group of 24 hospitals to a static group of 13 hospitals and a pre-post comparison of HSOPS results within intervention hospitals. Dependent variables were HSOPS items representing the four components of safety culture; independent variables were derived from items added to the HSOPS that measured the extent of team training, learning and transfer. We used a generalised linear mixed model approach to account for the correlated nature of the data. 59% of 2137 respondents from the intervention group reported receiving team training. Intervention group HSOPS scores were significantly higher than static group scores in three dimensions assessing the flexible and learning components of safety culture. The distribution of the adoption of team behaviours (transfer) varied in the intervention group from 2.8% to 31.0%. Adoption of team behaviours was significantly associated with odds of an individual reacting more positively at reassessment than baseline to nine items reflecting all four components of safety culture. Team training can result in transformational change in safety culture when the work environment supports the transfer of learning to new behaviour.

An Anesthesia Preinduction Checklist to Improve Information Exchange, Knowledge of Critical Information, Perception of Safety, and Possibly Perception of Teamwork in Anesthesia Teams.

PubMed

Tscholl, David W; Weiss, Mona; Kolbe, Michaela; Staender, Sven; Seifert, Burkhardt; Landert, Daniel; Grande, Bastian; Spahn, Donat R; Noethiger, Christoph B

2015-10-01

An anesthesia preinduction checklist (APIC) to be performed before anesthesia induction was introduced and evaluated with respect to 5 team-level outcomes, each being a surrogate end point for patient safety: information exchange (the percentage of checklist items exchanged by a team, out of 12 total items); knowledge of critical information (the percentage of critical information items out of 5 total items such as allergies, reported as known by the members of a team); team members' perceptions of safety (the median scores given by the members of a team on a continuous rating scale); their perception of teamwork (the median scores given by the members of a team on a continuous rating scale); and clinical performance (the percentage of completed items out of 14 required tasks, e.g., suction device checked). A prospective interventional study comparing anesthesia teams using the APIC with a control group not using the APIC was performed using a multimethod design. Trained observers rated information exchange and clinical performance during on-site observations of anesthesia inductions. After the observations, each team member indicated the critical information items they knew and their perceptions of safety and teamwork. One hundred five teams using the APIC were compared with 100 teams not doing so. The medians of the team-level outcome scores in the APIC group versus the control group were as follows: information exchange: 100% vs 33% (P < 0.001), knowledge of critical information: 100% vs 90% (P < 0.001), perception of safety: 91% vs 84% (P < 0.001), perception of teamwork: 90% vs 86% (P = 0.028), and clinical performance: 93% vs 93% (P = 0.60). This study provides empirical evidence that the use of a preinduction checklist significantly improves information exchange, knowledge of critical information, and perception of safety in anesthesia teams-all parameters contributing to patient safety. There was a trend indicating improved perception of teamwork.

15 CFR 270.2 - Definitions used in this part.

Code of Federal Regulations, 2013 CFR

2013-01-01

... INSTITUTE OF STANDARDS AND TECHNOLOGY, DEPARTMENT OF COMMERCE NATIONAL CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS General § 270.2 Definitions used in this part. The following definitions are applicable to this part: Act. The National Construction Safety Team Act (Pub. L. 107-231, 116 Stat. 1471...

15 CFR 270.2 - Definitions used in this part.

Code of Federal Regulations, 2011 CFR

2011-01-01

... INSTITUTE OF STANDARDS AND TECHNOLOGY, DEPARTMENT OF COMMERCE NATIONAL CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS General § 270.2 Definitions used in this part. The following definitions are applicable to this part: Act. The National Construction Safety Team Act (Pub. L. 107-231, 116 Stat. 1471...

15 CFR 270.2 - Definitions used in this part.

Code of Federal Regulations, 2012 CFR

2012-01-01

... INSTITUTE OF STANDARDS AND TECHNOLOGY, DEPARTMENT OF COMMERCE NATIONAL CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS General § 270.2 Definitions used in this part. The following definitions are applicable to this part: Act. The National Construction Safety Team Act (Pub. L. 107-231, 116 Stat. 1471...

15 CFR 270.2 - Definitions used in this part.

Code of Federal Regulations, 2014 CFR

2014-01-01

... INSTITUTE OF STANDARDS AND TECHNOLOGY, DEPARTMENT OF COMMERCE NATIONAL CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS General § 270.2 Definitions used in this part. The following definitions are applicable to this part: Act. The National Construction Safety Team Act (Pub. L. 107-231, 116 Stat. 1471...

15 CFR 270.2 - Definitions used in this part.

Code of Federal Regulations, 2010 CFR

2010-01-01

... INSTITUTE OF STANDARDS AND TECHNOLOGY, DEPARTMENT OF COMMERCE NATIONAL CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS General § 270.2 Definitions used in this part. The following definitions are applicable to this part: Act. The National Construction Safety Team Act (Pub. L. 107-231, 116 Stat. 1471...

Teams communicating through STEPPS.

PubMed

Stead, Karen; Kumar, Saravana; Schultz, Timothy J; Tiver, Sue; Pirone, Christy J; Adams, Robert J; Wareham, Conrad A

2009-06-01

To evaluate the effectiveness of the implementation of a TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety) program at an Australian mental health facility. TeamSTEPPS is an evidence-based teamwork training system developed in the United States. Five health care sites in South Australia implemented TeamSTEPPS using a train-the-trainer model over an 8-month intervention period commencing January 2008 and concluding September 2008. A team of senior clinical staff was formed at each site to drive the improvement process. Independent researchers used direct observation and questionnaire surveys to evaluate the effectiveness of the implementation in three outcome areas: observed team behaviours; staff attitudes and opinions; and clinical performance and outcome. The results reported here focus on one site, an inpatient mental health facility. Team knowledge, skills and attitudes; patient safety culture; incident reporting rates; seclusion rates; observation for the frequency of use of TeamSTEPPS tools. Outcomes included restructuring of multidisciplinary meetings and the introduction of structured communication tools. The evaluation of patient safety culture and of staff knowledge, skills and attitudes (KSA) to teamwork and communication indicated a significant improvement in two dimensions of patient safety culture (frequency of event reporting, and organisational learning) and a 6.8% increase in the total KSA score. Clinical outcomes included reduced rates of seclusion. TeamSTEPPS implementation had a substantial impact on patient safety culture, teamwork and communication at an Australian mental health facility. It encouraged a culture of learning from patient safety incidents and making continuous improvements.

Endoscopic non-technical skills team training: The next step in quality assurance of endoscopy training

PubMed Central

Matharoo, Manmeet; Haycock, Adam; Sevdalis, Nick; Thomas-Gibson, Siwan

2014-01-01

AIM: To investigate whether novel, non-technical skills training for Bowel Cancer Screening (BCS) endoscopy teams enhanced patient safety knowledge and attitudes. METHODS: A novel endoscopy team training intervention for BCS teams was developed and evaluated as a pre-post intervention study. Four multi-disciplinary BCS teams constituting BCS endoscopist(s), specialist screening practitioners, endoscopy nurses and administrative staff (A) from English BCS training centres participated. No patients were involved in this study. Expert multidisciplinary faculty delivered a single day’s training utilising real clinical examples. Pre and post-course evaluation comprised participants’ patient safety awareness, attitudes, and knowledge. Global course evaluations were also collected. RESULTS: Twenty-three participants attended and their patient safety knowledge improved significantly from 43%-55% (P ≤ 0.001) following the training intervention. 12/41 (29%) of the safety attitudes items significantly improved in the areas of perceived patient safety knowledge and awareness. The remaining safety attitude items: perceived influence on patient safety, attitudes towards error management, error management actions and personal views following an error were unchanged following training. Both qualitative and quantitative global course evaluations were positive: 21/23 (91%) participants strongly agreed/agreed that they were satisfied with the course. Qualitative evaluation included mandating such training for endoscopy teams outside BCS and incorporating team training within wider endoscopy training. Limitations of the study include no measure of increased patient safety in clinical practice following training. CONCLUSION: A novel comprehensive training package addressing patient safety, non-technical skills and adverse event analysis was successful in improving multi-disciplinary teams’ knowledge and safety attitudes. PMID:25516665

15 CFR 270.100 - General.

Code of Federal Regulations, 2012 CFR

2012-01-01

... STANDARDS AND TECHNOLOGY, DEPARTMENT OF COMMERCE NATIONAL CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Establishment and Deployment of Teams § 270.100 General. (a) Based on prior NIST experience, NIST expects that the Director will establish and deploy a Team to conduct an investigation at a...

15 CFR 270.351 - Protection of voluntarily submitted information.

Code of Federal Regulations, 2010 CFR

2010-01-01

... SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Collection and Preservation of Evidence; Information... Protection of voluntarily submitted information. Notwithstanding any other provision of law, a Team, NIST, any investigation participant, and any agency receiving information from a Team, NIST, or any other...

15 CFR 270.101 - Preliminary reconnaissance.

Code of Federal Regulations, 2013 CFR

2013-01-01

... INSTITUTE OF STANDARDS AND TECHNOLOGY, DEPARTMENT OF COMMERCE NATIONAL CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Establishment and Deployment of Teams § 270.101 Preliminary reconnaissance. (a) To... the site of a building failure. The Director may establish and deploy a Team to conduct the...

15 CFR 270.100 - General.

Code of Federal Regulations, 2010 CFR

2010-01-01

... STANDARDS AND TECHNOLOGY, DEPARTMENT OF COMMERCE NATIONAL CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Establishment and Deployment of Teams § 270.100 General. (a) Based on prior NIST experience, NIST expects that the Director will establish and deploy a Team to conduct an investigation at a...

15 CFR 270.351 - Protection of voluntarily submitted information.

Code of Federal Regulations, 2013 CFR

2013-01-01

... SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Collection and Preservation of Evidence; Information... Protection of voluntarily submitted information. Notwithstanding any other provision of law, a Team, NIST, any investigation participant, and any agency receiving information from a Team, NIST, or any other...

15 CFR 270.101 - Preliminary reconnaissance.

Code of Federal Regulations, 2010 CFR

2010-01-01

... INSTITUTE OF STANDARDS AND TECHNOLOGY, DEPARTMENT OF COMMERCE NATIONAL CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Establishment and Deployment of Teams § 270.101 Preliminary reconnaissance. (a) To... the site of a building failure. The Director may establish and deploy a Team to conduct the...

15 CFR 270.101 - Preliminary reconnaissance.

Code of Federal Regulations, 2012 CFR

2012-01-01

... INSTITUTE OF STANDARDS AND TECHNOLOGY, DEPARTMENT OF COMMERCE NATIONAL CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Establishment and Deployment of Teams § 270.101 Preliminary reconnaissance. (a) To... the site of a building failure. The Director may establish and deploy a Team to conduct the...

15 CFR 270.100 - General.

Code of Federal Regulations, 2013 CFR

2013-01-01

... STANDARDS AND TECHNOLOGY, DEPARTMENT OF COMMERCE NATIONAL CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Establishment and Deployment of Teams § 270.100 General. (a) Based on prior NIST experience, NIST expects that the Director will establish and deploy a Team to conduct an investigation at a...

15 CFR 270.351 - Protection of voluntarily submitted information.

Code of Federal Regulations, 2012 CFR

2012-01-01

... SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Collection and Preservation of Evidence; Information... Protection of voluntarily submitted information. Notwithstanding any other provision of law, a Team, NIST, any investigation participant, and any agency receiving information from a Team, NIST, or any other...

15 CFR 270.100 - General.

Code of Federal Regulations, 2014 CFR

2014-01-01

... STANDARDS AND TECHNOLOGY, DEPARTMENT OF COMMERCE NATIONAL CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Establishment and Deployment of Teams § 270.100 General. (a) Based on prior NIST experience, NIST expects that the Director will establish and deploy a Team to conduct an investigation at a...

15 CFR 270.351 - Protection of voluntarily submitted information.

Code of Federal Regulations, 2011 CFR

2011-01-01

... SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Collection and Preservation of Evidence; Information... Protection of voluntarily submitted information. Notwithstanding any other provision of law, a Team, NIST, any investigation participant, and any agency receiving information from a Team, NIST, or any other...

15 CFR 270.101 - Preliminary reconnaissance.

Code of Federal Regulations, 2014 CFR

2014-01-01

... INSTITUTE OF STANDARDS AND TECHNOLOGY, DEPARTMENT OF COMMERCE NATIONAL CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Establishment and Deployment of Teams § 270.101 Preliminary reconnaissance. (a) To... the site of a building failure. The Director may establish and deploy a Team to conduct the...

15 CFR 270.101 - Preliminary reconnaissance.

Code of Federal Regulations, 2011 CFR

2011-01-01

... INSTITUTE OF STANDARDS AND TECHNOLOGY, DEPARTMENT OF COMMERCE NATIONAL CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Establishment and Deployment of Teams § 270.101 Preliminary reconnaissance. (a) To... the site of a building failure. The Director may establish and deploy a Team to conduct the...

15 CFR 270.100 - General.

Code of Federal Regulations, 2011 CFR

2011-01-01

... STANDARDS AND TECHNOLOGY, DEPARTMENT OF COMMERCE NATIONAL CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Establishment and Deployment of Teams § 270.100 General. (a) Based on prior NIST experience, NIST expects that the Director will establish and deploy a Team to conduct an investigation at a...

How can leaders foster team learning? Effects of leader-assigned mastery and performance goals and psychological safety.

PubMed

Ashauer, Shirley A; Macan, Therese

2013-01-01

Learning and adapting to change are imperative as teams today face unprecedented change. Yet, an important part of learning involves challenging assumptions and addressing differences of opinion openly within a group--the kind of behaviors that pose the potential for embarrassment or threat. How can leaders foster an environment in which team members feel it is safe to take interpersonal risks in order to learn? In a study of 71 teams, we found that psychological safety and learning behavior were higher for teams with mastery than performance goal instructions or no goal instructions. Team psychological safety mediated the relationship between mastery and performance goal instructions and learning behavior. Findings contribute to our understanding of how leader-assigned goals are related to psychological safety and learning behavior in a team context, and suggest approaches to foster such processes.

15 CFR 270.202 - Coordination with search and rescue efforts.

Code of Federal Regulations, 2013 CFR

2013-01-01

... SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Investigations § 270.202 Coordination with search and... efforts being undertaken at the site of the building failure, including FEMA urban search and rescue teams...

15 CFR 270.202 - Coordination with search and rescue efforts.

Code of Federal Regulations, 2014 CFR

2014-01-01

... SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Investigations § 270.202 Coordination with search and... efforts being undertaken at the site of the building failure, including FEMA urban search and rescue teams...

15 CFR 270.202 - Coordination with search and rescue efforts.

Code of Federal Regulations, 2012 CFR

2012-01-01

... SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Investigations § 270.202 Coordination with search and... efforts being undertaken at the site of the building failure, including FEMA urban search and rescue teams...

15 CFR 270.202 - Coordination with search and rescue efforts.

Code of Federal Regulations, 2011 CFR

2011-01-01

... SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Investigations § 270.202 Coordination with search and... efforts being undertaken at the site of the building failure, including FEMA urban search and rescue teams...

15 CFR 270.202 - Coordination with search and rescue efforts.

Code of Federal Regulations, 2010 CFR

2010-01-01

... SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Investigations § 270.202 Coordination with search and... efforts being undertaken at the site of the building failure, including FEMA urban search and rescue teams...

Thick as thieves: the effects of ethical orientation and psychological safety on unethical team behavior.

PubMed

Pearsall, Matthew J; Ellis, Aleksander P J

2011-03-01

The purpose of this study was to uncover compositional and emergent influences on unethical behavior by teams. Results from 126 teams indicated that the presence of a formalistic orientation within the team was negatively related to collective unethical decisions. Conversely, the presence of a utilitarian orientation within the team was positively related to both unethical decisions and behaviors. Results also indicated that the relationship between utilitarianism and unethical outcomes was moderated by the level of psychological safety within the team, such that teams with high levels of safety were more likely to engage in unethical behaviors. Implications are discussed, as well as potential directions for future research. PsycINFO Database Record (c) 2011 APA, all rights reserved.

Safety Teams: An Approach to Engage Students in Laboratory Safety

ERIC Educational Resources Information Center

Alaimo, Peter J.; Langenhan, Joseph M.; Tanner, Martha J.; Ferrenberg, Scott M.

2010-01-01

We developed and implemented a yearlong safety program into our organic chemistry lab courses that aims to enhance student attitudes toward safety and to ensure students learn to recognize, demonstrate, and assess safe laboratory practices. This active, collaborative program involves the use of student "safety teams" and includes…

76 FR 42683 - Establishment of a Team Under the National Construction Safety Team Act

Federal Register 2010, 2011, 2012, 2013, 2014

2011-07-19

... Safety Team Act. The Team was established to study the effects of the tornado that touched down in Joplin... reconnaissance team to collect information and data related to the tornado that touched down in Joplin, MO, on... the effects of the tornado that touched down in Joplin, MO, on May 22. The NIST Director will appoint...

15 CFR 270.325 - Notice of authority to enter and inspect property where building components, materials, artifacts...

Code of Federal Regulations, 2012 CFR

2012-01-01

... CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Collection and Preservation of Evidence... pursuant to the Act, any member of a Team, or any other person authorized by the Director to support a Team... property to be inspected and to carry out the duties of the Team; (2) During reasonable hours, inspect any...

15 CFR 270.325 - Notice of authority to enter and inspect property where building components, materials, artifacts...

Code of Federal Regulations, 2010 CFR

2010-01-01

... CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Collection and Preservation of Evidence... pursuant to the Act, any member of a Team, or any other person authorized by the Director to support a Team... property to be inspected and to carry out the duties of the Team; (2) During reasonable hours, inspect any...

15 CFR 270.325 - Notice of authority to enter and inspect property where building components, materials, artifacts...

Code of Federal Regulations, 2011 CFR

2011-01-01

... CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Collection and Preservation of Evidence... pursuant to the Act, any member of a Team, or any other person authorized by the Director to support a Team... property to be inspected and to carry out the duties of the Team; (2) During reasonable hours, inspect any...

15 CFR 270.325 - Notice of authority to enter and inspect property where building components, materials, artifacts...

Code of Federal Regulations, 2013 CFR

2013-01-01

... CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Collection and Preservation of Evidence... pursuant to the Act, any member of a Team, or any other person authorized by the Director to support a Team... property to be inspected and to carry out the duties of the Team; (2) During reasonable hours, inspect any...

15 CFR 270.325 - Notice of authority to enter and inspect property where building components, materials, artifacts...

Code of Federal Regulations, 2014 CFR

2014-01-01

... CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Collection and Preservation of Evidence... pursuant to the Act, any member of a Team, or any other person authorized by the Director to support a Team... property to be inspected and to carry out the duties of the Team; (2) During reasonable hours, inspect any...

Reaping the Benefits of Task Conflict in Teams: The Critical Role of Team Psychological Safety Climate

ERIC Educational Resources Information Center

Bradley, Bret H.; Postlethwaite, Bennett E.; Klotz, Anthony C.; Hamdani, Maria R.; Brown, Kenneth G.

2012-01-01

Past research suggests that task conflict may improve team performance under certain conditions; however, we know little about these specific conditions. On the basis of prior theory and research on conflict in teams, we argue that a climate of psychological safety is one specific context under which task conflict will improve team performance.…

Mobilising a team for the WHO Surgical Safety Checklist: a qualitative video study.

PubMed

Korkiakangas, Terhi

2017-03-01

One challenge identified in the Surgical Safety Checklist literature is the inconsistent participation of operating teams in the safety checks. Less is known about how teams move from preparatory activities into a huddle, and how communication underpins this gathering. The objective of this study is to examine the ways of mobilising teams and the level of participation in the safety checks. Team participation in time-out and sign-out was examined from a video corpus of 20 elective surgical operations. Teams included surgeons, nurses and anaesthetists in a UK teaching hospital, scheduled to work in the operations observed. Qualitative video analysis of team participation was adapted from the study of social interaction. The key aspects of team mobilisation were the timing of the checklist, the distribution of personnel in the theatre and the instigation practices used. These were interlinked in bringing about the participation outcomes, the number of people huddling up for time-out and sign-out. Timing seemed appropriate when most personnel were present in the theatre suite; poor timing was marked by personnel dispersed through the theatre. Participation could be managed using the instigation practices, which included or excluded participation within teams. The factors hindering full-team participation at time-out and sign-out were the overlapping (eg, anaesthetic and nursing) responsibilities and the use of exclusive instigation practices. The implementation of the Surgical Safety Checklist represents a global concern in patient safety research. Yet how teams huddle for the checks has to be acknowledged as an issue in its own right. Appropriate mobilisation practices can help bringing fuller teams together, which has direct relevance to team training. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

Building effective critical care teams

PubMed Central

2011-01-01

Critical care is formulated and delivered by a team. Accordingly, behavioral scientific principles relevant to teams, namely psychological safety, transactive memory and leadership, apply to critical care teams. Two experts in behavioral sciences review the impact of psychological safety, transactive memory and leadership on medical team outcomes. A clinician then applies those principles to two routine critical care paradigms: daily rounds and resuscitations. Since critical care is a team endeavor, methods to maximize teamwork should be learned and mastered by critical care team members, and especially leaders. PMID:21884639

15 CFR 270.301 - Policy.

Code of Federal Regulations, 2010 CFR

2010-01-01

... STANDARDS AND TECHNOLOGY, DEPARTMENT OF COMMERCE NATIONAL CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Collection and Preservation of Evidence; Information Created Pursuant to an Investigation; and Protection of Information § 270.301 Policy. Evidence collected and information created by Team...

15 CFR 270.301 - Policy.

Code of Federal Regulations, 2013 CFR

2013-01-01

... STANDARDS AND TECHNOLOGY, DEPARTMENT OF COMMERCE NATIONAL CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Collection and Preservation of Evidence; Information Created Pursuant to an Investigation; and Protection of Information § 270.301 Policy. Evidence collected and information created by Team...

15 CFR 270.301 - Policy.

Code of Federal Regulations, 2012 CFR

2012-01-01

... STANDARDS AND TECHNOLOGY, DEPARTMENT OF COMMERCE NATIONAL CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Collection and Preservation of Evidence; Information Created Pursuant to an Investigation; and Protection of Information § 270.301 Policy. Evidence collected and information created by Team...

15 CFR 270.301 - Policy.

Code of Federal Regulations, 2014 CFR

2014-01-01

... STANDARDS AND TECHNOLOGY, DEPARTMENT OF COMMERCE NATIONAL CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Collection and Preservation of Evidence; Information Created Pursuant to an Investigation; and Protection of Information § 270.301 Policy. Evidence collected and information created by Team...

15 CFR 270.301 - Policy.

Code of Federal Regulations, 2011 CFR

2011-01-01

... STANDARDS AND TECHNOLOGY, DEPARTMENT OF COMMERCE NATIONAL CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Collection and Preservation of Evidence; Information Created Pursuant to an Investigation; and Protection of Information § 270.301 Policy. Evidence collected and information created by Team...

15 CFR 270.322 - Voluntary permission to enter and inspect property where building components, materials...

Code of Federal Regulations, 2013 CFR

2013-01-01

... CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Collection and Preservation of Evidence... records with respect to a building failure are located. After the Director establishes and deploys a Team, members of the public are encouraged to voluntarily permit Team members to enter property where building...

15 CFR 270.323 - Requests for permission to enter and inspect property where building components, materials...

Code of Federal Regulations, 2012 CFR

2012-01-01

... CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Collection and Preservation of Evidence... Team, the Lead Investigator or their designee may request permission to enter and inspect property... be inspected and to carry out the duties of the Team. (b) Requests for permission to enter and...

15 CFR 270.322 - Voluntary permission to enter and inspect property where building components, materials...

Code of Federal Regulations, 2014 CFR

2014-01-01

... CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Collection and Preservation of Evidence... records with respect to a building failure are located. After the Director establishes and deploys a Team, members of the public are encouraged to voluntarily permit Team members to enter property where building...

15 CFR 270.322 - Voluntary permission to enter and inspect property where building components, materials...

Code of Federal Regulations, 2010 CFR

2010-01-01

... CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Collection and Preservation of Evidence... records with respect to a building failure are located. After the Director establishes and deploys a Team, members of the public are encouraged to voluntarily permit Team members to enter property where building...

15 CFR 270.322 - Voluntary permission to enter and inspect property where building components, materials...

Code of Federal Regulations, 2011 CFR

2011-01-01

... CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Collection and Preservation of Evidence... records with respect to a building failure are located. After the Director establishes and deploys a Team, members of the public are encouraged to voluntarily permit Team members to enter property where building...

15 CFR 270.323 - Requests for permission to enter and inspect property where building components, materials...

Code of Federal Regulations, 2010 CFR

2010-01-01

... CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Collection and Preservation of Evidence... Team, the Lead Investigator or their designee may request permission to enter and inspect property... be inspected and to carry out the duties of the Team. (b) Requests for permission to enter and...

15 CFR 270.323 - Requests for permission to enter and inspect property where building components, materials...

Code of Federal Regulations, 2014 CFR

2014-01-01

... CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Collection and Preservation of Evidence... Team, the Lead Investigator or their designee may request permission to enter and inspect property... be inspected and to carry out the duties of the Team. (b) Requests for permission to enter and...

15 CFR 270.323 - Requests for permission to enter and inspect property where building components, materials...

Code of Federal Regulations, 2011 CFR

2011-01-01

... CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Collection and Preservation of Evidence... Team, the Lead Investigator or their designee may request permission to enter and inspect property... be inspected and to carry out the duties of the Team. (b) Requests for permission to enter and...

15 CFR 270.323 - Requests for permission to enter and inspect property where building components, materials...

Code of Federal Regulations, 2013 CFR

2013-01-01

... CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Collection and Preservation of Evidence... Team, the Lead Investigator or their designee may request permission to enter and inspect property... be inspected and to carry out the duties of the Team. (b) Requests for permission to enter and...

15 CFR 270.322 - Voluntary permission to enter and inspect property where building components, materials...

Code of Federal Regulations, 2012 CFR

2012-01-01

... CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Collection and Preservation of Evidence... records with respect to a building failure are located. After the Director establishes and deploys a Team, members of the public are encouraged to voluntarily permit Team members to enter property where building...

The Role of Interpersonal Relations in Healthcare Team Communication and Patient Safety: A Proposed Model of Interpersonal Process in Teamwork.

PubMed

Lee, Charlotte Tsz-Sum; Doran, Diane Marie

2017-06-01

Patient safety is compromised by medical errors and adverse events related to miscommunications among healthcare providers. Communication among healthcare providers is affected by human factors, such as interpersonal relations. Yet, discussions of interpersonal relations and communication are lacking in healthcare team literature. This paper proposes a theoretical framework that explains how interpersonal relations among healthcare team members affect communication and team performance, such as patient safety. We synthesized studies from health and social science disciplines to construct a theoretical framework that explicates the links among these constructs. From our synthesis, we identified two relevant theories: framework on interpersonal processes based on social relation model and the theory of relational coordination. The former involves three steps: perception, evaluation, and feedback; and the latter captures relational communicative behavior. We propose that manifestations of provider relations are embedded in the third step of the framework on interpersonal processes: feedback. Thus, varying team-member relationships lead to varying collaborative behavior, which affects patient-safety outcomes via a change in team communication. The proposed framework offers new perspectives for understanding how workplace relations affect healthcare team performance. The framework can be used by nurses, administrators, and educators to improve patient safety, team communication, or to resolve conflicts.

Effects of a team-based assessment and intervention on patient safety culture in general practice: an open randomised controlled trial.

PubMed

Hoffmann, B; Müller, V; Rochon, J; Gondan, M; Müller, B; Albay, Z; Weppler, K; Leifermann, M; Mießner, C; Güthlin, C; Parker, D; Hofinger, G; Gerlach, F M

2014-01-01

The measurement of safety culture in healthcare is generally regarded as a first step towards improvement. Based on a self-assessment of safety culture, the Frankfurt Patient Safety Matrix (FraTrix) aims to enable healthcare teams to improve safety culture in their organisations. In this study we assessed the effects of FraTrix on safety culture in general practice. We conducted an open randomised controlled trial in 60 general practices. FraTrix was applied over a period of 9 months during three facilitated team sessions in intervention practices. At baseline and after 12 months, scores were allocated for safety culture as expressed in practice structure and processes (indicators), in safety climate and in patient safety incident reporting. The primary outcome was the indicator error management. During the team sessions, practice teams reflected on their safety culture and decided on about 10 actions per practice to improve it. After 12 months, no significant differences were found between intervention and control groups in terms of error management (competing probability=0.48, 95% CI 0.34 to 0.63, p=0.823), 11 further patient safety culture indicators and safety climate scales. Intervention practices showed better reporting of patient safety incidents, reflected in a higher number of incident reports (mean (SD) 4.85 (4.94) vs 3.10 (5.42), p=0.045) and incident reports of higher quality (scoring 2.27 (1.93) vs 1.49 (1.67), p=0.038) than control practices. Applied as a team-based instrument to assess safety culture, FraTrix did not lead to measurable improvements in error management. Comparable studies with more positive results had less robust study designs. In future research, validated combined methods to measure safety culture will be required. In addition, more attention should be paid to evaluation of process parameters. Implemented actions and incident reporting may be more appropriate target endpoints. German Clinical Trials Register (Deutsches Register Klinischer Studien, DRKS) No. DRKS00000145.

The Influence of Individual and Team Cognitive Ability on Operators’ Task and Safety Performance: A Multilevel Field Study in Nuclear Power Plants

PubMed Central

Zhang, Jingyu; Li, Yongjuan; Wu, Changxu

2013-01-01

While much research has investigated the predictors of operators’ performance such as personality, attitudes and motivation in high-risk industries, its cognitive antecedents and boundary conditions have not been fully investigated. Based on a multilevel investigation of 312 nuclear power plant main control room operators from 50 shift teams, the present study investigated how general mental ability (GMA) at both individual and team level can influence task and safety performance. At the individual level, operators’ GMA was predictive of their task and safety performance and this trend became more significant as they accumulated more experience. At the team level, we found team GMA had positive influences on all three performance criteria. However, we also found a “big-fish-little-pond” effect insofar as team GMA had a relatively smaller effect and inhibited the contribution of individual GMA to workers’ extra-role behaviors (safety participation) compared to its clear beneficial influence on in-role behaviors (task performance and safety compliance). The possible mechanisms related to learning and social comparison processes are discussed. PMID:24391964

An observational analysis of surgical team compliance with perioperative safety practices after crew resource management training.

PubMed

France, Daniel J; Leming-Lee, Susie; Jackson, Tom; Feistritzer, Nancye R; Higgins, Michael S

2008-04-01

Acknowledging the need to improve team communication and coordination among health care providers, health care administrators and improvement officers have been quick to endorse and invest in aviation crew resource management (CRM). Despite the increased interest in CRM there exists limited data on the effectiveness of CRM to change team behavior and performance in clinical settings. Direct observational analyses were performed on 30 surgical teams (15 neurosurgery cases and 15 cardiac cases) to evaluate surgical team compliance with integrated safety and CRM practices after extensive CRM training. Observed surgical teams were compliant with only 60% of the CRM and perioperative safety practices emphasized in the training program. The results highlight many of the challenges the health care industry faces in its efforts to adapt CRM from aviation to medicine. Additional research is needed to develop and test new team training methods and performance feedback mechanisms for clinical teams.

15 CFR 270.313 - Requests for evidence.

Code of Federal Regulations, 2012 CFR

2012-01-01

... INSTITUTE OF STANDARDS AND TECHNOLOGY, DEPARTMENT OF COMMERCE NATIONAL CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Collection and Preservation of Evidence; Information Created Pursuant to an... the Director establishes and deploys a Team, the Lead Investigator, or their designee, may request the...

15 CFR 270.300 - Scope.

Code of Federal Regulations, 2012 CFR

2012-01-01

... STANDARDS AND TECHNOLOGY, DEPARTMENT OF COMMERCE NATIONAL CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Collection and Preservation of Evidence; Information Created Pursuant to an Investigation... pursuant to the Act, evidence will be collected, and information will be created by the Team, NIST, and...

15 CFR 270.313 - Requests for evidence.

Code of Federal Regulations, 2014 CFR

2014-01-01

... INSTITUTE OF STANDARDS AND TECHNOLOGY, DEPARTMENT OF COMMERCE NATIONAL CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Collection and Preservation of Evidence; Information Created Pursuant to an... the Director establishes and deploys a Team, the Lead Investigator, or their designee, may request the...

15 CFR 270.300 - Scope.

Code of Federal Regulations, 2011 CFR

2011-01-01

... STANDARDS AND TECHNOLOGY, DEPARTMENT OF COMMERCE NATIONAL CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Collection and Preservation of Evidence; Information Created Pursuant to an Investigation... pursuant to the Act, evidence will be collected, and information will be created by the Team, NIST, and...

15 CFR 270.313 - Requests for evidence.

Code of Federal Regulations, 2011 CFR

2011-01-01

... INSTITUTE OF STANDARDS AND TECHNOLOGY, DEPARTMENT OF COMMERCE NATIONAL CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Collection and Preservation of Evidence; Information Created Pursuant to an... the Director establishes and deploys a Team, the Lead Investigator, or their designee, may request the...

15 CFR 270.300 - Scope.

Code of Federal Regulations, 2013 CFR

2013-01-01

... STANDARDS AND TECHNOLOGY, DEPARTMENT OF COMMERCE NATIONAL CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Collection and Preservation of Evidence; Information Created Pursuant to an Investigation... pursuant to the Act, evidence will be collected, and information will be created by the Team, NIST, and...

15 CFR 270.300 - Scope.

Code of Federal Regulations, 2014 CFR

2014-01-01

... STANDARDS AND TECHNOLOGY, DEPARTMENT OF COMMERCE NATIONAL CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Collection and Preservation of Evidence; Information Created Pursuant to an Investigation... pursuant to the Act, evidence will be collected, and information will be created by the Team, NIST, and...

15 CFR 270.313 - Requests for evidence.

Code of Federal Regulations, 2010 CFR

2010-01-01

... INSTITUTE OF STANDARDS AND TECHNOLOGY, DEPARTMENT OF COMMERCE NATIONAL CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Collection and Preservation of Evidence; Information Created Pursuant to an... the Director establishes and deploys a Team, the Lead Investigator, or their designee, may request the...

15 CFR 270.300 - Scope.

Code of Federal Regulations, 2010 CFR

2010-01-01

... STANDARDS AND TECHNOLOGY, DEPARTMENT OF COMMERCE NATIONAL CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Collection and Preservation of Evidence; Information Created Pursuant to an Investigation... pursuant to the Act, evidence will be collected, and information will be created by the Team, NIST, and...

15 CFR 270.313 - Requests for evidence.

Code of Federal Regulations, 2013 CFR

2013-01-01

... INSTITUTE OF STANDARDS AND TECHNOLOGY, DEPARTMENT OF COMMERCE NATIONAL CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Collection and Preservation of Evidence; Information Created Pursuant to an... the Director establishes and deploys a Team, the Lead Investigator, or their designee, may request the...

The Implementation and Maintenance of a Behavioral Safety Process in a Petroleum Refinery

ERIC Educational Resources Information Center

Myers, Wanda V.; McSween, Terry E.; Medina, Rixio E.; Rost, Kristen; Alvero, Alicia M.

2010-01-01

A values-centered and team-based behavioral safety process was implemented in a petroleum oil refinery. Employee teams defined the refinery's safety values and related practices, which were used to guide the process design and implementation. The process included (a) a safety assessment; (b) the clarification of safety-related values and related…

A root cause analysis project in a medication safety course.

PubMed

Schafer, Jason J

2012-08-10

To develop, implement, and evaluate team-based root cause analysis projects as part of a required medication safety course for second-year pharmacy students. Lectures, in-class activities, and out-of-class reading assignments were used to develop students' medication safety skills and introduce them to the culture of medication safety. Students applied these skills within teams by evaluating cases of medication errors using root cause analyses. Teams also developed error prevention strategies and formally presented their findings. Student performance was assessed using a medication errors evaluation rubric. Of the 211 students who completed the course, the majority performed well on root cause analysis assignments and rated them favorably on course evaluations. Medication error evaluation and prevention was successfully introduced in a medication safety course using team-based root cause analysis projects.

DOE Office of Scientific and Technical Information (OSTI.GOV)

NONE

An Office of Inspector General Hotline allegation was received from an anonymous complainant regarding a July 1994 Martin Marietta Corporation Team`s health and safety review at three Department of Energy sites managed and operated by the then Martin Marietta Energy Systems. Inc. (Energy Systems), at Oak Ridge, Tennessee. We determined that the President of Energy Systems had requested a Corporate review at the three sites because of his concerns about safety incidents and accidents during the late Spring and early Summer of 1994. The Corporate Team`s charter was to determine if root causes existed for these safety incidents and accidentsmore » and to produce recommendations for the reduction or prevention of future safety incidents or accidents.« less

15 CFR 270.201 - Priority of investigation.

Code of Federal Regulations, 2010 CFR

2010-01-01

... INSTITUTE OF STANDARDS AND TECHNOLOGY, DEPARTMENT OF COMMERCE NATIONAL CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Investigations § 270.201 Priority of investigation. (a) General. Except as provided in this section, a Team investigation will have priority over any other investigation of any other...

15 CFR 270.205 - Reports.

Code of Federal Regulations, 2012 CFR

2012-01-01

... STANDARDS AND TECHNOLOGY, DEPARTMENT OF COMMERCE NATIONAL CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Investigations § 270.205 Reports. (a) Not later than 90 days after completing an investigation, a Team shall issue a public report which includes: (1) An analysis of the likely technical cause...

15 CFR 270.201 - Priority of investigation.

Code of Federal Regulations, 2014 CFR

2014-01-01

... INSTITUTE OF STANDARDS AND TECHNOLOGY, DEPARTMENT OF COMMERCE NATIONAL CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Investigations § 270.201 Priority of investigation. (a) General. Except as provided in this section, a Team investigation will have priority over any other investigation of any other...

15 CFR 270.350 - Freedom of Information Act.

Code of Federal Regulations, 2010 CFR

2010-01-01

... INSTITUTE OF STANDARDS AND TECHNOLOGY, DEPARTMENT OF COMMERCE NATIONAL CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Collection and Preservation of Evidence; Information Created Pursuant to an... documents submitted or received by NIST, a Team, or any other investigation participant, until the final...

15 CFR 270.350 - Freedom of Information Act.

Code of Federal Regulations, 2011 CFR

2011-01-01

... INSTITUTE OF STANDARDS AND TECHNOLOGY, DEPARTMENT OF COMMERCE NATIONAL CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Collection and Preservation of Evidence; Information Created Pursuant to an... documents submitted or received by NIST, a Team, or any other investigation participant, until the final...

15 CFR 270.316 - Public hearings.

Code of Federal Regulations, 2013 CFR

2013-01-01

... OF STANDARDS AND TECHNOLOGY, DEPARTMENT OF COMMERCE NATIONAL CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Collection and Preservation of Evidence; Information Created Pursuant to an... course of an investigation by a Team, if the Director considers it to be in the public interest, NIST may...

15 CFR 270.350 - Freedom of Information Act.

Code of Federal Regulations, 2012 CFR

2012-01-01

... INSTITUTE OF STANDARDS AND TECHNOLOGY, DEPARTMENT OF COMMERCE NATIONAL CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Collection and Preservation of Evidence; Information Created Pursuant to an... documents submitted or received by NIST, a Team, or any other investigation participant, until the final...

15 CFR 270.316 - Public hearings.

Code of Federal Regulations, 2012 CFR

2012-01-01

... OF STANDARDS AND TECHNOLOGY, DEPARTMENT OF COMMERCE NATIONAL CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Collection and Preservation of Evidence; Information Created Pursuant to an... course of an investigation by a Team, if the Director considers it to be in the public interest, NIST may...

15 CFR 270.330 - Moving and preserving evidence.

Code of Federal Regulations, 2013 CFR

2013-01-01

... NATIONAL INSTITUTE OF STANDARDS AND TECHNOLOGY, DEPARTMENT OF COMMERCE NATIONAL CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Collection and Preservation of Evidence; Information Created Pursuant to... preserving evidence. (a) A Team and NIST will take all necessary steps in moving and preserving evidence...

15 CFR 270.316 - Public hearings.

Code of Federal Regulations, 2014 CFR

2014-01-01

... OF STANDARDS AND TECHNOLOGY, DEPARTMENT OF COMMERCE NATIONAL CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Collection and Preservation of Evidence; Information Created Pursuant to an... course of an investigation by a Team, if the Director considers it to be in the public interest, NIST may...

15 CFR 270.201 - Priority of investigation.

Code of Federal Regulations, 2011 CFR

2011-01-01

... INSTITUTE OF STANDARDS AND TECHNOLOGY, DEPARTMENT OF COMMERCE NATIONAL CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Investigations § 270.201 Priority of investigation. (a) General. Except as provided in this section, a Team investigation will have priority over any other investigation of any other...

15 CFR 270.316 - Public hearings.

Code of Federal Regulations, 2011 CFR

2011-01-01

... OF STANDARDS AND TECHNOLOGY, DEPARTMENT OF COMMERCE NATIONAL CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Collection and Preservation of Evidence; Information Created Pursuant to an... course of an investigation by a Team, if the Director considers it to be in the public interest, NIST may...

15 CFR 270.330 - Moving and preserving evidence.

Code of Federal Regulations, 2011 CFR

2011-01-01

... NATIONAL INSTITUTE OF STANDARDS AND TECHNOLOGY, DEPARTMENT OF COMMERCE NATIONAL CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Collection and Preservation of Evidence; Information Created Pursuant to... preserving evidence. (a) A Team and NIST will take all necessary steps in moving and preserving evidence...

15 CFR 270.330 - Moving and preserving evidence.

Code of Federal Regulations, 2010 CFR

2010-01-01

... NATIONAL INSTITUTE OF STANDARDS AND TECHNOLOGY, DEPARTMENT OF COMMERCE NATIONAL CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Collection and Preservation of Evidence; Information Created Pursuant to... preserving evidence. (a) A Team and NIST will take all necessary steps in moving and preserving evidence...

15 CFR 270.312 - Voluntary submission of evidence.

Code of Federal Regulations, 2010 CFR

2010-01-01

... NATIONAL INSTITUTE OF STANDARDS AND TECHNOLOGY, DEPARTMENT OF COMMERCE NATIONAL CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Collection and Preservation of Evidence; Information Created Pursuant to... of evidence. After the Director establishes and deploys a Team, members of the public are encouraged...

15 CFR 270.330 - Moving and preserving evidence.

Code of Federal Regulations, 2012 CFR

2012-01-01

... NATIONAL INSTITUTE OF STANDARDS AND TECHNOLOGY, DEPARTMENT OF COMMERCE NATIONAL CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Collection and Preservation of Evidence; Information Created Pursuant to... preserving evidence. (a) A Team and NIST will take all necessary steps in moving and preserving evidence...

15 CFR 270.312 - Voluntary submission of evidence.

Code of Federal Regulations, 2013 CFR

2013-01-01

... NATIONAL INSTITUTE OF STANDARDS AND TECHNOLOGY, DEPARTMENT OF COMMERCE NATIONAL CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Collection and Preservation of Evidence; Information Created Pursuant to... of evidence. After the Director establishes and deploys a Team, members of the public are encouraged...

15 CFR 270.201 - Priority of investigation.

Code of Federal Regulations, 2012 CFR

2012-01-01

... INSTITUTE OF STANDARDS AND TECHNOLOGY, DEPARTMENT OF COMMERCE NATIONAL CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Investigations § 270.201 Priority of investigation. (a) General. Except as provided in this section, a Team investigation will have priority over any other investigation of any other...

15 CFR 270.312 - Voluntary submission of evidence.

Code of Federal Regulations, 2012 CFR

2012-01-01

... NATIONAL INSTITUTE OF STANDARDS AND TECHNOLOGY, DEPARTMENT OF COMMERCE NATIONAL CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Collection and Preservation of Evidence; Information Created Pursuant to... of evidence. After the Director establishes and deploys a Team, members of the public are encouraged...

15 CFR 270.312 - Voluntary submission of evidence.

Code of Federal Regulations, 2014 CFR

2014-01-01

... NATIONAL INSTITUTE OF STANDARDS AND TECHNOLOGY, DEPARTMENT OF COMMERCE NATIONAL CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Collection and Preservation of Evidence; Information Created Pursuant to... of evidence. After the Director establishes and deploys a Team, members of the public are encouraged...

15 CFR 270.350 - Freedom of Information Act.

Code of Federal Regulations, 2013 CFR

2013-01-01

... INSTITUTE OF STANDARDS AND TECHNOLOGY, DEPARTMENT OF COMMERCE NATIONAL CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Collection and Preservation of Evidence; Information Created Pursuant to an... documents submitted or received by NIST, a Team, or any other investigation participant, until the final...

15 CFR 270.312 - Voluntary submission of evidence.

Code of Federal Regulations, 2011 CFR

2011-01-01

... NATIONAL INSTITUTE OF STANDARDS AND TECHNOLOGY, DEPARTMENT OF COMMERCE NATIONAL CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Collection and Preservation of Evidence; Information Created Pursuant to... of evidence. After the Director establishes and deploys a Team, members of the public are encouraged...

15 CFR 270.205 - Reports.

Code of Federal Regulations, 2010 CFR

2010-01-01

... STANDARDS AND TECHNOLOGY, DEPARTMENT OF COMMERCE NATIONAL CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Investigations § 270.205 Reports. (a) Not later than 90 days after completing an investigation, a Team shall issue a public report which includes: (1) An analysis of the likely technical cause...

15 CFR 270.316 - Public hearings.

Code of Federal Regulations, 2010 CFR

2010-01-01

... OF STANDARDS AND TECHNOLOGY, DEPARTMENT OF COMMERCE NATIONAL CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Collection and Preservation of Evidence; Information Created Pursuant to an... course of an investigation by a Team, if the Director considers it to be in the public interest, NIST may...

15 CFR 270.330 - Moving and preserving evidence.

Code of Federal Regulations, 2014 CFR

2014-01-01

... NATIONAL INSTITUTE OF STANDARDS AND TECHNOLOGY, DEPARTMENT OF COMMERCE NATIONAL CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Collection and Preservation of Evidence; Information Created Pursuant to... preserving evidence. (a) A Team and NIST will take all necessary steps in moving and preserving evidence...

15 CFR 270.201 - Priority of investigation.

Code of Federal Regulations, 2013 CFR

2013-01-01

... INSTITUTE OF STANDARDS AND TECHNOLOGY, DEPARTMENT OF COMMERCE NATIONAL CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Investigations § 270.201 Priority of investigation. (a) General. Except as provided in this section, a Team investigation will have priority over any other investigation of any other...

15 CFR 270.350 - Freedom of Information Act.

Code of Federal Regulations, 2014 CFR

2014-01-01

... INSTITUTE OF STANDARDS AND TECHNOLOGY, DEPARTMENT OF COMMERCE NATIONAL CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Collection and Preservation of Evidence; Information Created Pursuant to an... documents submitted or received by NIST, a Team, or any other investigation participant, until the final...

Evaluation of aviation-based safety team training in a hospital in The Netherlands.

PubMed

De Korne, Dirk F; Van Wijngaarden, Jeroen D H; Van Dyck, Cathy; Hiddema, U Francis; Klazinga, Niek S

2014-01-01

The purpose of this paper is to evaluate the implementation of a broad-scale team resource management (TRM) program on safety culture in a Dutch eye hospital, detailing the program's content and procedures. Aviation-based TRM training is recognized as a useful approach to increase patient safety, but little is known about how it affects safety culture. Pre- and post-assessments of the hospitals' safety culture was based on interviews with ophthalmologists, anesthesiologists, residents, nurses, and support staff. Interim observations were made at training sessions and in daily hospital practice. The program consisted of safety audits of processes and (team) activities, interactive classroom training sessions by aviation experts, a flight simulator session, and video recording of team activities with subsequent feedback. Medical professionals considered aviation experts inspiring role models and respected their non-hierarchical external perspective and focus on medical-technical issues. The post-assessment showed that ophthalmologists and other hospital staff had become increasingly aware of safety issues. The multidisciplinary approach promoted social (team) orientation that replaced the former functionally-oriented culture. The number of reported near-incidents greatly increased; the number of wrong-side surgeries stabilized to a minimum after an initial substantial reduction. The study was observational and the hospital's variety of efforts to improve safety culture prevented us from establishing a causal relation between improvement and any one specific intervention. Aviation-based TRM training can be a useful to stimulate safety culture in hospitals. Safety and quality improvements are not single treatment interventions but complex socio-technical interventions. A multidisciplinary system approach and focus on "team" instead of "profession" seems both necessary and difficult in hospital care.

Climbing the Extravehicular Activity (EVA) Wall - Safely

NASA Technical Reports Server (NTRS)

Fuentes, Jose; Greene, Stacie

2010-01-01

The success of the EVA team, that includes the EVA project office, Crew Office, Mission Operations, Engineering and Safety, is assured by the full integration of all necessary disciplines. Safety participation in all activities from hardware development concepts, certification and crew training, provides for a strong partnership within the team. Early involvement of Safety on the EVA team has mitigated risk and produced a high degree of mission success.

15 CFR 270.200 - Technical conduct of investigation.

Code of Federal Regulations, 2014 CFR

2014-01-01

... NATIONAL INSTITUTE OF STANDARDS AND TECHNOLOGY, DEPARTMENT OF COMMERCE NATIONAL CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Investigations § 270.200 Technical conduct of investigation. (a... hours of the event, if possible. The Director may establish and deploy a Team to conduct the preliminary...

15 CFR 270.200 - Technical conduct of investigation.

Code of Federal Regulations, 2012 CFR

2012-01-01

... NATIONAL INSTITUTE OF STANDARDS AND TECHNOLOGY, DEPARTMENT OF COMMERCE NATIONAL CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Investigations § 270.200 Technical conduct of investigation. (a... hours of the event, if possible. The Director may establish and deploy a Team to conduct the preliminary...

15 CFR 270.200 - Technical conduct of investigation.

Code of Federal Regulations, 2013 CFR

2013-01-01

... NATIONAL INSTITUTE OF STANDARDS AND TECHNOLOGY, DEPARTMENT OF COMMERCE NATIONAL CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Investigations § 270.200 Technical conduct of investigation. (a... hours of the event, if possible. The Director may establish and deploy a Team to conduct the preliminary...

15 CFR 270.200 - Technical conduct of investigation.

Code of Federal Regulations, 2010 CFR

2010-01-01

... NATIONAL INSTITUTE OF STANDARDS AND TECHNOLOGY, DEPARTMENT OF COMMERCE NATIONAL CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Investigations § 270.200 Technical conduct of investigation. (a... hours of the event, if possible. The Director may establish and deploy a Team to conduct the preliminary...

15 CFR 270.200 - Technical conduct of investigation.

Code of Federal Regulations, 2011 CFR

2011-01-01

... NATIONAL INSTITUTE OF STANDARDS AND TECHNOLOGY, DEPARTMENT OF COMMERCE NATIONAL CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Investigations § 270.200 Technical conduct of investigation. (a... hours of the event, if possible. The Director may establish and deploy a Team to conduct the preliminary...

15 CFR 270.315 - Subpoenas.

Code of Federal Regulations, 2010 CFR

2010-01-01

... STANDARDS AND TECHNOLOGY, DEPARTMENT OF COMMERCE NATIONAL CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Collection and Preservation of Evidence; Information Created Pursuant to an Investigation...

15 CFR 270.315 - Subpoenas.

Code of Federal Regulations, 2014 CFR

2014-01-01

... STANDARDS AND TECHNOLOGY, DEPARTMENT OF COMMERCE NATIONAL CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Collection and Preservation of Evidence; Information Created Pursuant to an Investigation...

15 CFR 270.315 - Subpoenas.

Code of Federal Regulations, 2011 CFR

2011-01-01

... STANDARDS AND TECHNOLOGY, DEPARTMENT OF COMMERCE NATIONAL CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Collection and Preservation of Evidence; Information Created Pursuant to an Investigation...

15 CFR 270.315 - Subpoenas.

Code of Federal Regulations, 2013 CFR

2013-01-01

... STANDARDS AND TECHNOLOGY, DEPARTMENT OF COMMERCE NATIONAL CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Collection and Preservation of Evidence; Information Created Pursuant to an Investigation...

15 CFR 270.315 - Subpoenas.

Code of Federal Regulations, 2012 CFR

2012-01-01

... STANDARDS AND TECHNOLOGY, DEPARTMENT OF COMMERCE NATIONAL CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Collection and Preservation of Evidence; Information Created Pursuant to an Investigation...

Staff Turnover in Assertive Community Treatment (Act) Teams: The Role of Team Climate.

PubMed

Zhu, Xi; Wholey, Douglas R; Cain, Cindy; Natafgi, Nabil

2017-03-01

Staff turnover in Assertive Community Treatment (ACT) teams can result in interrupted services and diminished support for clients. This paper examines the effect of team climate, defined as team members' shared perceptions of their work environment, on turnover and individual outcomes that mediate the climate-turnover relationship. We focus on two climate dimensions: safety and quality climate and constructive conflict climate. Using survey data collected from 26 ACT teams, our analyses highlight the importance of safety and quality climate in reducing turnover, and job satisfaction as the main mediator linking team climate to turnover. The findings offer practical implications for team management.

The patient safety culture as perceived by staff at two different emergency departments before and after introducing a flow-oriented working model with team triage and lean principles: a repeated cross-sectional study.

PubMed

Burström, Lena; Letterstål, Anna; Engström, Marie-Louise; Berglund, Anders; Enlund, Mats

2014-07-09

Patient safety is of the utmost importance in health care. The patient safety culture in an institution has great impact on patient safety. To enhance patient safety and to design strategies to reduce medical injuries, there is a current focus on measuring the patient safety culture. The aim of the present study was to describe the patient safety culture in an ED at two different hospitals before and after a Quality improvement (QI) project that was aimed to enhance patient safety. A repeated cross-sectional design, using the Hospital Survey On Patient Safety Culture questionnaire before and after a quality improvement project in two emergency departments at a county hospital and a university hospital. The questionnaire was developed to obtain a better understanding of the patient safety culture of an entire hospital or of specific departments. The Swedish version has 51 questions and 15 dimensions. At the county hospital, a difference between baseline and follow-up was observed in three dimensions. For two of these dimensions, Team-work within hospital and Communication openness, a higher score was measured at the follow-up. At the university hospital, a higher score was measured at follow-up for the two dimensions Team-work across hospital units and Team-work within hospital. The result showed changes in the self-estimated patient safety culture, mainly regarding team-work and communication openness. Most of the improvements at follow-up were seen by physicians, and mainly at the county hospital.

The development and psychometric evaluation of a safety climate measure for primary care.

PubMed

de Wet, C; Spence, W; Mash, R; Johnson, P; Bowie, P

2010-12-01

Building a safety culture is an important part of improving patient care. Measuring perceptions of safety climate among healthcare teams and organisations is a key element of this process. Existing measurement instruments are largely developed for secondary care settings in North America and many lack adequate psychometric testing. Our aim was to develop and test an instrument to measure perceptions of safety climate among primary care teams in National Health Service for Scotland. Questionnaire development was facilitated through a steering group, literature review, semistructured interviews with primary care team members, a modified Delphi and completion of a content validity index by experts. A cross-sectional postal survey utilising the questionnaire was undertaken in a random sample of west of Scotland general practices to facilitate psychometric evaluation. Statistical methods, including exploratory and confirmatory factor analysis, and Cronbach and Raykov reliability coefficients were conducted. Of the 667 primary care team members based in 49 general practices surveyed, 563 returned completed questionnaires (84.4%). Psychometric evaluation resulted in the development of a 30-item questionnaire with five safety climate factors: leadership, teamwork, communication, workload and safety systems. Retained items have strong factor loadings to only one factor. Reliability coefficients was satisfactory (α = 0.94 and ρ = 0.93). This study is the first stage in the development of an appropriately valid and reliable safety climate measure for primary care. Measuring safety climate perceptions has the potential to help primary care organisations and teams focus attention on safety-related issues and target improvement through educational interventions. Further research is required to explore acceptability and feasibility issues for primary care teams and the potential for organisational benchmarking.

15 CFR 270.311 - Collection of evidence.

Code of Federal Regulations, 2014 CFR

2014-01-01

... INSTITUTE OF STANDARDS AND TECHNOLOGY, DEPARTMENT OF COMMERCE NATIONAL CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Collection and Preservation of Evidence; Information Created Pursuant to an...

15 CFR 270.311 - Collection of evidence.

Code of Federal Regulations, 2013 CFR

2013-01-01

... INSTITUTE OF STANDARDS AND TECHNOLOGY, DEPARTMENT OF COMMERCE NATIONAL CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Collection and Preservation of Evidence; Information Created Pursuant to an...

15 CFR 270.311 - Collection of evidence.

Code of Federal Regulations, 2010 CFR

2010-01-01

... INSTITUTE OF STANDARDS AND TECHNOLOGY, DEPARTMENT OF COMMERCE NATIONAL CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Collection and Preservation of Evidence; Information Created Pursuant to an...

15 CFR 270.311 - Collection of evidence.

Code of Federal Regulations, 2012 CFR

2012-01-01

... INSTITUTE OF STANDARDS AND TECHNOLOGY, DEPARTMENT OF COMMERCE NATIONAL CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Collection and Preservation of Evidence; Information Created Pursuant to an...

15 CFR 270.311 - Collection of evidence.

Code of Federal Regulations, 2011 CFR

2011-01-01

... INSTITUTE OF STANDARDS AND TECHNOLOGY, DEPARTMENT OF COMMERCE NATIONAL CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Collection and Preservation of Evidence; Information Created Pursuant to an...

75 FR 38107 - Agency Information Collection Activities: Proposed Collection; Comment Request

Federal Register 2010, 2011, 2012, 2013, 2014

2010-07-01

... TeamSTEPPS[supreg] (aka Team Strategies and Tools for Enhancing Performance and Patient Safety) to provide an evidence-based suite of tools and strategies for training teamwork- based patient safety to... TeamSTEPPS and are afforded the opportunity to observe the tools and strategies provided in the program...

Safety in Team Sports. Sports Safety Series, Monograph No. 3.

ERIC Educational Resources Information Center

Borozne, Joseph, Ed.; And Others

This monograph examines methods of promoting safe practices in the conduct of selected team sports with the aim of reducing and eliminating the occurrance of injuries. The team sports discussed are baseball and softball, basketball, field hockey, tackle football, touch and flag football, ice hockey, lacrosse, and soccer. (MJB)

15 CFR 270.104 - Size and composition of a Team.

Code of Federal Regulations, 2010 CFR

2010-01-01

... NATIONAL INSTITUTE OF STANDARDS AND TECHNOLOGY, DEPARTMENT OF COMMERCE NATIONAL CONSTRUCTION SAFETY TEAMS... disciplines: civil, structural, mechanical, electrical, fire, forensic, safety, architectural, and materials...

Interprofessional team management in pediatric critical care: some challenges and possible solutions

PubMed Central

Stocker, Martin; Pilgrim, Sina B; Burmester, Margarita; Allen, Meredith L; Gijselaers, Wim H

2016-01-01

Background Aiming for and ensuring effective patient safety is a major priority in the management and culture of every health care organization. The pediatric intensive care unit (PICU) has become a workplace with a high diversity of multidisciplinary physicians and professionals. Therefore, delivery of high-quality care with optimal patient safety in a PICU is dependent on effective interprofessional team management. Nevertheless, ineffective interprofessional teamwork remains ubiquitous. Methods We based our review on the framework for interprofessional teamwork recently published in association with the UK Centre for Advancement of Interprofessional Education. Articles were selected to achieve better understanding and to include and translate new ideas and concepts. Findings The barrier between autonomous nurses and doctors in the PICU within their silos of specialization, the failure of shared mental models, a culture of disrespect, and the lack of empowering parents as team members preclude interprofessional team management and patient safety. A mindset of individual responsibility and accountability embedded in a network of equivalent partners, including the patient and their family members, is required to achieve optimal interprofessional care. Second, working competently as an interprofessional team is a learning process. Working declared as a learning process, psychological safety, and speaking up are pivotal factors to learning in daily practice. Finally, changes in small steps at the level of the microlevel unit are the bases to improve interprofessional team management and patient safety. Once small things with potential impact can be changed in one’s own unit, engagement of health care professionals occurs and projects become accepted. Conclusion Bottom–up patient safety initiatives encouraging participation of every single care provider by learning effective interprofessional team management within daily practice may be an effective way of fostering patient safety. PMID:26955279

Interprofessional team management in pediatric critical care: some challenges and possible solutions.

PubMed

Stocker, Martin; Pilgrim, Sina B; Burmester, Margarita; Allen, Meredith L; Gijselaers, Wim H

2016-01-01

Aiming for and ensuring effective patient safety is a major priority in the management and culture of every health care organization. The pediatric intensive care unit (PICU) has become a workplace with a high diversity of multidisciplinary physicians and professionals. Therefore, delivery of high-quality care with optimal patient safety in a PICU is dependent on effective interprofessional team management. Nevertheless, ineffective interprofessional teamwork remains ubiquitous. We based our review on the framework for interprofessional teamwork recently published in association with the UK Centre for Advancement of Interprofessional Education. Articles were selected to achieve better understanding and to include and translate new ideas and concepts. The barrier between autonomous nurses and doctors in the PICU within their silos of specialization, the failure of shared mental models, a culture of disrespect, and the lack of empowering parents as team members preclude interprofessional team management and patient safety. A mindset of individual responsibility and accountability embedded in a network of equivalent partners, including the patient and their family members, is required to achieve optimal interprofessional care. Second, working competently as an interprofessional team is a learning process. Working declared as a learning process, psychological safety, and speaking up are pivotal factors to learning in daily practice. Finally, changes in small steps at the level of the microlevel unit are the bases to improve interprofessional team management and patient safety. Once small things with potential impact can be changed in one's own unit, engagement of health care professionals occurs and projects become accepted. Bottom-up patient safety initiatives encouraging participation of every single care provider by learning effective interprofessional team management within daily practice may be an effective way of fostering patient safety.

Exploring the importance of team psychological safety in the development of two interprofessional teams.

PubMed

O'Leary, Denise Fiona

2016-01-01

It has been previously demonstrated that interactions within interprofessional teams are characterised by effective communication, shared decision-making, and knowledge sharing. This article outlines aspects of an action research study examining the emergence of these characteristics within change management teams made up of nurses, general practitioners, physiotherapists, care assistants, a health and safety officer, and a client at two residential care facilities for older people in Ireland. The theoretical concept of team psychological safety (TPS) is utilised in presenting these characteristics. TPS has been defined as an atmosphere within a team where individuals feel comfortable engaging in discussion and reflection without fear of censure. Study results suggest that TPS was an important catalyst in enhancing understanding and power sharing across professional boundaries and thus in the development of interprofessional teamwork. There were differences between the teams. In one facility, the team developed many characteristics of interprofessional teamwork while at the other there was only a limited shift. Stability in team membership and organisational norms relating to shared decision-making emerged as particularly important in accounting for differences in the development of TPS and interprofessional teamwork.

Developing Expert Teams with a Strong Safety Culture

NASA Technical Reports Server (NTRS)

Rogers, David G.

2010-01-01

Would you like to lead a world renowned team that draws out all the talents and expertise of its members and consistently out performs all others in the industry? Ever wonder why so many organizations fail to truly learn from past mistakes only to repeat the same ones at a later date? Are you a program/project manager or team member in a high-risk organization where the decisions made often carry the highest of consequences? Leadership, communication, team building, critical decision-making and continuous team improvement skills and behaviors are mere talking points without the attitudes, commitment and strategies necessary to make them the very fabric of a team. Developing Expert Teams with a Strong Safety Culture, will provide you with proven knowledge and strategies to take your team soaring to heights you may have not thought possible. A myriad of teams have applied these strategies and techniques within their organization team environments: military and commercial aviation, astronaut flight crews, Shuttle flight controllers, members of the Space Shuttle Program Mission Management Team, air traffic controllers, nuclear power control teams, surgical teams, and the fire service report having spectacular success. Many industry leaders are beginning to realize that although the circumstances and environments of these teams may differ greatly to their own, the core elements, governing principles and dynamics involved in managing and building a stellar safety conscious team remain identical.

An interprofessional training course in crises and human factors for perioperative teams.

PubMed

Stephens, Tim; Hunningher, Annie; Mills, Helen; Freeth, Della

2016-09-01

Improving patient safety and the culture of care are health service priorities that coexist with financial pressures on organisations. Research suggests team training and better team processes can improve team culture, safety, performance, and clinical outcomes, yet opportunities for interprofessional learning remain scarce. Perioperative practitioners work in a high pressure, high-risk environment without the benefits of stable team membership: this limits opportunities and momentum for team-initiated collaborative improvements. This article describes an interprofessional course focused on crises and human factors which comprised a 1-day event and a multifaceted sustainment programme for perioperative practitioners, grouped by surgical specialty. Participants reported increased understanding and confidence to enact processes and behaviours that support patient safety, including: team behaviours (communication, coordination, cooperation and back-up, leadership, situational awareness); recognising different perspectives and expectations within the team; briefing and debriefing; after action review; and using specialty-specific incident reports to generate specialty-specific interprofessional improvement plans. Participants valued working with specialty colleagues away from normal work pressures. In the high-pressure arena of front-line healthcare delivery, improving patient safety and theatre efficiency can often be erroneously considered conflicting agendas. Interprofessional collaboration amongst staff participating in this initiative enabled general and specialty-specific interprofessional learning that transcended this conflict.

Ensuring the safety of surgical teams when managing casualties of a radiological dirty bomb.

PubMed

Williams, Geraint; O'Malley, Michael; Nocera, Antony

2010-09-01

The capacity for surgical teams to ensure their own safety when dealing with the consequences caused by the detonation of a radiological dirty bomb is primarily determined by prior knowledge, familiarity and training for this type of event. This review article defines the associated radiological terminology with an emphasis on the personal safety of surgical team members in respect to the principles of radiological protection. The article also describes a technique for use of hand held radiation monitors and will discuss the identification and management of radiologically contaminated patients who may pose a significant danger to the surgical team. 2010 Elsevier Ltd. All rights reserved.

Intensive care nurses' perceptions of simulation-based team training for building patient safety in intensive care: a descriptive qualitative study.

PubMed

Ballangrud, Randi; Hall-Lord, Marie Louise; Persenius, Mona; Hedelin, Birgitta

2014-08-01

To describe intensive care nurses' perceptions of simulation-based team training for building patient safety in intensive care. Failures in team processes are found to be contributory factors to incidents in an intensive care environment. Simulation-based training is recommended as a method to make health-care personnel aware of the importance of team working and to improve their competencies. The study uses a qualitative descriptive design. Individual qualitative interviews were conducted with 18 intensive care nurses from May to December 2009, all of which had attended a simulation-based team training programme. The interviews were analysed by qualitative content analysis. One main category emerged to illuminate the intensive care nurse perception: "training increases awareness of clinical practice and acknowledges the importance of structured work in teams". Three generic categories were found: "realistic training contributes to safe care", "reflection and openness motivates learning" and "finding a common understanding of team performance". Simulation-based team training makes intensive care nurses more prepared to care for severely ill patients. Team training creates a common understanding of how to work in teams with regard to patient safety. Copyright © 2014 Elsevier Ltd. All rights reserved.

Effects of patient safety auditing in hospital care: results of a mixed-method evaluation (part 1).

PubMed

Hanskamp-Sebregts, Mirelle; Zegers, Marieke; Westert, Gert P; Boeijen, Wilma; Teerenstra, Steven; van Gurp, Petra J; Wollersheim, Hub

2018-06-15

To evaluate the effectiveness of internal auditing in hospital care focussed on improving patient safety. A before-and-after mixed-method evaluation study was carried out in eight departments of a university medical center in the Netherlands. Internal auditing and feedback focussed on improving patient safety. The effect of internal auditing was assessed 15 months after the audit, using linear mixed models, on the patient, professional, team and departmental levels. The measurement methods were patient record review on adverse events (AEs), surveys regarding patient experiences, safety culture and team climate, analysis of administrative hospital data (standardized mortality rate, SMR) and safety walk rounds (SWRs) to observe frontline care processes on safety. The AE rate decreased from 36.1% to 31.3% and the preventable AE rate from 5.5% to 3.6%; however, the differences before and after auditing were not statistically significant. The patient-reported experience measures regarding patient safety improved slightly over time (P < 0.001). The SMR, patient safety culture and team climate remained unchanged after the internal audit. The SWRs showed that medication safety and information security were improved (P < 0.05). Internal auditing was associated with improved patient experiences and observed safety on wards. No effects were found on adverse outcomes, safety culture and team climate 15 months after the internal audit.

Recent Experiences of the NASA Engineering and Safety Center (NESC) GN and C Technical Discipline Team (TDT)

NASA Technical Reports Server (NTRS)

Dennehy, Cornelius J.

2010-01-01

The NASA Engineering and Safety Center (NESC), initially formed in 2003, is an independently funded NASA Program whose dedicated team of technical experts provides objective engineering and safety assessments of critical, high risk projects. The GN&C Technical Discipline Team (TDT) is one of fifteen such discipline-focused teams within the NESC organization. The TDT membership is composed of GN&C specialists from across NASA and its partner organizations in other government agencies, industry, national laboratories, and universities. This paper will briefly define the vision, mission, and purpose of the NESC organization. The role of the GN&C TDT will then be described in detail along with an overview of how this team operates and engages in its objective engineering and safety assessments of critical NASA projects. This paper will then describe selected recent experiences, over the period 2007 to present, of the GN&C TDT in which they directly performed or supported a wide variety of NESC assessments and consultations.

Teamwork and patient safety in dynamic domains of healthcare: a review of the literature.

PubMed

Manser, T

2009-02-01

This review examines current research on teamwork in highly dynamic domains of healthcare such as operating rooms, intensive care, emergency medicine, or trauma and resuscitation teams with a focus on aspects relevant to the quality and safety of patient care. Evidence from three main areas of research supports the relationship between teamwork and patient safety: (1) Studies investigating the factors contributing to critical incidents and adverse events have shown that teamwork plays an important role in the causation and prevention of adverse events. (2) Research focusing on healthcare providers' perceptions of teamwork demonstrated that (a) staff's perceptions of teamwork and attitudes toward safety-relevant team behavior were related to the quality and safety of patient care and (b) perceptions of teamwork and leadership style are associated with staff well-being, which may impact clinician' ability to provide safe patient care. (3) Observational studies on teamwork behaviors related to high clinical performance have identified patterns of communication, coordination, and leadership that support effective teamwork. In recent years, research using diverse methodological approaches has led to significant progress in team research in healthcare. The challenge for future research is to further develop and validate instruments for team performance assessment and to develop sound theoretical models of team performance in dynamic medical domains integrating evidence from all three areas of team research identified in this review. This will help to improve team training efforts and aid the design of clinical work systems supporting effective teamwork and safe patient care.

OSMA Research and Technology Strategy Team Summary

NASA Technical Reports Server (NTRS)

Wetherholt, Martha

2010-01-01

This slide presentation reviews the work of the Office of Safety and Mission Assurance (OSMA), and the OSMA Research and Technology Strategy (ORTS) team. There is discussion of the charter of the team, Technology Readiness Levels (TRLs) and how the teams responsibilities are related to these TRLs. In order to improve the safety of all levels of the development through the TRL phases, improved communication, understanding and cooperation is required at all levels, particularly at the mid level technologies development.

15 CFR 270.321 - Entry and inspection of property where building components, materials, artifacts, and records...

Code of Federal Regulations, 2010 CFR

2010-01-01

... NATIONAL INSTITUTE OF STANDARDS AND TECHNOLOGY, DEPARTMENT OF COMMERCE NATIONAL CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Collection and Preservation of Evidence; Information Created Pursuant to...

15 CFR 270.321 - Entry and inspection of property where building components, materials, artifacts, and records...

Code of Federal Regulations, 2013 CFR

2013-01-01

... NATIONAL INSTITUTE OF STANDARDS AND TECHNOLOGY, DEPARTMENT OF COMMERCE NATIONAL CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Collection and Preservation of Evidence; Information Created Pursuant to...

15 CFR 270.321 - Entry and inspection of property where building components, materials, artifacts, and records...

Code of Federal Regulations, 2014 CFR

2014-01-01

... NATIONAL INSTITUTE OF STANDARDS AND TECHNOLOGY, DEPARTMENT OF COMMERCE NATIONAL CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Collection and Preservation of Evidence; Information Created Pursuant to...

15 CFR 270.321 - Entry and inspection of property where building components, materials, artifacts, and records...

Code of Federal Regulations, 2011 CFR

2011-01-01

... NATIONAL INSTITUTE OF STANDARDS AND TECHNOLOGY, DEPARTMENT OF COMMERCE NATIONAL CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Collection and Preservation of Evidence; Information Created Pursuant to...

15 CFR 270.321 - Entry and inspection of property where building components, materials, artifacts, and records...

Code of Federal Regulations, 2012 CFR

2012-01-01

... NATIONAL INSTITUTE OF STANDARDS AND TECHNOLOGY, DEPARTMENT OF COMMERCE NATIONAL CONSTRUCTION SAFETY TEAMS NATIONAL CONSTRUCTION SAFETY TEAMS Collection and Preservation of Evidence; Information Created Pursuant to...

"We've Got Creative Differences": The Effects of Task Conflict and Participative Safety on Team Creative Performance

ERIC Educational Resources Information Center

Fairchild, Joshua; Hunter, Samuel T.

2014-01-01

Although both participative safety and team task conflict are widely thought to be related to team creative performance, the nature of this relationship is still not well understood, and prior studies have frequently yielded conflicting results. This study examines the ambiguity in the extant literature and proposes that "both"…

Cognition-based and affect-based trust as mediators of leader behavior influences on team performance.

PubMed

Schaubroeck, John; Lam, Simon S K; Peng, Ann Chunyan

2011-07-01

We develop a model in which cognitive and affective trust in the leader mediate the relationship between leader behavior and team psychological states that, in turn, drive team performance. The model is tested on a sample of 191 financial services teams in Hong Kong and the U.S. Servant leadership influenced team performance through affect-based trust and team psychological safety. Transformational leadership influenced team performance indirectly through cognition-based trust. Cognition-based trust directly influenced team potency and indirectly (through affect-based trust) influenced team psychological safety. The effects of leader behavior on team performance were fully mediated through the trust in leader variables and the team psychological states. Servant leadership explained an additional 10% of the variance in team performance beyond the effect of transformational leadership. We discuss implications of these results for research on the relationship between leader behavior and team performance, and for efforts to enhance leader development by combining knowledge from different leadership theories.

Impact of the time-out process on safety attitude in a tertiary neurosurgical department.

PubMed

McLaughlin, Nancy; Winograd, Deborah; Chung, Hallie R; Van de Wiele, Barbara; Martin, Neil A

2014-11-01

In July 2011, the UCLA Health System released its current time-out process protocol used across the Health System. Numerous interventions were performed to improve checklist completion and time-out process observance. This study assessed the impact of the current protocol for the time-out on healthcare providers' safety attitude and operating room safety climate. All members involved in neurosurgical procedures in the main operating room of the Ronald Reagan UCLA Medical Center were asked to anonymously complete an online survey on their overall perception of the time-out process. The survey was completed by 93 of 128 members of the surgical team. Overall, 98.9% felt that performing a pre-incision time-out improves patient safety. The majority of respondents (97.8%) felt that the team member introductions helped to promote a team spirit during the case. In addition, 93.5% felt that performing a time-out helped to ensure all team members were comfortable to voice safety concerns throughout the case. All respondents felt that the attending surgeon should be present during the time-out and 76.3% felt that he/she should lead the time-out. Unanimously, it was felt that the review of anticipated critical elements by the attending surgeon was helpful to respondents' role during the case. Responses revealed that although the time-out brings the team together physically, it does not necessarily reinforce teamwork. The time-out process favorably impacted team members' safety attitudes and perception as well as overall safety climate in neurosurgical ORs. Survey responses identified leadership training and teamwork training as two avenues for future improvement. Copyright © 2014 Elsevier Inc. All rights reserved.

Inter-professional in-situ simulated team and resuscitation training for patient safety: Description and impact of a programmatic approach.

PubMed

Zimmermann, Katja; Holzinger, Iris Bachmann; Ganassi, Lorena; Esslinger, Peter; Pilgrim, Sina; Allen, Meredith; Burmester, Margarita; Stocker, Martin

2015-10-29

Inter-professional teamwork is key for patient safety and team training is an effective strategy to improve patient outcome. In-situ simulation is a relatively new strategy with emerging efficacy, but best practices for the design, delivery and implementation have yet to be evaluated. Our aim is to describe and evaluate the implementation of an inter-professional in-situ simulated team and resuscitation training in a teaching hospital with a programmatic approach. We designed and implemented a team and resuscitation training program according to Kern's six steps approach for curriculum development. General and specific needs assessments were conducted as independent cross-sectional surveys. Teamwork, technical skills and detection of latent safety threats were defined as specific objectives. Inter-professional in-situ simulation was used as educational strategy. The training was embedded within the workdays of participants and implemented in our highest acuity wards (emergency department, intensive care unit, intermediate care unit). Self-perceived impact and self-efficacy were sampled with an anonymous evaluation questionnaire after every simulated training session. Assessment of team performance was done with the team-based self-assessment tool TeamMonitor applying Van der Vleuten's conceptual framework of longitudinal evaluation after experienced real events. Latent safety threats were reported during training sessions and after experienced real events. The general and specific needs assessments clearly identified the problems, revealed specific training needs and assisted with stakeholder engagement. Ninety-five interdisciplinary staff members of the Children's Hospital participated in 20 in-situ simulated training sessions within 2 years. Participant feedback showed a high effect and acceptance of training with reference to self-perceived impact and self-efficacy. Thirty-five team members experiencing 8 real critical events assessed team performance with TeamMonitor. Team performance assessment with TeamMonitor was feasible and identified specific areas to target future team training sessions. Training sessions as well as experienced real events revealed important latent safety threats that directed system changes. The programmatic approach of Kern's six steps for curriculum development helped to overcome barriers of design, implementation and assessment of an in-situ team and resuscitation training program. This approach may help improve effectiveness and impact of an in-situ simulated training program.

Safety climate and its association with office type and team involvement in primary care.

PubMed

Gehring, Katrin; Schwappach, David L B; Battaglia, Markus; Buff, Roman; Huber, Felix; Sauter, Peter; Wieser, Markus

2013-09-01

To assess differences in safety climate perceptions between occupational groups and types of office organization in primary care. Primary care physicians and nurses working in outpatient offices were surveyed about safety climate. Explorative factor analysis was performed to determine the factorial structure. Differences in mean climate scores between staff groups and types of office were tested. Logistic regression analysis was conducted to determine predictors for a 'favorable' safety climate. 630 individuals returned the survey (response rate, 50%). Differences between occupational groups were observed in the means of the 'team-based error prevention'-scale (physician 4.0 vs. nurse 3.8, P < 0.001). Medical centers scored higher compared with single-handed offices and joint practices on the 'team-based error prevention'-scale (4.3 vs. 3.8 vs. 3.9, P < 0.001) but less favorable on the 'rules and risks'-scale (3.5 vs. 3.9 vs. 3.7, P < 0.001). Characteristics on the individual and office level predicted favorable 'team-based error prevention'-scores. Physicians (OR = 0.4, P = 0.01) and less experienced staff (OR 0.52, P = 0.04) were less likely to provide favorable scores. Individuals working at medical centers were more likely to provide positive scores compared with single-handed offices (OR 3.33, P = 0.001). The largest positive effect was associated with at least monthly team meetings (OR 6.2, P < 0.001) and participation in quality circles (OR 4.49, P < 0.001). Results indicate that frequent quality circle participation and team meetings involving all team members are effective ways to strengthen safety climate in terms of team-based strategies and activities in error prevention.

9. BUILDING 65 ADDITION. LASER SAFETY TEAM. FLOOR PLAN, ELEVATIONS, ...

Library of Congress Historic Buildings Survey, Historic Engineering Record, Historic Landscapes Survey

9. BUILDING 65 ADDITION. LASER SAFETY TEAM. FLOOR PLAN, ELEVATIONS, ETC. March 21, 1973 - Frankford Arsenal, Building No. 65, South of Tacony Street between Bridge Street & tracks of former Pennsylvania Railroad, Philadelphia, Philadelphia County, PA

Interprofessional education in team communication: working together to improve patient safety.

PubMed

Brock, Douglas; Abu-Rish, Erin; Chiu, Chia-Ru; Hammer, Dana; Wilson, Sharon; Vorvick, Linda; Blondon, Katherine; Schaad, Douglas; Liner, Debra; Zierler, Brenda

2013-05-01

Communication failures in healthcare teams are associated with medical errors and negative health outcomes. These findings have increased emphasis on training future health professionals to work effectively within teams. The Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) communication training model, widely employed to train healthcare teams, has been less commonly used to train student interprofessional teams. The present study reports the effectiveness of a simulation-based interprofessional TeamSTEPPS training in impacting student attitudes, knowledge and skills around interprofessional communication. Three hundred and six fourth-year medical, third-year nursing, second-year pharmacy and second-year physician assistant students took part in a 4 h training that included a 1 h TeamSTEPPS didactic session and three 1 h team simulation and feedback sessions. Students worked in groups balanced by a professional programme in a self-selected focal area (adult acute, paediatric, obstetrics). Preassessments and postassessments were used for examining attitudes, beliefs and reported opportunities to observe or participate in team communication behaviours. One hundred and forty-nine students (48.7%) completed the preassessments and postassessments. Significant differences were found for attitudes toward team communication (p<0.001), motivation (p<0.001), utility of training (p<0.001) and self-efficacy (p=0.005). Significant attitudinal shifts for TeamSTEPPS skills included, team structure (p=0.002), situation monitoring (p<0.001), mutual support (p=0.003) and communication (p=0.002). Significant shifts were reported for knowledge of TeamSTEPPS (p<0.001), advocating for patients (p<0.001) and communicating in interprofessional teams (p<0.001). Effective team communication is important in patient safety. We demonstrate positive attitudinal and knowledge effects in a large-scale interprofessional TeamSTEPPS-based training involving four student professions.

Interprofessional education in team communication: working together to improve patient safety.

PubMed

Brock, Douglas; Abu-Rish, Erin; Chiu, Chia-Ru; Hammer, Dana; Wilson, Sharon; Vorvick, Linda; Blondon, Katherine; Schaad, Douglas; Liner, Debra; Zierler, Brenda

2013-11-01

Communication failures in healthcare teams are associated with medical errors and negative health outcomes. These findings have increased emphasis on training future health professionals to work effectively within teams. The Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) communication training model, widely employed to train healthcare teams, has been less commonly used to train student interprofessional teams. The present study reports the effectiveness of a simulation-based interprofessional TeamSTEPPS training in impacting student attitudes, knowledge and skills around interprofessional communication. Three hundred and six fourth-year medical, third-year nursing, second-year pharmacy and second-year physician assistant students took part in a 4 h training that included a 1 h TeamSTEPPS didactic session and three 1 h team simulation and feedback sessions. Students worked in groups balanced by a professional programme in a self-selected focal area (adult acute, paediatric, obstetrics). Preassessments and postassessments were used for examining attitudes, beliefs and reported opportunities to observe or participate in team communication behaviours. One hundred and forty-nine students (48.7%) completed the preassessments and postassessments. Significant differences were found for attitudes toward team communication (p<0.001), motivation (p<0.001), utility of training (p<0.001) and self-efficacy (p=0.005). Significant attitudinal shifts for TeamSTEPPS skills included, team structure (p=0.002), situation monitoring (p<0.001), mutual support (p=0.003) and communication (p=0.002). Significant shifts were reported for knowledge of TeamSTEPPS (p<0.001), advocating for patients (p<0.001) and communicating in interprofessional teams (p<0.001). Effective team communication is important in patient safety. We demonstrate positive attitudinal and knowledge effects in a large-scale interprofessional TeamSTEPPS-based training involving four student professions.

Use of a Surgical Safety Checklist to Improve Team Communication.

PubMed

Cabral, Richard A; Eggenberger, Terry; Keller, Kathryn; Gallison, Barry S; Newman, David

2016-09-01

To improve surgical team communication, a team at Broward Health Imperial Point Hospital, Ft Lauderdale, Florida, implemented a program for process improvement using a locally adapted World Health Organization Surgical Safety Checklist. This program included a standardized, comprehensive time out and a briefing/debriefing process. Postimplementation responses to the Safety Attitudes Questionnaire revealed a significant increase in the surgical team's perception of communication compared with that reported on the pretest (6% improvement resulting in t79 = -1.72, P < .05, d = 0.39). Perceptions of communication increased significantly for nurses (12% increase, P = .002), although the increase for surgeons and surgical technologists was lower (4% for surgeons, P = .15 and 2.3% for surgical technologists, P = .06). As a result of this program, we have observed improved surgical teamwork behaviors and an enhanced culture of safety in the OR. Copyright © 2016 AORN, Inc. Published by Elsevier Inc. All rights reserved.

Examining the Role of School Resource Officers on School Safety and Crisis Response Teams

ERIC Educational Resources Information Center

Eklund, Katie; Meyer, Lauren; Bosworth, Kris

2018-01-01

School resource officers (SROs) are being increasingly employed in schools to respond to incidents of school violence and to help address safety concerns among students and staff. While previous research on school safety and crisis teams has examined the role of school mental health professionals' and administrators, fewer studies have evaluated…

Communication and relationship skills for rapid response teams at hamilton health sciences.

PubMed

Cziraki, Karen; Lucas, Janie; Rogers, Toni; Page, Laura; Zimmerman, Rosanne; Hauer, Lois Ann; Daniels, Charlotte; Gregoroff, Susan

2008-01-01

Rapid response teams (RRT) are an important safety strategy in the prevention of deaths in patients who are progressively failing outside of the intensive care unit. The goal is to intervene before a critical event occurs. Effective teamwork and communication skills are frequently cited as critical success factors in the implementation of these teams. However, there is very little literature that clearly provides an education strategy for the development of these skills. Training in simulation labs offers an opportunity to assess and build on current team skills; however, this approach does not address how to meet the gaps in team communication and relationship skill management. At Hamilton Health Sciences (HHS) a two-day program was developed in collaboration with the RRT Team Leads, Organizational Effectiveness and Patient Safety Leaders. Participants reflected on their conflict management styles and considered how their personality traits may contribute to team function. Communication and relationship theories were reviewed and applied in simulated sessions in the relative safety of off-site team sessions. The overwhelming positive response to this training has been demonstrated in the incredible success of these teams from the perspective of the satisfaction surveys of the care units that call the team, and in the multi-phased team evaluation of their application to practice. These sessions offer a useful approach to the development of the soft skills required for successful RRT implementation.

A case for safety leadership team training of hospital managers.

PubMed

Singer, Sara J; Hayes, Jennifer; Cooper, Jeffrey B; Vogt, Jay W; Sales, Michael; Aristidou, Angela; Gray, Garry C; Kiang, Mathew V; Meyer, Gregg S

2011-01-01

Delivering safe patient care remains an elusive goal. Resolving problems in complex organizations like hospitals requires managers to work together. Safety leadership training that encourages managers to exercise learning-oriented, team-based leadership behaviors could promote systemic problem solving and enhance patient safety. Despite the need for such training, few programs teach multidisciplinary groups of managers about specific behaviors that can enhance their role as leadership teams in the realm of patient safety. The aims of this study were to describe a learning-oriented, team-based, safety leadership training program composed of reinforcing exercises and to provide evidence confirming the need for such training and demonstrating behavior change among management groups after training. Twelve groups of managers from an academic medical center based in the Northeast United States were randomly selected to participate in the program and exposed to its customized, experience-based, integrated, multimodal curriculum. We extracted data from transcripts of four training sessions over 15 months with groups of managers about the need for the training in these groups and change in participants' awareness, professional behaviors, and group activity. Training transcripts confirmed the need for safety leadership team training and provided evidence of the potential for training to increase targeted behaviors. The training increased awareness and use of leadership behaviors among many managers and led to new routines and coordinated effort among most management groups. Enhanced learning-oriented leadership often helped promote a learning orientation in managers' work areas. Team-based training that promotes specific learning-oriented leader behaviors can promote behavioral change among multidisciplinary groups of hospital managers.

Recent Experiences of the NASA Engineering and Safety Center (NESC) Guidance Navigation and Control (GN and C) Technical Discipline Team (TDT)

NASA Technical Reports Server (NTRS)

Dennehy, Cornelius J.

2011-01-01

The NASA Engineering and Safety Center (NESC) is an independently funded NASA Program whose dedicated team of technical experts provides objective engineering and safety assessments of critical, high risk projects. NESC's strength is rooted in the diverse perspectives and broad knowledge base that add value to its products, affording customers a responsive, alternate path for assessing and preventing technical problems while protecting vital human and national resources. The Guidance Navigation and Control (GN&C) Technical Discipline Team (TDT) is one of fifteen such discipline-focused teams within the NESC organization. The TDT membership is composed of GN&C specialists from across NASA and its partner organizations in other government agencies, industry, national laboratories, and universities. This paper will briefly define the vision, mission, and purpose of the NESC organization. The role of the GN&C TDT will then be described in detail along with an overview of how this team operates and engages in its objective engineering and safety assessments of critical NASA.

Safety Evaluation Report: Development of Improved Composite Pressure Vessels for Hydrogen Storage, Lincoln Composites, Lincoln, NE, May 25, 2010

DOE Office of Scientific and Technical Information (OSTI.GOV)

Fort, III, William C.; Kallman, Richard A.; Maes, Miguel

2010-12-22

Lincoln Composites operates a facility for designing, testing, and manufacturing composite pressure vessels. Lincoln Composites also has a U.S. Department of Energy (DOE)-funded project to develop composite tanks for high-pressure hydrogen storage. The initial stage of this project involves testing the permeation of high-pressure hydrogen through polymer liners. The company recently moved and is constructing a dedicated research/testing laboratory at their new location. In the meantime, permeation tests are being performed in a corner of a large manufacturing facility. The safety review team visited the Lincoln Composites site on May 25, 2010. The project team presented an overview of themore » company and project and took the safety review team on a tour of the facility. The safety review team saw the entire process of winding a carbon fiber/resin tank on a liner, installing the boss and valves, and curing and painting the tank. The review team also saw the new laboratory that is being built for the DOE project and the temporary arrangement for the hydrogen permeation tests.« less

Implementation of team training in medical education in Denmark

PubMed Central

Ostergaard, H; Ostergaard, D; Lippert, A

2004-01-01

In the field of medicine, team training aiming at improving team skills such as leadership, communication, co-operation, and followership at the individual and the team level seems to reduce risk of serious events and therefore increase patient safety. The preferred educational method for this type of training is simulation. Team training is not, however, used routinely in the hospital. In this paper, we describe a framework for the development of a team training course based on need assessment, learning objectives, educational methods including full-scale simulation and evaluations strategies. The use of this framework is illustrated by the present multiprofessional team training in advanced cardiac life support, trauma team training and neonatal resuscitation in Denmark. The challenges of addressing all aspects of team skills, the education of the facilitators, and establishment of evaluation strategies to document the effect of the different types of training on patient safety are discussed. PMID:15465962

Implementation of team training in medical education in Denmark.

PubMed

Østergaard, H T; Østergaard, D; Lippert, A

2004-10-01

In the field of medicine, team training aiming at improving team skills such as leadership, communication, co-operation, and followership at the individual and the team level seems to reduce risk of serious events and therefore increase patient safety. The preferred educational method for this type of training is simulation. Team training is not, however, used routinely in the hospital. In this paper, we describe a framework for the development of a team training course based on need assessment, learning objectives, educational methods including full-scale simulation and evaluations strategies. The use of this framework is illustrated by the present multiprofessional team training in advanced cardiac life support, trauma team training and neonatal resuscitation in Denmark. The challenges of addressing all aspects of team skills, the education of the facilitators, and establishment of evaluation strategies to document the effect of the different types of training on patient safety are discussed.

Implementation of team training in medical education in Denmark.

PubMed

Østergaard, H T; Østergaard, D; Lippert, A

2008-10-01

In the field of medicine, team training aiming at improving team skills such as leadership, communication, co-operation, and followership at the individual and the team level seems to reduce risk of serious events and therefore increase patient safety. The preferred educational method for this type of training is simulation. Team training is not, however, used routinely in the hospital. In this paper, we describe a framework for the development of a team training course based on need assessment, learning objectives, educational methods including full-scale simulation and evaluations strategies. The use of this framework is illustrated by the present multiprofessional team training in advanced cardiac life support, trauma team training and neonatal resuscitation in Denmark. The challenges of addressing all aspects of team skills, the education of the facilitators, and establishment of evaluation strategies to document the effect of the different types of training on patient safety are discussed.

Using Contemporary Leadership Skills in Medication Safety Programs.

PubMed

Hertig, John B; Hultgren, Kyle E; Weber, Robert J

2016-04-01

The discipline of studying medication errors and implementing medication safety programs in hospitals dates to the 1970s. These initial programs to prevent errors focused only on pharmacy operation changes - and not the broad medication use system. In the late 1990s, research showed that faulty systems, and not faulty people, are responsible for errors and require a multidisciplinary approach. The 2013 ASHP Statement on the Role of the Medication Safety Leader recommended that medication safety leaders be integrated team members rather than a single point of contact. Successful medication safety programs must employ a new approach - one that embraces the skills of all health care team members and positions many leaders to improve safety. This approach requires a new set of leadership skills based on contemporary management principles, including followership, team-building, tracking and assessing progress, storytelling and communication, and cultivating innovation, all of which promote transformational change. The application of these skills in developing or changing a medication safety program is reviewed in this article.

Using Contemporary Leadership Skills in Medication Safety Programs

PubMed Central

Hertig, John B.; Hultgren, Kyle E.; Weber, Robert J.

2016-01-01

The discipline of studying medication errors and implementing medication safety programs in hospitals dates to the 1970s. These initial programs to prevent errors focused only on pharmacy operation changes – and not the broad medication use system. In the late 1990s, research showed that faulty systems, and not faulty people, are responsible for errors and require a multidisciplinary approach. The 2013 ASHP Statement on the Role of the Medication Safety Leader recommended that medication safety leaders be integrated team members rather than a single point of contact. Successful medication safety programs must employ a new approach – one that embraces the skills of all health care team members and positions many leaders to improve safety. This approach requires a new set of leadership skills based on contemporary management principles, including followership, team-building, tracking and assessing progress, storytelling and communication, and cultivating innovation, all of which promote transformational change. The application of these skills in developing or changing a medication safety program is reviewed in this article. PMID:27303083

Applying lessons from commercial aviation safety and operations to resuscitation.

PubMed

Ornato, Joseph P; Peberdy, Mary Ann

2014-02-01

Both commercial aviation and resuscitation are complex activities in which team members must respond to unexpected emergencies in a consistent, high quality manner. Lives are at stake in both activities and the two disciplines have similar leadership structures, standard setting processes, training methods, and operational tools. Commercial aviation crews operate with remarkable consistency and safety, while resuscitation team performance and outcomes are highly variable. This commentary provides the perspective of two physician-pilots showing how commercial aviation training, operations, and safety principles can be adapted to resuscitation team training and performance. Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.

Reducing health care hazards: lessons from the commercial aviation safety team.

PubMed

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

2009-01-01

The movement to improve quality of care and patient safety has grown, but examples of measurable and sustained progress are rare. The slow progress made in health care contrasts with the success of aviation safety. After a tragic 1995 plane crash, the aviation industry and government created the Commercial Aviation Safety Team to reduce fatal accidents. This public-private partnership of safety officials and technical experts is responsible for the decreased average rate of fatal aviation accidents. We propose a similar partnership in the health care community to coordinate national efforts and move patient safety and quality forward.

Leveraging Social Science-Healthcare Collaborations to Improve Teamwork and Patient Safety.

PubMed

Fernandez, Rosemarie; Grand, James A

2015-12-01

Effective teamwork is critical to the provision of safe, effective healthcare. High functioning teams adapt to rapidly changing patient and environmental factors, preventing diagnostic and treatment errors. While the emphasis on teamwork and patient safety is relatively new, significant team-related foundational and implementation research exists in disciplines outside of healthcare. Social scientists, including, organizational psychologists, have expertise in the study of teams, multi-team units, and organizations. This article highlights guiding team science principles from the organizational psychology literature that can be applied to the study of teams in healthcare. The authors' goal is to provide some common language and understanding around teams and teamwork. Additionally, they hope to impart an appreciation for the potential synergy present within clinician-social scientist collaborations. Copyright © 2015 Mosby, Inc. All rights reserved.

Effects of a Brief Team Training Program on Surgical Teams' Nontechnical Skills: An Interrupted Time-Series Study.

PubMed

Gillespie, Brigid M; Harbeck, Emma; Kang, Evelyn; Steel, Catherine; Fairweather, Nicole; Panuwatwanich, Kriengsak; Chaboyer, Wendy

2017-04-27

Up to 60% of adverse events in surgery are the result of poor communication and teamwork. Nontechnical skills in surgery (NOTSS) are critical to the success of surgery and patient safety. The study aim was to evaluate the effect of a brief team training intervention on teams' observed NOTSS. Pretest-posttest interrupted time-series design with statistical process control analysis was used to detect longitudinal changes in teams' NOTSS. We evaluated NOTSS using the revised NOTECHS weekly for 20 to 25 weeks before and after implementation of a team training program. We observed 179 surgical procedures with cardiac, vascular, upper gastrointestinal, and hepatobiliary teams. Mean posttest NOTECHS scores increased across teams, showing special cause variation. There were also significant before and after improvements in NOTECHS scores in respect to professional role and in the use of the Surgical Safety Checklist. Our results suggest associated improvements in teams' NOTSS after implementation of the team training program.

S-TEAMS: A Truly Multiprofessional Course Focusing on Nontechnical Skills to Improve Patient Safety in the Operating Theater.

PubMed

Stewart-Parker, Emma; Galloway, Robert; Vig, Stella

Possessing adequate nontechnical skills (NTS) in operating theaters is of increasing interest to health care professionals, yet these are rarely formally taught. Teams make human errors despite technical expertise and knowledge, compromising patient safety. We designed a 1-day, multiprofessional, multidisciplinary course to teach, practice, and apply these skills through simulation. The course, "S-TEAMS," comprised a morning of lectures, case studies, and interactive teamworking exercises. The afternoon divided the group into multiprofessional teams to rotate around simulated scenarios. During the scenarios, teams were encouraged to focus on NTS, including communication strategies, situational awareness, and prompts such as checklists. A thorough debrief with experienced clinician observers followed. Data was collected through self-assessments, immediate and 6-month feedback to assess whether skills continued to be used and their effect on safety. In total, 68 health care professionals have completed the course thus far. All participants felt the course had a clear structure and that learning objectives were explicit. Overall, 95% felt the scenarios had good or excellent relevance to clinical practice. Self-assessments revealed a 55% increase in confidence for "speaking up" in difficult situations. Long-term data revealed 97% of the participants continued to use the skills, with 88% feeling the course had prevented them from making errors. Moreover, 94% felt the course had directly improved patient safety. There is a real demand and enthusiasm for developing NTS within the modern theater team. The simple and easily reproducible format of S-TEAMS is sustainable and inclusive, and crucially, the skills taught continue to be used in long term to improve patient safety and teamworking. Copyright © 2016 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.

Tiger Team Assessment of the Sandia National Laboratories, Livermore, California

DOE Office of Scientific and Technical Information (OSTI.GOV)

Not Available

1990-08-01

This report provides the results of the Tiger Team Assessment of the Sandia National Laboratories (SNL) in Livermore, California, conducted from April 30 to May 18, 1990. The purpose of the assessment was to provide the Secretary of Energy with the status of environment, safety and health (ES H) activities at SNL, Livermore. The assessment was conducted by a team consisting of three subteams of federal and private sector technical specialists in the disciplines of environment, safety and health, and management. On-site activities for the assessment included document reviews, observation of site operations, and discussions and interviews with DOE personnel,more » site contractor personnel, and regulators. Using these sources of information and data, the Tiger Team identified a significant number of findings and concerns having to do with the environment, safety and health, and management, as well as concerns regarding noncompliance with Occupational Safety and Health Administration (OSHA) standards. Although the Tiger Team concluded that none of the findings or concerns necessitated immediate cessation of any operations at SNL, Livermore, it does believe that a sizable number of them require prompt management attention. A special area of concern identified for the near-term health and safety of on-site personnel pertained to the on-site Trudell Auto Repair Shop site. Several significant OSHA concerns and environmental findings relating to this site prompted the Tiger Team Leader to immediately advise SNL, Livermore and AL management of the situation. A case study was prepared by the Team, because the root causes of the problems associated with this site were believed to reflect the overall root causes for the areas of ES H noncompliance at SNL, Livermore. 4 figs., 3 tabs.« less

A multicenter trial of aviation-style training for surgical teams.

PubMed

Catchpole, Ken R; Dale, Trevor J; Hirst, D Guy; Smith, J Phillip; Giddings, Tony A E B

2010-09-01

This study measured the effect of aviation-style team training on 3 surgical teams from different specialties. It focused on team working and communication, particularly briefing, time-out, and debriefing, and sought to understand how improvements in team skills could be implemented in a broad range of naturalistic surgical environments to improve safety, quality, and efficiency. Surgical teams performing maxillofacial, vascular, and neurosurgery were studied during 112 operations: 51 before and 61 after intervention. Human factors experts delivered the training of up to 2 days in the classroom followed by 6 days of coaching in theater for each team. Trained observers measured teamwork using the Oxford NOTECHS and the frequency of preoperative briefings, pre-incision time-outs, and postoperative debriefings. The Safety Attitudes Questionnaire and ethnographic observations were used to provide contextual details. There were significantly more time-outs (chi = 18.17, P < 0.001), briefings (chi = 8.62, P = 0.004), and debriefings (chi = 8.58, P = 0.004) after the intervention. The NOTECHS scores showed an interaction between site and intervention (F2,106 = 7.57, P = 0.001). The Safety Attitudes Questionnaire and ethnographic observations helped understand these differences. Aviation-style teamwork training can increase compliance and team performance, but this was influenced by the attitude and collaboration of key individuals, and the effect was reduced by significant latent failures. This study demonstrates the need to improve organizational and personal management factors in the National Health Service if training in patient safety is to be effective and sustained. It also shows the influence of working conditions on clinical studies of quality improvement.

The attributes of successful de-escalation and restraint teams.

PubMed

Snorrason, Jón; Biering, Páll

2018-06-04

Inpatient violence is a widespread problem on psychiatric wards often with serious consequences, and psychiatric hospitals have set up teams to de-escalate and restrain patients with aggression (D-E&R teams) which are specially trained to respond to it in a safe manner. Successful de-escalation and restraining of patients with aggression depend not only on the methods learned in training but also on the confidence of the team. Therefore, it is of great importance to understand the factors that enhance D-E&R teams' competence in managing patients with aggression in a successful and safe manner. The aim of this hermeneutic study was to identify and understand those factors. Purposive-expert sampling was used and twelve D-E&R team members with significant experience participated in the study. The central theme found was a safe team. Ensuring the safety of the team and its members was found to be a prerequisite for successful teamwork in managing patients with aggression in a safe manner. This central theme falls into two interacting domains: the internal dynamics of the team and the team's interaction with patients. Several themes, such as mutual trust, flexibility, and knowing one's role, influence these domains and hence strengthen or weaken the confidence and safety of the team. The findings of the study will contribute to a better understanding of these factors; understanding which could be used to improve the training, supervision, and quality assessment of D-E&R teams and hence lead to more safety in psychiatric wards. © 2018 Australian College of Mental Health Nurses Inc.

Implementation of Water Safety Plans (WSPs): A Case Study in the Coastal Area in Semarang City, Indonesia

NASA Astrophysics Data System (ADS)

Budiyono; Ginandjar, P.; Saraswati, L. D.; Pangestuti, D. R.; Martini; Jati, S. P.

2018-02-01

An area of 508.28 hectares in North Semarang is flooded by tidal inundation, including Bandarharjo village, which could affect water quality in the area. People in Bandarharjo use safe water from deep groundwater, without disinfection process. More than 90% of water samples in the Bandaharjo village had poor bacteriological quality. The aimed of the research was to describe the implementation of Water Safety Plans (WSPs) program in Bandarharjo village. This was a descriptive study with steps for implementations adopted the guidelines and tools of the World Health Organization. The steps consist of introducing WSPs program, team building, training the team, examination of water safety before risk assessment, risk assessment, minor repair I, examination of water safety risk, minor repair II (after monitoring). Data were analyzed using descriptive methods. WSPs program has been introduced and formed WSPs team, and the training of the team has been conducted. The team was able to conduct risks assessment, planned the activities, examined water quality, conduct minor repair and monitoring at the source, distribution, and households connection. The WSPs program could be implemented in the coastal area in Semarang, however regularly supervision and some adjustment are needed.

Implementation of a Surgical Safety Checklist: Impact on Surgical Team Perspectives

PubMed Central

Papaconstantinou, Harry T.; Jo, ChanHee; Reznik, Scott I.; Smythe, W. Roy; Wehbe-Janek, Hania

2013-01-01

Background The World Health Organization (WHO) surgical safety checklist has been shown to decrease mortality and complications and has been adopted worldwide. However, system flaws and human errors persist. Identifying provider perspectives of patient safety initiatives may identify strategies for improvement. The purpose of this study was to determine provider perspectives of surgical safety checklist implementation in an effort to improve initiatives that enhance surgical patients' safety. Methods In September 2010, a WHO-adapted surgical safety checklist was implemented at our institution. Surgical teams were invited to complete a checklist-focused questionnaire 1 month before and 1 year after implementation. Baseline and follow-up results were compared. Results A total of 437 surgical care providers responded to the survey: 45% of providers responded at baseline and 64% of providers responded at follow-up. Of the total respondents, 153 (35%) were nurses, 104 (24%) were anesthesia providers, and 180 (41%) were surgeons. Overall, we found an improvement in the awareness of patient safety and quality of care, with significant improvements in the perception of the value of and participation in the time-out process, in surgical team communication, and in the establishment and clarity of patient care needs. Some discordance was noted between surgeons and other surgical team members, indicating that barriers in communication still exist. Overall, approximately 65% of respondents perceived that the checklist improved patient safety and patient care; however, we found a strong negative perception of operating room efficiency. Conclusion Implementation of a surgical safety checklist improves perceptions of surgical safety. Barriers to implementation exist, but staff feedback may be used to enhance the sustainability and success of patient safety initiatives. PMID:24052757

Patient safety incidents in hospice care: observations from interdisciplinary case conferences.

PubMed

Oliver, Debra Parker; Demiris, George; Wittenberg-Lyles, Elaine; Gage, Ashley; Dewsnap-Dreisinger, Mariah L; Luetkemeyer, Jamie

2013-12-01

In the home hospice environment, issues arise every day presenting challenges to the safety, care, and quality of the dying experience. The literature pertaining to the safety challenges in this environment is limited. The study explored two research questions; 1) What types of patient safety incidents occur in the home hospice setting? 2) How many of these incidents are recognized by the hospice staff and/or the patient or caregiver as a patient safety incident? Video-recordings of hospice interdisciplinary team case conferences were reviewed and coded for patient safety incidents. Patient safety incidents were defined as any event or circumstance that could have resulted or did result in unnecessary harm to the patient or caregiver, or that could have resulted or did result in a negative impact on the quality of the dying experience for the patient. Codes for categories of patient safety incidents were based on the International Classification for Patient Safety. The setting for the study included two rural hospice programs in one Midwestern state in the United States. One hospice team had two separately functioning teams, the second hospice had three teams. 54 video-recordings were reviewed and coded. Patient safety incidents were identified that involved issues in clinical process, medications, falls, family or caregiving, procedural problems, documentation, psychosocial issues, administrative challenges and accidents. This study distinguishes categories of patient safety events that occur in home hospice care. Although the scope and definition of potential patient safety incidents in hospice is unique, the events observed in this study are similar to those observed with in other settings. This study identifies an operating definition and a potential classification for further research on patient safety incidents in hospice. Further research and consensus building of the definition of patient safety incidents and patient safety incidents in this setting is recommended.

Integrating team training strategies into obstetrical emergency simulation training.

PubMed

Daniel, Linda T; Simpson, Ellen K

2009-01-01

Successful management of obstetrical emergencies such as shoulder dystocia requires the coordinated efforts of a multidisciplinary team of professionals. Simulation education provides an opportunity to learn and master simple as well as complex technical skills needed in emergent situations. Team training has been shown to improve the quality of communication among team members and consequently has an enormous impact on human performance. In the healthcare environment, especially obstetrics where the stakes are high, integrating team training into simulation education can advance efforts to create and sustain a culture of safety. With over 7,100 deliveries annually, our 1,100-bed, two-hospital regional healthcare system embarked on this journey to advance the culture of safety.

Evaluation and Customization of WHO Safety Checklist for Patient Safety in Otorhinolaryngology.

PubMed

Dabholkar, Yogesh; Velankar, Haritosh; Suryanarayan, Sneha; Dabholkar, Twinkle Y; Saberwal, Akanksha A; Verma, Bhavika

2018-03-01

The WHO has designed a safe surgery checklist to enhance communication and awareness of patient safety during surgery and to minimise complications. WHO recommends that the check-list be evaluated and customised by end users as a tool to promote safe surgery. The aim of present study was to evaluate the impact of WHO safety checklist on patient safety awareness in otorhinolaryngology and to customise it for the speciality. A prospective structured questionnaire based study was done in ENT operating room for duration of 1 month each for cases, before and after implementation of safe surgery checklist. The feedback from respondents (surgeons, nurses and anaesthetists) was used to arrive at a customised checklist for otolaryngology as per WHO guidelines. The checklist significantly improved team member's awareness of patient's identity (from 17 to 86%) and each other's identity and roles (from 46 to 94%) and improved team communication (from 73 to 92%) in operation theatre. There was a significant improvement in preoperative check of equipment and critical events were discussed more frequently. The checklist could be effectively customised to suit otolaryngology needs as per WHO guidelines. The modified checklist needs to be validated by otolaryngology associations. We conclude from our study that the WHO Surgical safety check-list has a favourable impact on patient safety awareness, team-work and communication of operating team and can be customised for otolaryngology setting.

Building a collaborative culture in cardiothoracic operating rooms: pre and postintervention study protocol for evaluation of the implementation of teamSTEPPS training and the impact on perceived psychological safety

PubMed Central

Ben Abdallah, Arbi; Maniar, Hersh; Avidan, Michael Simon; Bollini, Mara L; Patterson, George Alexander; Steinberg, Aaron; Scaggs, Katie; Dribin, Brenda V; Ridley, Clare H

2017-01-01

Introduction The importance of effective communication, a key component of teamwork, is well recognised in the healthcare setting. Establishing a culture that encourages and empowers team members to speak openly in the cardiothoracic (CT) operating room (OR) is necessary to improve patient safety in this high-risk environment. Methods and analysis This study will take place at Barnes-Jewish Hospital, an academic hospital in affiliation with Washington University School of Medicine located in the USA. All team members participating in cardiac and thoracic OR cases during this 17-month study period will be identified by the primary surgical staff attending on the OR schedule. TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety) training course will be taught to all CT OR staff. Before TeamSTEPPS training, staff will respond to a 39-item questionnaire that includes constructs from the Agency for Healthcare Research and Quality Hospital Survey on Patient Safety Culture, Edmondson’s ‘Measure of psychological safety’ questionnaire, and questionnaires on turnover intentions, job satisfaction and ‘burnout’. The questionnaires will be readministered at 6 and 12 months. The primary outcomes to be assessed include the perceived psychological safety of CT OR team members, the overall effect of TeamSTEPPS on burnout and job satisfaction, and observed turnover rate among the OR nurses. As secondary outcomes, we will be assessing self-reported rates of medical error and near misses in the ORs with a questionnaire at the end of each case. Ethics and dissemination Ethics approval is not indicated as this project does not meet the federal definitions of research requiring the oversight of the Institutional Review Board (IRB). Patient health information (PHI) will not be generated during the implementation of this project. Results of the trial will be made accessible to the public when published in a peer-reviewed journal following the completion of the study. PMID:28963302

10 CFR 70.62 - Safety program and integrated safety analysis.

Code of Federal Regulations, 2011 CFR

2011-01-01

...) Radiological hazards related to possessing or processing licensed material at its facility; (ii) Chemical hazards of licensed material and hazardous chemicals produced from licensed material; (iii) Facility... performed by a team with expertise in engineering and process operations. The team shall include at least...

78 FR 79010 - Criteria to Certify Coal Mine Rescue Teams

Federal Register 2010, 2011, 2012, 2013, 2014

2013-12-27

... to Certify Coal Mine Rescue Teams AGENCY: Mine Safety and Health Administration, Labor. ACTION... updated the coal mine rescue team certification criteria. The Mine Improvement and New Emergency Response... mine operator to certify the qualifications of a coal mine rescue team is that team members are...

Building the occupational health team: keys to successful interdisciplinary collaboration.

PubMed

Wachs, Joy E

2005-04-01

Teamwork among occupational health and safety professionals, management, and employees is vital to solving today's complex problems cost-effectively. No single discipline can meet all the needs of workers and the workplace. However, teamwork can be time-consuming and difficult if attention is not given to the role of the team leader, the necessary skills of team members, and the importance of a supportive environment. Bringing team members together regularly to foster positive relationships and infuse them with the philosophy of strength in diversity is essential for teams to be sustained and work to be accomplished. By working in tandem, occupational health and safety professionals can become the model team in business and industry delivering on their promise of a safe and healthy workplace for America's work force.

Michigan Health & Hospital Association Keystone Obstetrics: a statewide collaborative for perinatal patient safety in Michigan.

PubMed

Simpson, Kathleen Rice; Knox, G Eric; Martin, Morgan; George, Chris; Watson, Sam R

2011-12-01

Preventable harm to mothers and infants during labor and birth is a significant patient safety and professional liability issue. A Michigan Health & Hospital Association Keystone Center for Patient Safety & Quality Obstetric Collaborative Project involved perinatal teams from 15 Michigan hospitals during an 11-month period in 2009. The purpose of the project was to promote safe care practices during labor and birth using the Comprehensive Unit-based Safety Program (CUSP). Consistent with the CUSP model, this project's components included assessing and promoting a culture of safety; interdisciplinary team building; case review; learning from defects through multiple methods of education; team and individual coaching and peer encouragement; administrative support for the establishment of a fundamental safety infrastructure; and ongoing evaluation of care processes and outcomes. Study measures included 32 components of a perinatal patient infrastructure, 6 care processes during labor and birth, and 4 neonatal outcomes. Significant improvements were found in the safety culture (Safety Attitudes Questionnaire), the perinatal patient safety infrastructure components, and all care processes. Although the project was successful, getting buy-in from all members of the clinical team in each hospital for all of the measures was challenging at times. There was initial resistance to some of the measures and their various expected aspects of care. For example, some of the clinicians were initially reluctant to adopt the recommended standardized oxytocin protocol. Peer encouragement and unit-based feedback on progress in minimizing early elective births proved useful in many hospitals. A CUSP in obstetrics can be beneficial in improving the care of mothers and infants during labor and birth.

Team Training and Institutional Protocols to Prevent Shoulder Dystocia Complications.

PubMed

Smith, Samuel

2016-12-01

Shoulder dystocia is an obstetrical emergency that may result in significant neonatal complications. It requires rapid recognition and a coordinated response. Standardization of care, teamwork and communication, and clinical simulation are the key components of patient safety programs in obstetrics. Simulation-based team training and institutional protocols for the management of shoulder dystocia are emerging as integral components of many labor and delivery safety initiatives because of their impact on technical skills and team performance.

Moving Toward Improved Teamwork in Cancer Care: The Role of Psychological Safety in Team Communication.

PubMed

Jain, Anshu K; Fennell, Mary L; Chagpar, Anees B; Connolly, Hannah K; Nembhard, Ingrid M

2016-11-01

Effective communication is a requirement in the teamwork necessary for improved coordination to deliver patient-centered, value-based cancer care. Communication is particularly important when care providers are geographically distributed or work across organizations. We review organizational and teams research on communication to highlight psychological safety as a key determinant of high-quality communication within teams. We first present the concept of psychological safety, findings about its communication effects for teamwork, and factors that affect it. We focus on five factors applicable to cancer care delivery: familiarity, clinical hierarchy-related status differences, geographic dispersion, boundary spanning, and leader behavior. To illustrate how these factors facilitate or hinder psychologically safe communication and teamwork in cancer care, we review the case of a patient as she experiences the treatment-planning process for early-stage breast cancer in a community setting. Our analysis is summarized in a key principle: Teamwork in cancer care requires high-quality communication, which depends on psychological safety for all team members, clinicians and patients alike. We conclude with a discussion of the implications of psychological safety in clinical care and suggestions for future research.

78 FR 52927 - Agency Information Collection Activities: Proposed Collection; Comment Request

Federal Register 2010, 2011, 2012, 2013, 2014

2013-08-27

... TeamSTEPPS[supreg] (aka Team Strategies and Tools for Enhancing Performance and Patient Safety) to provide an evidence-based suite of tools and strategies for training teamwork- based patient safety to... strategies provided in the program in action. In addition to developing Master Trainers, AHRQ has also...

School Safety Review Checklist

ERIC Educational Resources Information Center

Vermont Department of Education, 2005

2005-01-01

The School Safety Review Checklist is an important component of the broader school crisis resources that have been developed by the Vermont School Crisis Planning Team. The Team is comprised of members from the law enforcement, emergency management, health, and education organizations who have worked throughout the year to update school and…

Speeding Up Team Learning.

ERIC Educational Resources Information Center

Edmondson, Amy; Bohmer, Richard; Pisano, Gary

2001-01-01

A study of 16 cardiac surgery teams looked at how the teams adapted to new ways of working. The challenge of team management is to implement new processes as quickly as possible. Steps for creating a learning team include selecting a mix of skills and expertise, framing the challenge, and creating an environment of psychological safety. (JOW)

Confronting Safety Gaps across Labor and Delivery Teams

PubMed Central

Maxfield, David G.; Lyndon, Audrey; Kennedy, Holly Powell; O’Keeffe, Dan; Zlatnik, Marya G.

2013-01-01

We assessed the occurrence of four safety concerns among labor and delivery teams: dangerous shortcuts, missing competencies, disrespect, and performance problems. 3282 participants completed surveys. 92% of physicians (906/985), 93% of midwives (385/414), and 98% of nurses (1846/1884) observed at least one concern within the preceding year. A majority of respondents said these concerns undermined patient safety, harmed patients, or led them to seriously consider transferring or leaving their positions. Only 9% of physicians, 13% of midwives, and 13% of nurses shared their full concerns with the person involved. Organizational silence is evident within labor and delivery teams. Improvement will require multiple strategies, employed at the personal, social, and structural levels. PMID:23871951

KSC-03pd0272

NASA Image and Video Library

2003-02-05

KENNEDY SPACE CENTER, FLA. - Don Maxwell, Safety, United Space Alliance, checks a map of Texas during a meeting of the Recovery Management Team at KSC. The team is part of the investigation into the accident that claimed orbiter Columbia and her crew of seven on Feb. 1, 2003, over East Texas as they returned to Earth after a 16-day research mission. Other team members are Russ DeLoach, chief, Shuttle Mission Assurance Branch, NASA; George Jacobs, Shuttle Engineering; Jeff Campbell, Shuttle Engineering; Dave Rainer, Launch and Landing Operations; the two co-chairs of the Response Management Team, Denny Gagen, Landing Recovery Manager, Chris Hasselbring, Landing Operations, USA; and Larry Ulmer, Safety, NASA. The team is coordinating KSC technical support and assets to the Mishap Investigation Team in Barksdale, La., and providing support for the Recovery teams in Los Angeles, Texas, New Mexico, Arizona and California. In addition, the team is following up on local leads pertaining to potential debris in the KSC area. .

A patient safety course for preclinical medical students.

PubMed

Shekhter, Ilya; Rosen, Lisa; Sanko, Jill; Everett-Thomas, Ruth; Fitzpatrick, Maureen; Birnbach, David

2012-12-01

We developed a course to introduce incoming third-year medical students to the subject of patient safety, to focus their attention on teamwork and communication, and to create an awareness of patient-safe practices that will positively impact their performance as clinicians. The course, held prior to the start of clinical rotations, consisted of lectures, web-based didactic materials, small group activities and simulation exercises, with an emphasis on experiential learning. First, students inspected a 'room of horrors', which is a simulated clinical environment riddled with errors. Second, we used lenticular puzzles in small groups to elicit teamwork behaviours that parallel real-life interactions in health care. Each team was given 8 minutes to complete a 48-piece puzzle, with five pieces removed at random and given to other teams. The salient teaching point of this exercise is that for a team to complete the task, team members must communicate with members of their own team as well as with other teams. Last, simulation scenarios provided a clinical context to reinforce the skills introduced through the puzzle exercise and lectures. The students were split into groups of six or seven members and challenged with two scenarios. Both scenarios focused on a 56-year-old man in respiratory distress. The teams were debriefed on both clinical management and teamwork. The vast majority of the students (93%) agreed that the course improved their patient safety knowledge and skills. The positive response from students to the introductory course is an important step in fostering a culture of patient safety. © Blackwell Publishing Ltd 2012.

Preoperative Safety Briefing Project

PubMed Central

DeFontes, James; Surbida, Stephanie

2004-01-01

Context: Increased media attention on surgical procedures that were performed on the wrong anatomic site or wrong patient has prompted the health care industry to identify and address human factors that lead to medical errors. Objective: To increase patient safety in the perioperative setting, our objective was to create a climate of improved communication, collaboration, team-work, and situational awareness while the surgical team reviewed pertinent information about the patient and the pending procedure. Methods: A team of doctors, nurses, and technicians used human factors principles to develop the Preoperative Safety Briefing for use by surgical teams, a briefing similar to the preflight checklist used by the airline industry. A six-month pilot of the briefing began in the Kaiser Permanente (KP) Anaheim Medical Center in February 2002. Four indicators of safety culture were used to measure success of the pilot: occurrence of wrong-site/wrong procedures, attitudinal survey data, near-miss reports, and nursing personnel turnover data. Results: Wrong-site surgeries decreased from 3 to 0 (300%) per year; employee satisfaction increased 19%; nursing personnel turnover decreased 16%; and perception of the safety climate in the operating room improved from “good” to “outstanding.” Operating suite personnel perception of teamwork quality improved substantially. Operating suite personnel perception of patient safety as a priority, of personnel communication, of their taking responsibility for patient safety, of nurse input being well received, of overall morale, and of medical errors being handled appropriately also improved substantially. Conclusions: Team members who work together and communicate well can quickly detect and more easily avoid errors. The Preoperative Safety Briefing is now standard in many operating suites in the KP Orange County Service Area. The concepts and design of this project are transferable, and similar projects are underway in the Departments of Radiology and of Labor and Delivery at KP Anaheim Medical Center. PMID:26704913

Report on the oversight assessment of the operational readiness review of the Replacement Tritium Facility at Savannah River Site

DOE Office of Scientific and Technical Information (OSTI.GOV)

Lee, B.T.

1993-03-01

This report presents the results of an oversight assessment (OA) conducted by the US Department of Energy's (DOE) Office of Environment, Safety and Health (EH) of operational readiness review (ORR) activities for the Replacement Tritium Facility (RTF) located at Savannah River Site (SRS). The EH OA of this facility took place concurrently with an ORR conducted by the DOE Office of Defense Programs (DP). The DP ORR was conducted from January 19 through February 5, 1993. The EH OA was performed in accordance with the protocol and procedures specified in EH Program for Oversight Assessment of Operational Readiness Evaluations formore » Startups and Restarts,'' dated September 15, 1992. The EH OA Team evaluated the DP ORR to determine whether it was thorough and demonstrated sufficient inquisitiveness to verify that the implementation of programs and procedures adequately ensures the protection of worker safety and health. The EH OA Team performed its evaluation of the DP ORR in the following technical areas: occupational safety, industrial hygiene, and respiratory protection; fire protection; and chemical safety. In the areas of fire protection and chemical safety, the EH OA Team conducted independent vertical-slice reviews to confirm DP ORR results. Within each technical area, the EH OA Team reviewed the DP ORR Plan, including the Criteria Review and Approach Documents (CRADs); the qualifications of individual DP ORR team members; the performance of planned DP ORR activities; and the results of the DP ORR.« less

Report on the oversight assessment of the operational readiness review of the Replacement Tritium Facility at Savannah River Site

DOE Office of Scientific and Technical Information (OSTI.GOV)

Lee, B.T.

1993-03-01

This report presents the results of an oversight assessment (OA) conducted by the US Department of Energy`s (DOE) Office of Environment, Safety and Health (EH) of operational readiness review (ORR) activities for the Replacement Tritium Facility (RTF) located at Savannah River Site (SRS). The EH OA of this facility took place concurrently with an ORR conducted by the DOE Office of Defense Programs (DP). The DP ORR was conducted from January 19 through February 5, 1993. The EH OA was performed in accordance with the protocol and procedures specified in ``EH Program for Oversight Assessment of Operational Readiness Evaluations formore » Startups and Restarts,`` dated September 15, 1992. The EH OA Team evaluated the DP ORR to determine whether it was thorough and demonstrated sufficient inquisitiveness to verify that the implementation of programs and procedures adequately ensures the protection of worker safety and health. The EH OA Team performed its evaluation of the DP ORR in the following technical areas: occupational safety, industrial hygiene, and respiratory protection; fire protection; and chemical safety. In the areas of fire protection and chemical safety, the EH OA Team conducted independent vertical-slice reviews to confirm DP ORR results. Within each technical area, the EH OA Team reviewed the DP ORR Plan, including the Criteria Review and Approach Documents (CRADs); the qualifications of individual DP ORR team members; the performance of planned DP ORR activities; and the results of the DP ORR.« less

Work-team implementation.

PubMed

Reiste, K K; Hubrich, A

1996-02-01

The authors describe the implementation of the Work-Team Concept at the Frigidaire plans in Jefferson, Iowa. By forming teams, plant staff have made significant improvements in worker safety, product quality, customer service, cost-effectiveness, and overall employee well-being.

Multidisciplinary safety team (MDST) factors of success.

DOT National Transportation Integrated Search

2014-11-01

This project included a literature review and summary that focused on subjects related to team building, team/committee member : motivational strategies, and tools for effective and efficient committee meetings. It also completed an online survey of ...

Thick as Thieves: The Effects of Ethical Orientation and Psychological Safety on Unethical Team Behavior

ERIC Educational Resources Information Center

Pearsall, Matthew J.; Ellis, Aleksander P. J.

2011-01-01

The purpose of this study was to uncover compositional and emergent influences on unethical behavior by teams. Results from 126 teams indicated that the presence of a formalistic orientation within the team was negatively related to collective unethical decisions. Conversely, the presence of a utilitarian orientation within the team was positively…

Multidisciplinary crisis simulations: the way forward for training surgical teams.

PubMed

Undre, Shabnam; Koutantji, Maria; Sevdalis, Nick; Gautama, Sanjay; Selvapatt, Nowlan; Williams, Samantha; Sains, Parvinderpal; McCulloch, Peter; Darzi, Ara; Vincent, Charles

2007-09-01

High-reliability organizations have stressed the importance of non-technical skills for safety and of regularly providing such training to their teams. Recently safety skills training has been applied in the practice of medicine. In this study, we developed and piloted a module using multidisciplinary crisis scenarios in a simulated operating theatre to train entire surgical teams. Twenty teams participated (n = 80); each consisted of a trainee surgeon, anesthetist, operating department practitioner (ODP), and scrub nurse. Crisis scenarios such as difficult intubation, hemorrhage, or cardiac arrest were simulated. Technical and non-technical skills (leadership, communication, team skills, decision making, and vigilance), were assessed by clinical experts and by two psychologists using relevant technical and human factors rating scales. Participants received technical and non-technical feedback, and the whole team received feedback on teamwork. Trainees assessed the training favorably. For technical skills there were no differences between surgical trainees' assessment scores and the assessment scores of the trainers. However, nurses overrated their technical skill. Regarding non-technical skills, leadership and decision making were scored lower than the other three non-technical skills (communication, team skills, and vigilance). Surgeons scored lower than nurses on communication and teamwork skills. Surgeons and anesthetists scored lower than nurses on leadership. Multidisciplinary simulation-based team training is feasible and well received by surgical teams. Non-technical skills can be assessed alongside technical skills, and differences in performance indicate where there is a need for further training. Future work should focus on developing team performance measures for training and on the development and evaluation of systematic training for technical and non-technical skills to enhance team performance and safety in surgery.

Stepping Up Occupational Safety and Health Through Employee Participation.

ERIC Educational Resources Information Center

Vaughan, Gary R.

1986-01-01

The effectiveness of the Occupational Safety and Health Act of 1970 is examined, and it is suggested that employee participation could help improve occupational safety and health in the future, through safety committees, safety circles, safety teams, and individual participation. (MSE)

Final Report of the NASA Office of Safety and Mission Assurance Agile Benchmarking Team

NASA Technical Reports Server (NTRS)

Wetherholt, Martha

2016-01-01

To ensure that the NASA Safety and Mission Assurance (SMA) community remains in a position to perform reliable Software Assurance (SA) on NASAs critical software (SW) systems with the software industry rapidly transitioning from waterfall to Agile processes, Terry Wilcutt, Chief, Safety and Mission Assurance, Office of Safety and Mission Assurance (OSMA) established the Agile Benchmarking Team (ABT). The Team's tasks were: 1. Research background literature on current Agile processes, 2. Perform benchmark activities with other organizations that are involved in software Agile processes to determine best practices, 3. Collect information on Agile-developed systems to enable improvements to the current NASA standards and processes to enhance their ability to perform reliable software assurance on NASA Agile-developed systems, 4. Suggest additional guidance and recommendations for updates to those standards and processes, as needed. The ABT's findings and recommendations for software management, engineering and software assurance are addressed herein.

How Action-Learning Coaches Foster a Climate Conducive to Learning

ERIC Educational Resources Information Center

Gibson, Sara Henderson

2011-01-01

Today's businesses rely on the effective functioning of self-directed work teams to learn how to solve complex problems and take action. A key factor in a team's ability to perform in this manner is a group climate characterized by psychological safety. Psychological safety must often compete with a climate of evaluative pressure frequently found…

Attitudes to teamwork and safety among Italian surgeons and operating room nurses.

PubMed

Prati, Gabriele; Pietrantoni, Luca

2014-01-01

Previous studies have shown that surgical team members' attitudes about safety and teamwork in the operating theatre may play a role in patient safety. The aim of this study was to assess attitudes about teamwork and safety among Italian surgeons and operating room nurses. Fifty-five surgeons and 48 operating room nurses working in operating theatres at one hospital in Italy completed the Operating Room Management Attitudes Questionnaire (ORMAQ). Results showed several discrepancies in attitudes about teamwork and safety between surgeons and operating room nurses. Surgeons had more positive views on the quality of surgical leadership, communication, teamwork, and organizational climate in the theatre than operating room nurses. Operating room nurses reported that safety rules and procedures were more frequently disregarded than the surgeons. The results are only partially aligned with previous ORMAQ surveys of surgical teams in other countries. The differences emphasize the influence of national culture, as well as the particular healthcare system. This study shows discrepancies on many aspects in attitudes to teamwork and safety between surgeons and operating room nurses. The findings support implementation and use of team interventions and human factor training. Finally, attitude surveys provide a method for assessing safety culture in surgery, for evaluating the effectiveness of training initiatives, and for collecting data for a hospital's quality assurance programme.

KSC-03pd0271

NASA Image and Video Library

2003-02-05

KENNEDY SPACE CENTER, FLA. - Two members of the Recovery Management Team at KSC are at work in the Operations Support Building. At left is Don Maxwell, Safety, United Space Alliance, and at right is Larry Ulmer, Safety, NASA. They are part of the investigation into the accident that claimed orbiter Columbia and her crew of seven on Feb. 1, 2003, over East Texas as they returned to Earth after a 16-day research mission. Other team members are Russ DeLoach, chief, Shuttle Mission Assurance Branch, NASA; George Jacobs, Shuttle Engineering; Jeff Campbell, Shuttle Engineering; Dave Rainer, Launch and Landing Operations; and the two co-chairs of the Response Management Team, Denny Gagen, Landing Recovery Manager, and Chris Hasselbring, Landing Operations, USA. The team is coordinating KSC technical support and assets to the Mishap Investigation Team in Barksdale, La., and providing support for the Recovery teams in Los Angeles, Texas, New Mexico, Arizona and California. In addition, the team is following up on local leads pertaining to potential debris in the KSC area. .

What makes maternity teams effective and safe? Lessons from a series of research on teamwork, leadership and team training.

PubMed

Siassakos, Dimitrios; Fox, Robert; Bristowe, Katherine; Angouri, Jo; Hambly, Helen; Robson, Lauren; Draycott, Timothy J

2013-11-01

We describe lessons for safety from a synthesis of seven studies of teamwork, leadership and team training across a healthcare region. Two studies identified successes and challenges in a unit with embedded team training: a staff survey demonstrated a positive culture but a perceived need for greater senior presence; training improved actual emergency care, but wide variation in team performance remained. Analysis of multicenter simulation records showed that variation in patient safety and team efficiency correlated with their teamwork but not individual knowledge, skills or attitudes. Safe teams tended to declare the emergency earlier, hand over in a more structured way, and use closed-loop communication. Focused and directed communication was also associated with better patient-actor perception of care. Focus groups corroborated these findings, proposed that the capability and experience of the leader is more important than seniority, and identified teamwork and leadership issues that require further research. © 2013 Nordic Federation of Societies of Obstetrics and Gynecology.

Are There Potential Safety Problems Concerning the Use of Electronic Performance-Tracking Systems? The Experience of a Multisport Elite Club.

PubMed

Medina, Daniel; Pons, Eduard; Gomez, Antonio; Guitart, Marc; Martin, Andres; Vazquez-Guerrero, Jairo; Camenforte, Ismael; Carles, Berta; Font, Roger

2017-09-01

Despite approval of the use of electronic performance-tracking systems (EPTSs) during competition by the International Football Association Board, other team-sport organizations and leagues have banned their use due to "safety concerns," with no evidence to support this assertion. The aim of the current brief report was to provide empirical evidence to support the widespread use of EPTSs across all sports by examining safety issues concerning their use in a multi-team-sport club. Five outdoor football teams (1st team, 2nd team, under 19 [U-19], under 18 [U-18], and 1st team female) and 3 indoor-sport (basketball, futsal, and handball) teams were monitored, accounting for a total of 63,734 h of training and 12,748 h of game time. A questionnaire was sent to all fitness coaches involved, and the clinical history was reviewed for every medical issue reported. Six minor chest contusions were recorded in female football goalkeepers wearing the frontal chest strap (3.17 episodes per 1000 training h). During training, 3 episodes of minor skin abrasion affecting the thoracic area due to wearing vests too tight were recorded in the U-19 football team (0.21 per 1000 h) and 2 episodes in U-18 (0.39 per 1000 h). It must be noted that none of these episodes resulted in lost days of training or games, and none required medical assistance. In conclusion, empirical evidence confirms that EPTSs are safe to use across team sports.

A haemovigilance team provides both significant financial and quality benefits in a University Hospital.

PubMed

Decadt, Ine; Costermans, Els; Van de Poel, Maai; Kesteloot, Katrien; Devos, Timothy

2017-04-01

Haemovigilance is the process of surveillance of blood transfusion procedures including unexpected hazards and reactions during the transfusion pathway in both donors and recipients. The haemovigilance team aims to increase blood transfusion safety and to decrease both morbidity and mortality in donors and recipients. The team collects data about transfusion reactions and incidents, instructs the involved health workers and assures the tracing of blood components. The haemovigilance team at the University Hospitals Leuven has played a pioneering role in the development of haemovigilance in Belgium Although the literature about safety and quality improvements by haemovigilance systems is abundant, there are no published data available measuring their financial impact in a hospital. Therefore, we studied the costs and returns of the haemovigilance team at the University Hospitals Leuven. This study has a descriptive explorative design. Research of the current costs and returns of the haemovigilance team were based upon data from the Medical Administration of the hospital. Data were analyzed descriptively. The haemovigilance team of the University Hospitals Leuven is financially viable: the direct costs are covered by the annual financial support of the National Public Health Service. The indirect returns come from two important tasks of the haemovigilance team itself: correction of the electronic registration of administered blood component and improvement of the return of conform preserved blood components to the blood bank. Besides safety and quality improvement, which are obviously their main goals, the haemovigilance team also implies a financial benefit for the hospital. Copyright © 2016 Elsevier Ltd. All rights reserved.

Summary of Tiger Team Assessment and Technical Safety Appraisal recurring concerns in the Maintenance Area

DOE Office of Scientific and Technical Information (OSTI.GOV)

Not Available

1993-01-01

Tiger Team Assessments and Technical Safety Appraisals (TSA) were reviewed and evaluated for concerns in the Maintenance Area (MA). Two hundred and thirty one (231) maintenance concerns were identified by the Tiger Team Assessments and TSA reports. These recurring concerns appear below. A summary of the Noteworthy Practices that were identified and a compilation of the maintenance concerns for each performance objective that were not considered as recurring are also included. Where the Tiger Team Assessment and TSA identified the operating contractor or facility by name, the concern has been modified to remove the name while retaining the intent ofmore » the comment.« less

Defining Components of Team Leadership and Membership in Prehospital Emergency Medical Services.

PubMed

Crowe, Remle P; Wagoner, Robert L; Rodriguez, Severo A; Bentley, Melissa A; Page, David

2017-01-01

Teamwork is critical for patient and provider safety in high-stakes environments, including the setting of prehospital emergency medical services (EMS). We sought to describe the components of team leadership and team membership on a single patient call where multiple EMS providers are present. We conducted a two-day focus group with nine subject matter experts in crew resource management (CRM) and EMS using a structured nominal group technique (NGT). The specific question posed to the group was, "What are the specific components of team leadership and team membership on a single patient call where multiple EMS providers are present?" After round-robin submission of ideas and in-depth discussion of the meaning of each component, participants voted on the most important components of team leadership and team membership. Through the NGT process, we identified eight components of team leadership: a) creates an action plan; b) communicates; c) receives, processes, verifies, and prioritizes information; d) reconciles incongruent information; e) demonstrates confidence, compassion, maturity, command presence, and trustworthiness; f) takes charge; g) is accountable for team actions and outcomes; and h) assesses the situation and resources and modifies the plan. The eight essential components of team membership identified included: a) demonstrates followership, b) maintains situational awareness, c) demonstrates appreciative inquiry, d) does not freelance, e) is an active listener, f) accurately performs tasks in a timely manner, g) is safety conscious and advocates for safety at all times, and h) leaves ego and rank at the door. This study used a highly structured qualitative technique and subject matter experts to identify components of teamwork essential for prehospital EMS providers. These findings and may be used to help inform the development of future EMS training and assessment initiatives.

Improving health care quality and safety: the role of collective learning.

PubMed

Singer, Sara J; Benzer, Justin K; Hamdan, Sami U

2015-01-01

Despite decades of effort to improve quality and safety in health care, this goal feels increasingly elusive. Successful examples of improvement are infrequently replicated. This scoping review synthesizes 76 empirical or conceptual studies (out of 1208 originally screened) addressing learning in quality or safety improvement, that were published in selected health care and management journals between January 2000 and December 2014 to deepen understanding of the role that collective learning plays in quality and safety improvement. We categorize learning activities using a theoretical model that shows how leadership and environmental factors support collective learning processes and practices, and in turn team and organizational improvement outcomes. By focusing on quality and safety improvement, our review elaborates the premise of learning theory that leadership, environment, and processes combine to create conditions that promote learning. Specifically, we found that learning for quality and safety improvement includes experimentation (including deliberate experimentation, improvisation, learning from failures, exploration, and exploitation), internal and external knowledge acquisition, performance monitoring and comparison, and training. Supportive learning environments are characterized by team characteristics like psychological safety, appreciation of differences, openness to new ideas social motivation, and team autonomy; team contextual factors including learning resources like time for reflection, access to knowledge, organizational capabilities; incentives; and organizational culture, strategy, and structure; and external environmental factors including institutional pressures, environmental dynamism and competitiveness and learning collaboratives. Lastly learning in the context of quality and safety improvement requires leadership that reinforces learning through actions and behaviors that affect people, such as coaching and trust building, and through influencing contextual factors, including providing resources, developing culture, and taking strategic actions that support improvement. Our review highlights the importance of leadership in both promoting a supportive learning environment and implementing learning processes.

Improving health care quality and safety: the role of collective learning

PubMed Central

Singer, Sara J; Benzer, Justin K; Hamdan, Sami U

2015-01-01

Despite decades of effort to improve quality and safety in health care, this goal feels increasingly elusive. Successful examples of improvement are infrequently replicated. This scoping review synthesizes 76 empirical or conceptual studies (out of 1208 originally screened) addressing learning in quality or safety improvement, that were published in selected health care and management journals between January 2000 and December 2014 to deepen understanding of the role that collective learning plays in quality and safety improvement. We categorize learning activities using a theoretical model that shows how leadership and environmental factors support collective learning processes and practices, and in turn team and organizational improvement outcomes. By focusing on quality and safety improvement, our review elaborates the premise of learning theory that leadership, environment, and processes combine to create conditions that promote learning. Specifically, we found that learning for quality and safety improvement includes experimentation (including deliberate experimentation, improvisation, learning from failures, exploration, and exploitation), internal and external knowledge acquisition, performance monitoring and comparison, and training. Supportive learning environments are characterized by team characteristics like psychological safety, appreciation of differences, openness to new ideas social motivation, and team autonomy; team contextual factors including learning resources like time for reflection, access to knowledge, organizational capabilities; incentives; and organizational culture, strategy, and structure; and external environmental factors including institutional pressures, environmental dynamism and competitiveness and learning collaboratives. Lastly learning in the context of quality and safety improvement requires leadership that reinforces learning through actions and behaviors that affect people, such as coaching and trust building, and through influencing contextual factors, including providing resources, developing culture, and taking strategic actions that support improvement. Our review highlights the importance of leadership in both promoting a supportive learning environment and implementing learning processes. PMID:29355197

75 FR 18888 - Mine Rescue Teams and Arrangements for Emergency Medical Assistance and Transportation for...

Federal Register 2010, 2011, 2012, 2013, 2014

2010-04-13

... DEPARTMENT OF LABOR Mine Safety and Health Administration Mine Rescue Teams and Arrangements for... revising the Agency's requirements for mine rescue teams for underground coal mines on February 8, 2008... provisions. Consistent with the Court's decision, MSHA revised its requirements for mine rescue teams for...

Confronting safety gaps across labor and delivery teams.

PubMed

Maxfield, David G; Lyndon, Audrey; Kennedy, Holly Powell; O'Keeffe, Daniel F; Zlatnik, Marya G

2013-11-01

We assessed the occurrence of 4 safety concerns among labor and delivery teams: dangerous shortcuts, missing competencies, disrespect, and performance problems. A total of 3282 participants completed surveys, and 92% of physicians (906 of 985), 93% of midwives (385 of 414), and 98% of nurses (1846 of 1884) observed at least 1 concern within the preceding year. A majority of respondents said these concerns undermined patient safety, harmed patients, or led them to seriously consider transferring or leaving their positions. Only 9% of physicians, 13% of midwives, and 13% of nurses shared their full concerns with the person involved. Organizational silence is evident within labor-and-delivery teams. Improvement will require multiple strategies, used at the personal, social, and structural levels. Copyright © 2013 Mosby, Inc. All rights reserved.

DARHT: INTEGRATION OF AUTHORIZATION BASIS REQUIREMENTS AND WORKER SAFETY

DOE Office of Scientific and Technical Information (OSTI.GOV)

D. A. MC CLURE; C. A. NELSON; R. L. BOUDRIE

2001-04-01

This document describes the results of consensus agreements reached by the DARHT Safety Planning Team during the development of the update of the DARHT Safety Analysis Document (SAD). The SAD is one of the Authorization Basis (AB) Documents required by the Department prior to granting approval to operate the DARHT Facility. The DARHT Safety Planning Team is lead by Mr. Joel A. Baca of the Department of Energy Albuquerque Operations Office (DOE/AL). Team membership is drawn from the Department of Energy Albuquerque Operations Office, the Department of Energy Los Alamos Area Office (DOE/LAAO), and several divisions of the Los Alamosmore » National Laboratory. Revision 1 of the DARHT SAD had been written as part of the process for gaining approval to operate the Phase 1 (First Axis) Accelerator. Early in the planning stage for the required update of the SAD for the approval to operate both Phase 1 and Phase 2 (First Axis and Second Axis) DARHT Accelerator, it was discovered that a conflict existed between the Laboratory approach to describing the management of facility and worker safety.« less

Clinical leadership: using observations of care to focus risk management and quality improvement activities in the clinical setting.

PubMed

Ferguson, Lorraine; Calvert, Judy; Davie, Marilyn; Fallon, Mark; Fred, Nada; Gersbach, Vicki; Sinclair, Lynn

2007-04-01

In an era when patient safety and quality of care are a daily concern for health care professionals, it is important for nurse managers and other clinical leaders to have a repertoire of skills and interventions that can be used to motivate and engage clinical teams in risk assessment and continuous quality improvement at the level of patient care delivery. This paper describes how a cohort of clinical leaders who were undertaking a leadership development program used a relatively simple, patient-focused intervention called the 'observation of care' to help focus the clinical team's attention on areas for improvement within the clinical setting. The main quality and safety themes arising out of the observations that were undertaken by the Clinical Leaders (CLs) were related to the environment, occupational health and safety, communication and team function, clinical practice and patient care. The observations of care also provided the CLs with many opportunities to acknowledge and celebrate exemplary practice as it was observed as a means of enhancing the development of a quality and safety culture within the clinical setting. The 'observation of care' intervention can be used by Clinical Leader's to engage and motivate clinical teams to focus on continuously improving the safety and quality of their own work environment and the care delivered to patients within that environment.

National Ignition Facility Construction Safety Management Review

DOE Office of Scientific and Technical Information (OSTI.GOV)

Warner, B.E.

2000-02-01

An accident occurred at the NIF construction site on January 13, 2000, in which a worker sustained a serious injury when a 42-inch-diameter duct fell during installation. Following the accident, NIF Project Management chartered two review teams: (1) an Incident Analysis Team to independently assess the direct and root causes of the accident, and (2) a Management Review Team to review the roles and responsibilities of the line, support, and construction management organizations involved. This report provides a discussion of the information gathered by the Management Review Team and provides a list of observations and recommendations based on an analysismore » of the information. The Management Review Team includes senior managers who represent several Directorates within LLNL and DOE OAK: Dick Billia representing Engineering; Dave Leary representing Business Services and Public Affairs; Jim Jackson representing Hazards Control; Chuck Taylor representing DOE OAK; Arnie Clobes representing the ICF/NIF Program; and Jon Yatabe and Bruce Warner (Chairperson) representing the NIF Project. The attached letter from the NIF Project Manager, Ed Moses, to the Management Review Team contains the team's Charter. The team was asked to evaluate the effectiveness of the line management and its supporting safety functions in managing safety during NIF construction. The evaluation was to include the current conventional facility construction, which is 85% complete, and upcoming activities such as Beampath Infrastructure System installation, which will begin in the next six months and which represents a significant amount of work over the next two to three years. The remainder of this document describes the Management Review Team's review process (Section 2), its observations gathered during the review (Section 3), and its recommendations to the NIF Project Manager based on those observations (Section 4).« less

Human Performance Models of Pilot Behavior

NASA Technical Reports Server (NTRS)

Foyle, David C.; Hooey, Becky L.; Byrne, Michael D.; Deutsch, Stephen; Lebiere, Christian; Leiden, Ken; Wickens, Christopher D.; Corker, Kevin M.

2005-01-01

Five modeling teams from industry and academia were chosen by the NASA Aviation Safety and Security Program to develop human performance models (HPM) of pilots performing taxi operations and runway instrument approaches with and without advanced displays. One representative from each team will serve as a panelist to discuss their team s model architecture, augmentations and advancements to HPMs, and aviation-safety related lessons learned. Panelists will discuss how modeling results are influenced by a model s architecture and structure, the role of the external environment, specific modeling advances and future directions and challenges for human performance modeling in aviation.

Federal and tribal lands road safety audits : case studies

DOT National Transportation Integrated Search

2009-12-01

A road safety audit (RSA) is a formal safety performance examination by an independent, multidisciplinary team. RSAs are an effective tool for proactively improving the safety performance of a road project during the planning and design stages, and f...

Improving patient safety culture in general practice: an interview study

PubMed Central

Verbakel, Natasha J; de Bont, Antoinette A; Verheij, Theo JM; Wagner, Cordula; Zwart, Dorien LM

2015-01-01

Background When improving patient safety a positive safety culture is key. As little is known about improving patient safety culture in primary care, this study examined whether administering a culture questionnaire with or without a complementary workshop could be used as an intervention for improving safety culture. Aim To gain insight into how two interventions affected patient safety culture in everyday practice. Design and setting After conducting a randomised control trial of two interventions, this was a qualitative study conducted in 30 general practices to aid interpretation of the previous quantitative findings. Method Interviews were conducted at practice locations (n = 27) with 24 GPs and 24 practice nurses. The theory of communities of practice — in particular, its concepts of a domain, a community, and a practice — was used to interpret the findings by examining which elements were or were not present in the participating practices. Results Communal awareness of the problem was only raised after getting together and discussing patient safety. The combination of a questionnaire and workshop enhanced the interaction of team members and nourished team feelings. This shared experience also helped them to understand and develop tools and language for daily practice. Conclusion In order for patient safety culture to improve, the safety culture questionnaire was more successful when accompanied by a practice workshop. Initial discussion and negotiation of shared goals during the workshop fuelled feelings of coherence and belonging to a community wishing to learn about enhancing patient safety. Team meetings and day-to-day interactions enhanced further liaison and sharing, making patient safety a common and conscious goal. PMID:26622035

Geophysics Integrated Studies in the Sun Earth System: A Cooperative Project of Vietnam, Europe, and Africa

NASA Astrophysics Data System (ADS)

Amory-Mazaudier, C.; et al.

2006-11-01

lhminh@igp.ncst.ac.vn The Hanoi Institute of Geophysics (Vietnam) will participate to international Heliophysical Year. This paper presents Vietnam‘s participation into this International cooperative project : the Vietnamese network of magnetometers, meteorological stations, ionosondes and GPS receivers involved in campaigns of measurements, the research field selected for the training of young Vietnamese scientists, and the Institutes involve in this training. This paper also presents some particularities of geophysical parameters in Vietnam : the strong amplitude of the equatorial electrojet observed by satellite data and confirmed by magnetic observations at the ground level presented for the first time to the international community, the monsoon signature etc. Finally the differences between the Asian sector and the African sector lead to the development of comparative studies between Asia and Africa.

78 FR 58567 - Criteria to Certify Coal Mine Rescue Teams

Federal Register 2010, 2011, 2012, 2013, 2014

2013-09-24

... to Certify Coal Mine Rescue Teams AGENCY: Mine Safety and Health Administration, Labor. ACTION...) is requesting comments on revised instruction guides for coal mine rescue team training. MSHA prescribes training materials through the issuance of instruction guides. Existing standards for coal mine...

29 CFR 1926.1076 - Qualifications of dive team.

Code of Federal Regulations, 2011 CFR

2011-07-01

... 29 Labor 8 2011-07-01 2011-07-01 false Qualifications of dive team. 1926.1076 Section 1926.1076 Labor Regulations Relating to Labor (Continued) OCCUPATIONAL SAFETY AND HEALTH ADMINISTRATION... § 1926.1076 Qualifications of dive team. Note: The requirements applicable to construction work under...

29 CFR 1926.1076 - Qualifications of dive team.

Code of Federal Regulations, 2010 CFR

2010-07-01

... 29 Labor 8 2010-07-01 2010-07-01 false Qualifications of dive team. 1926.1076 Section 1926.1076 Labor Regulations Relating to Labor (Continued) OCCUPATIONAL SAFETY AND HEALTH ADMINISTRATION... § 1926.1076 Qualifications of dive team. Note: The requirements applicable to construction work under...

29 CFR 1926.1076 - Qualifications of dive team.

Code of Federal Regulations, 2013 CFR

2013-07-01

... 29 Labor 8 2013-07-01 2013-07-01 false Qualifications of dive team. 1926.1076 Section 1926.1076 Labor Regulations Relating to Labor (Continued) OCCUPATIONAL SAFETY AND HEALTH ADMINISTRATION... § 1926.1076 Qualifications of dive team. Note: The requirements applicable to construction work under...

29 CFR 1926.1076 - Qualifications of dive team.

Code of Federal Regulations, 2014 CFR

2014-07-01

... 29 Labor 8 2014-07-01 2014-07-01 false Qualifications of dive team. 1926.1076 Section 1926.1076 Labor Regulations Relating to Labor (Continued) OCCUPATIONAL SAFETY AND HEALTH ADMINISTRATION... § 1926.1076 Qualifications of dive team. Note: The requirements applicable to construction work under...

29 CFR 1926.1076 - Qualifications of dive team.

Code of Federal Regulations, 2012 CFR

2012-07-01

... 29 Labor 8 2012-07-01 2012-07-01 false Qualifications of dive team. 1926.1076 Section 1926.1076 Labor Regulations Relating to Labor (Continued) OCCUPATIONAL SAFETY AND HEALTH ADMINISTRATION... § 1926.1076 Qualifications of dive team. Note: The requirements applicable to construction work under...

Safety Action; Traffic and Pedestrian Safety. A Guide for Teachers in the Elementary Schools.

ERIC Educational Resources Information Center

Department of Transportation, Washington, DC.

GRADES OR AGES: Elementary, grades 1-6. SUBJECT MATTER: Safety action, traffic and pedestrian safety. ORGANIZATION AND PHYSICAL APPEARANCE: After introductory material explaining the philosophy of the guide, the elementary school child, characteristics of children as related to safety, and the responsibility of the safety team, the guide has…

Designing a critical care nurse-led rapid response team using only available resources: 6 years later.

PubMed

Mitchell, Anne; Schatz, Marilyn; Francis, Heather

2014-06-01

Rapid response teams have been introduced to intervene in the care of patients whose condition deteriorates unexpectedly by bringing clinical experts quickly to the patient's bedside. Evidence supporting the need to overcome failure to deliver optimal care in hospitals is robust; whether rapid response teams demonstrate benefit by improving patient safety and reducing the occurrence of adverse events remains controversial. Despite inconsistent evidence regarding the effectiveness of rapid response teams, concerns regarding care and costly consequences of unaddressed deterioration in patients' condition have prompted many hospitals to implement rapid response teams as a patient safety strategy. A cost-neutral structure for a rapid response team led by a nurse from the intensive care unit was implemented with the goal of reducing cardiopulmonary arrests occurring outside the intensive care unit. The results of 6 years' experience indicate that a sustainable and effective rapid response team response can be put into practice without increasing costs or adding positions and can decrease the percentage of cardiopulmonary arrests occurring outside the intensive care unit. ©2014 American Association of Critical-Care Nurses.

Team learning and effectiveness in virtual project teams: the role of beliefs about interpersonal context.

PubMed

Ortega, Aída; Sánchez-Manzanares, Miriam; Gil, Francisco; Rico, Ramón

2010-05-01

There has been increasing interest in team learning processes in recent years. Researchers have investigated the impact of team learning on team effectiveness and analyzed the enabling conditions for the process, but team learning in virtual teams has been largely ignored. This study examined the relationship between team learning and effectiveness in virtual teams, as well as the role of team beliefs about interpersonal context. Data from 48 teams performing a virtual consulting project over 4 weeks indicate a mediating effect of team learning on the relationship between beliefs about the interpersonal context (psychological safety, task interdependence) and team effectiveness (satisfaction, viability). These findings suggest the importance of team learning for developing effective virtual teams.

Working Together for Safety: A State Team Approach to Preventing Occupational Injuries in Young People

ERIC Educational Resources Information Center

Posner, Marc

2005-01-01

This report describes the Northeast Young Worker Resource Center. It begins with two case studies that demonstrate the value of the State team approach. The remainder of the document describes the experiences and activities of the State teams in the Northeast; the products developed by the teams for teens, parents, employers, school staff, health…

Increasing patient safety with neonates via handoff communication during delivery: a call for interprofessional health care team training across GME and CME.

PubMed

Vanderbilt, Allison A; Pappada, Scott M; Stein, Howard; Harper, David; Papadimos, Thomas J

2017-01-01

Hospitals have struggled for years regarding the handoff process of communicating patient information from one health care professional to another. Ineffective handoff communication is recognized as a serious patient safety risk within the health care community. It is essential to take communication into consideration when examining the safety of neonates who require immediate medical attention after birth; effective communication is vital for positive patient outcomes, especially with neonates in a delivery room setting. Teamwork and effective communication across the health care continuum are essential for providing efficient, quality care that leads to favorable patient outcomes. Interprofessional simulation and team training can benefit health care professionals by improving interprofessional competence, defined as one's knowledge of other professionals including an understanding of their training and skillsets, and role clarity. Interprofessional teams that include members with specialization in obstetrics, gynecology, and neonatology have the potential to considerably benefit from training effective handoff and communication practices that would ensure the safety of the neonate upon birth. We must strive to provide the most comprehensive systematic, standardized, interprofessional handoff communication training sessions for such teams, through Graduate Medical Education and Continuing Medical Education that will meet the needs across the educational continuum.

Perceptions of Risk and Safety in the ICU: A Qualitative Study of Cognitive Processes Relating to Staffing*

PubMed Central

D’Lima, Danielle M.; Brett, Stephen J.

2018-01-01

Objectives: The aims of this study were to 1) examine individual professionals’ perceptions of staffing risks and safe staffing in intensive care and 2) identify and examine the cognitive processes that underlie these perceptions. Design: Qualitative case study methodology with nurses, doctors, and physiotherapists. Setting: Three mixed medical and surgical adult ICUs, each on a separate hospital site within a 1,200-bed academic, tertiary London hospital group. Subjects: Forty-four ICU team members of diverse professional backgrounds and seniority. Interventions: None. Main Results: Four themes (individual, team, unit, and organizational) were identified. Individual care provision was influenced by the pragmatist versus perfectionist stance of individuals and team dynamics by the concept of an “A” team and interdisciplinary tensions. Perceptions of safety hinged around the importance of achieving a “dynamic balance” influenced by the burden of prevailing circumstances and the clinical status of patients. Organizationally, professionals’ risk perceptions affected their willingness to take personal responsibility for interactions beyond the unit. Conclusions: This study drew on cognitive research, specifically theories of cognitive dissonance, psychological safety, and situational awareness to explain how professionals’ cognitive processes impacted on ICU behaviors. Our results may have implications for relationships, management, and leadership in ICU. First, patient care delivery may be affected by professionals’ perfectionist or pragmatic approach. Perfectionists’ team role may be compromised and they may experience cognitive dissonance and subsequent isolation/stress. Second, psychological safety in a team may be improved within the confines of a perceived “A” team but diminished by interdisciplinary tensions. Third, counter intuitively, higher “situational” awareness for some individuals increased their stress and anxiety. Finally, our results suggest that professionals have varying concepts of where their personal responsibility to minimize risk begins and ends, which we have termed “risk horizons” and that these horizons may affect their behavior both within and beyond the unit. PMID:29077619

Perceptions of Risk and Safety in the ICU: A Qualitative Study of Cognitive Processes Relating to Staffing.

PubMed

D'Lima, Danielle M; Murray, Eleanor J; Brett, Stephen J

2018-01-01

The aims of this study were to 1) examine individual professionals' perceptions of staffing risks and safe staffing in intensive care and 2) identify and examine the cognitive processes that underlie these perceptions. Qualitative case study methodology with nurses, doctors, and physiotherapists. Three mixed medical and surgical adult ICUs, each on a separate hospital site within a 1,200-bed academic, tertiary London hospital group. Forty-four ICU team members of diverse professional backgrounds and seniority. None. Four themes (individual, team, unit, and organizational) were identified. Individual care provision was influenced by the pragmatist versus perfectionist stance of individuals and team dynamics by the concept of an "A" team and interdisciplinary tensions. Perceptions of safety hinged around the importance of achieving a "dynamic balance" influenced by the burden of prevailing circumstances and the clinical status of patients. Organizationally, professionals' risk perceptions affected their willingness to take personal responsibility for interactions beyond the unit. This study drew on cognitive research, specifically theories of cognitive dissonance, psychological safety, and situational awareness to explain how professionals' cognitive processes impacted on ICU behaviors. Our results may have implications for relationships, management, and leadership in ICU. First, patient care delivery may be affected by professionals' perfectionist or pragmatic approach. Perfectionists' team role may be compromised and they may experience cognitive dissonance and subsequent isolation/stress. Second, psychological safety in a team may be improved within the confines of a perceived "A" team but diminished by interdisciplinary tensions. Third, counter intuitively, higher "situational" awareness for some individuals increased their stress and anxiety. Finally, our results suggest that professionals have varying concepts of where their personal responsibility to minimize risk begins and ends, which we have termed "risk horizons" and that these horizons may affect their behavior both within and beyond the unit.

Simulation-based multiprofessional obstetric anaesthesia training conducted in situ versus off-site leads to similar individual and team outcomes: a randomised educational trial

PubMed Central

Sørensen, Jette Led; van der Vleuten, Cees; Rosthøj, Susanne; Østergaard, Doris; LeBlanc, Vicki; Johansen, Marianne; Ekelund, Kim; Starkopf, Liis; Lindschou, Jane; Gluud, Christian; Weikop, Pia; Ottesen, Bent

2015-01-01

Objective To investigate the effect of in situ simulation (ISS) versus off-site simulation (OSS) on knowledge, patient safety attitude, stress, motivation, perceptions of simulation, team performance and organisational impact. Design Investigator-initiated single-centre randomised superiority educational trial. Setting Obstetrics and anaesthesiology departments, Rigshospitalet, University of Copenhagen, Denmark. Participants 100 participants in teams of 10, comprising midwives, specialised midwives, auxiliary nurses, nurse anaesthetists, operating theatre nurses, and consultant doctors and trainees in obstetrics and anaesthesiology. Interventions Two multiprofessional simulations (clinical management of an emergency caesarean section and a postpartum haemorrhage scenario) were conducted in teams of 10 in the ISS versus the OSS setting. Primary outcome Knowledge assessed by a multiple choice question test. Exploratory outcomes Individual outcomes: scores on the Safety Attitudes Questionnaire, stress measurements (State-Trait Anxiety Inventory, cognitive appraisal and salivary cortisol), Intrinsic Motivation Inventory and perceptions of simulations. Team outcome: video assessment of team performance. Organisational impact: suggestions for organisational changes. Results The trial was conducted from April to June 2013. No differences between the two groups were found for the multiple choice question test, patient safety attitude, stress measurements, motivation or the evaluation of the simulations. The participants in the ISS group scored the authenticity of the simulation significantly higher than did the participants in the OSS group. Expert video assessment of team performance showed no differences between the ISS versus the OSS group. The ISS group provided more ideas and suggestions for changes at the organisational level. Conclusions In this randomised trial, no significant differences were found regarding knowledge, patient safety attitude, motivation or stress measurements when comparing ISS versus OSS. Although participant perception of the authenticity of ISS versus OSS differed significantly, there were no differences in other outcomes between the groups except that the ISS group generated more suggestions for organisational changes. Trial registration number NCT01792674. PMID:26443654

Enhancing the traditional hospital design process: a focus on patient safety.

PubMed

Reiling, John G; Knutzen, Barbara L; Wallen, Thomas K; McCullough, Susan; Miller, Ric; Chernos, Sonja

2004-03-01

In 2002 St. Joseph's Community Hospital (West Bend, WI), a member of SynergyHealth, brought together leaders in health care and systems engineering to develop a set of safety-driven facility design principles that would guide the hospital design process. DESIGNING FOR SAFETY: Hospital leadership recognized that a cross-departmental team approach would be needed and formed the 11-member Facility Design Advisory Council, which, with departmental teams and the aid of architects, was responsible for overseeing the design process and for ensuring that the safety considerations were met. The design process was a team approach, with input from national experts, patients and families, hospital staff and physicians, architects, contractors, and the community. The new facility, designed using safety-driven design principles, reflects many innovative design elements, including truly standardized patient rooms, new technology to minimize falls, and patient care alcoves for every patient room. The new hospital has been designed with maximum adaptability and flexibility in mind, to accommodate changes and provide for future growth. The architects labeled the innovative design. The Synergy Model, to describe the process of shaping the entire building and its spaces to work efficiently as a whole for the care and safety of patients. Construction began on the new facility in August 2003 and is expected to be completed in 2005.

Safety measurement and monitoring in healthcare: a framework to guide clinical teams and healthcare organisations in maintaining safety

PubMed Central

Vincent, Charles; Burnett, Susan; Carthey, Jane

2014-01-01

Patients, clinicians and managers all want to be reassured that their healthcare organisation is safe. But there is no consensus about what we mean when we ask whether a healthcare organisation is safe or how this is achieved. In the UK, the measurement of harm, so important in the evolution of patient safety, has been neglected in favour of incident reporting. The use of softer intelligence for monitoring and anticipation of problems receives little mention in official policy. The Francis Inquiry report into patient treatment at the Mid Staffordshire NHS Foundation Trust set out 29 recommendations on measurement, more than on any other topic, and set the measurement of safety an absolute priority for healthcare organisations. The Berwick review found that most healthcare organisations at present have very little capacity to analyse, monitor or learn from safety and quality information. This paper summarises the findings of a more extensive report and proposes a framework which can guide clinical teams and healthcare organisations in the measurement and monitoring of safety and in reviewing progress against safety objectives. The framework has been used so far to promote self-reflection at both board and clinical team level, to stimulate an organisational check or analysis in the gaps of information and to promote discussion of ‘what could we do differently’. PMID:24764136

Identifying and preventing medical errors in patients with limited English proficiency: key findings and tools for the field.

PubMed

Wasserman, Melanie; Renfrew, Megan R; Green, Alexander R; Lopez, Lenny; Tan-McGrory, Aswita; Brach, Cindy; Betancourt, Joseph R

2014-01-01

Since the 1999 Institute of Medicine (IOM) report To Err is Human, progress has been made in patient safety, but few efforts have focused on safety in patients with limited English proficiency (LEP). This article describes the development, content, and testing of two new evidence-based Agency for Healthcare Research and Quality (AHRQ) tools for LEP patient safety. In the content development phase, a comprehensive mixed-methods approach was used to identify common causes of errors for LEP patients, high-risk scenarios, and evidence-based strategies to address them. Based on our findings, Improving Patient Safety Systems for Limited English Proficient Patients: A Guide for Hospitals contains recommendations to improve detection and prevention of medical errors across diverse populations, and TeamSTEPPS Enhancing Safety for Patients with Limited English Proficiency Module trains staff to improve safety through team communication and incorporating interpreters in the care process. The Hospital Guide was validated with leaders in quality and safety at diverse hospitals, and the TeamSTEPPS LEP module was field-tested in varied settings within three hospitals. Both tools were found to be implementable, acceptable to their audiences, and conducive to learning. Further research on the impact of the combined use of the guide and module would shed light on their value as a multifaceted intervention. © 2014 National Association for Healthcare Quality.

Do safety checklists improve teamwork and communication in the operating room? A systematic review.

PubMed

Russ, Stephanie; Rout, Shantanu; Sevdalis, Nick; Moorthy, Krishna; Darzi, Ara; Vincent, Charles

2013-12-01

The aim of this systematic review was to assess the impact of surgical safety checklists on the quality of teamwork and communication in the operating room (OR). Safety checklists have been shown to impact positively on patient morbidity and mortality following surgery, but it is unclear whether this clinical improvement is related to an improvement in OR teamwork and communication. A systematic search strategy of MEDLINE, EMBASE, PsycINFO, Google Scholar, and the Cochrane Database for Systematic Reviews was undertaken to obtain relevant articles. After de-duplication and the addition of limits, 315 articles were screened for inclusion by 2 researchers and all articles meeting a set of prespecified inclusion criteria were retained. Information regarding the type of checklist, study design, assessment tools used, outcomes, and study limitations was extracted. Twenty articles formed the basis of this systematic review. All articles described an empirical study relating to a case-specific safety checklist for surgery as the primary intervention, with some measure of change/improvement in teamwork and/or communication relating to its use. The methods for assessing teamwork and communication varied greatly, including surveys, observations, interviews, and 360° assessments. The evidence suggests that safety checklists improve the perceived quality of OR teamwork and communication and reduce observable errors relating to poor team skills. This is likely to function through establishing an open platform for communication at the start of a procedure: encouraging the sharing of critical case-related information, promoting team coordination and decision making, flagging knowledge gaps, and enhancing team cohesion. However, the evidence would also suggest that when used suboptimally or when individuals have not bought in to the process, checklists may conversely have a negative impact on the function of the team. Safety checklists are beneficial for OR teamwork and communication and this may be one mechanism through which patient outcomes are improved. Future research should aim to further elucidate the relationship between how safety checklists are used and team skills in the OR using more consistent methodological approaches and utilizing validated measures of teamwork such that best practice guidelines can be established.

Integrating team resource management program into staff training improves staff's perception and patient safety in organ procurement and transplantation: the experience in a university-affiliated medical center in Taiwan.

PubMed

Hsu, Ya-Chi; Jerng, Jih-Shuin; Chang, Ching-Wen; Chen, Li-Chin; Hsieh, Ming-Yuan; Huang, Szu-Fen; Liu, Yueh-Ping; Hung, Kuan-Yu

2014-08-11

The process involved in organ procurement and transplantation is very complex that requires multidisciplinary coordination and teamwork. To prevent error during the processes, teamwork education and training might play an important role. We wished to evaluate the efficacy of implementing a Team Resource Management (TRM) program on patient safety and the behaviors of the team members involving in the process. We implemented a TRM training program for the organ procurement and transplantation team members of the National Taiwan University Hospital (NTUH), a teaching medical center in Taiwan. This 15-month intervention included TRM education and training courses for the healthcare workers, focused group skill training for the procurement and transplantation team members, video demonstration and training, and case reviews with feedbacks. Teamwork culture was evaluated and all procurement and transplantation cases were reviewed to evaluate the application of TRM skills during the actual processes. During the intervention period, a total of 34 staff members participated the program, and 67 cases of transplantations were performed. Teamwork framework concept was the most prominent dimension that showed improvement from the participants for training. The team members showed a variety of teamwork behaviors during the process of procurement and transplantation during the intervention period. Of note, there were two potential donors with a positive HIV result, for which the procurement processed was timely and successfully terminated by the team. None of the recipients was transplanted with an infected organ. No error in communication or patient identification was noted during review of the case records. Implementation of a Team Resource Management program improves the teamwork culture as well as patient safety in organ procurement and transplantation.

Important Non-Technical Skills in Video-Assisted Thoracoscopic Surgery Lobectomy: Team Perspectives.

PubMed

Gjeraa, Kirsten; Mundt, Anna S; Spanager, Lene; Hansen, Henrik J; Konge, Lars; Petersen, René H; Østergaard, Doris

2017-07-01

Safety in the operating room is dependent on the team's non-technical skills. The importance of non-technical skills appears to be different for minimally invasive surgery as compared with open surgery. The aim of this study was to identify which non-technical skills are perceived by team members to be most important for patient safety, in the setting of video-assisted thoracoscopic surgery (VATS) lobectomy. This was an explorative, semistructured interview-based study with 21 participants from all four thoracic surgery centers in Denmark that perform VATS lobectomy. Data analysis was deductive, and directed content analysis was used to code the text into the Oxford Non-Technical Skills system for evaluating operating teams' non-technical skills. The most important non-technical skills described by the VATS teams were planning and preparation, situation awareness, problem solving, leadership, risk assessment, and teamwork. These non-technical skills enabled the team to achieve shared mental models, which in turn facilitated their efforts to anticipate next steps. This was viewed as important by the participants as they saw VATS lobectomy as a high-risk procedure with complementary and overlapping scopes of practice between surgical and anesthesia subteams. This study identified six non-technical skills that serve as the foundation for shared mental models of the patient, the current situation, and team resources. These findings contribute three important additions to the shared mental model construct: planning and preparation, risk assessment, and leadership. Shared mental models are crucial for patient safety because they enable VATS teams to anticipate problems through adaptive patterns of both implicit and explicit coordination. Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Integrating team resource management program into staff training improves staff’s perception and patient safety in organ procurement and transplantation: the experience in a university-affiliated medical center in Taiwan

PubMed Central

2014-01-01

Background The process involved in organ procurement and transplantation is very complex that requires multidisciplinary coordination and teamwork. To prevent error during the processes, teamwork education and training might play an important role. We wished to evaluate the efficacy of implementing a Team Resource Management (TRM) program on patient safety and the behaviors of the team members involving in the process. Methods We implemented a TRM training program for the organ procurement and transplantation team members of the National Taiwan University Hospital (NTUH), a teaching medical center in Taiwan. This 15-month intervention included TRM education and training courses for the healthcare workers, focused group skill training for the procurement and transplantation team members, video demonstration and training, and case reviews with feedbacks. Teamwork culture was evaluated and all procurement and transplantation cases were reviewed to evaluate the application of TRM skills during the actual processes. Results During the intervention period, a total of 34 staff members participated the program, and 67 cases of transplantations were performed. Teamwork framework concept was the most prominent dimension that showed improvement from the participants for training. The team members showed a variety of teamwork behaviors during the process of procurement and transplantation during the intervention period. Of note, there were two potential donors with a positive HIV result, for which the procurement processed was timely and successfully terminated by the team. None of the recipients was transplanted with an infected organ. No error in communication or patient identification was noted during review of the case records. Conclusion Implementation of a Team Resource Management program improves the teamwork culture as well as patient safety in organ procurement and transplantation. PMID:25115403

Patient safety ward round checklist via an electronic app: implications for harm prevention.

PubMed

Keller, C; Arsenault, S; Lamothe, M; Bostan, S R; O'Donnell, R; Harbison, J; Doherty, C P

2017-11-06

Patient safety is a value at the core of modern healthcare. Though awareness in the medical community is growing, implementing systematic approaches similar to those used in other high reliability industries is proving difficult. The aim of this research was twofold, to establish a baseline for patient safety practices on routine ward rounds and to test the feasibility of implementing an electronic patient safety checklist application. Two research teams were formed; one auditing a medical team to establish a procedural baseline of "usual care" practice and an intervention team concurrently was enforcing the implementation of the checklist. The checklist was comprised of eight standard clinical practice items. The program was conducted over a 2-week period and 1 month later, a retrospective analysis of patient charts was conducted using a global trigger tool to determine variance between the experimental groups. Finally, feedback from the physician participants was considered. The results demonstrated a statistically significant difference on five variables of a total of 16. The auditing team observed low adherence to patient identification (0.0%), hand decontamination (5.5%), and presence of nurse on ward rounds (6.8%). Physician feedback was generally positive. The baseline audit demonstrated significant practice bias on daily ward rounds which tended to omit several key-proven patient safety practices such as prompting hand decontamination and obtaining up to date reports from nursing staff. Results of the intervention arm demonstrate the feasibility of using the Checklist App on daily ward rounds.

Learning from Science and Sport - How we, Safety, "Engage with Rigor"

NASA Astrophysics Data System (ADS)

Herd, A.

2012-01-01

As the world of spaceflight safety is relatively small and potentially inward-looking, we need to be aware of the "outside world". We should then try to remind ourselves to be open to the possibility that data, knowledge or experience from outside of the spaceflight community may provide some constructive alternate perspectives. This paper will assess aspects from two seemingly tangential fields, science and sport, and align these with the world of safety. In doing so some useful insights will be given to the challenges we face and may provide solutions relevant in our everyday (of safety engineering). Sport, particularly a contact sport such as rugby union, requires direct interaction between members of two (opposing) teams. Professional, accurately timed and positioned interaction for a desired outcome. These interactions, whilst an essential part of the game, are however not without their constraints. The rugby scrum has constraints as to the formation and engagement of the two teams. The controlled engagement provides for an interaction between the two teams in a safe manner. The constraints arising from the reality that an incorrect engagement could cause serious injury to members of either team. In academia, scientific rigor is applied to assure that the arguments provided and the conclusions drawn in academic papers presented for publication are valid, legitimate and credible. The scientific goal of the need for rigor may be expressed in the example of achieving a statistically relevant sample size, n, in order to assure analysis validity of the data pool. A failure to apply rigor could then place the entire study at risk of failing to have the respective paper published. This paper will consider the merits of these two different aspects, scientific rigor and sports engagement, and offer a reflective look at how this may provide a "modus operandi" for safety engineers at any level whether at their desks (creating or reviewing safety assessments) or in a safety review meeting (providing a verbal critique of the presented safety case).

Pre-surgery briefings and safety climate in the operating theatre.

PubMed

Allard, Jon; Bleakley, Alan; Hobbs, Adrian; Coombes, Lee

2011-08-01

In 2008, the WHO produced a surgical safety checklist against a background of a poor patient safety record in operating theatres. Formal team briefings are now standard practice in high-risk settings such as the aviation industry and improve safety, but are resisted in surgery. Research evidence is needed to persuade the surgical workforce to adopt safety procedures such as briefings. To investigate whether exposure to pre-surgery briefings is related to perception of safety climate. Three Safety Attitude Questionnaires, completed by operating theatre staff in 2003, 2004 and 2006, were used to evaluate the effects of an educational intervention introducing pre-surgery briefings. Individual practitioners who agree with the statement 'briefings are common in the operating theatre' also report a better 'safety climate' in operating theatres. The study reports a powerful link between briefing practices and attitudes towards safety. Findings build on previous work by reporting on the relationship between briefings and safety climate within a 4-year period. Briefings, however, remain difficult to establish in local contexts without appropriate team-based patient safety education. Success in establishing a safety culture, with associated practices, may depend on first establishing unidirectional, positive change in attitudes to create a safety climate.

Evaluating pedestrian safety improvements : final report.

DOT National Transportation Integrated Search

2012-12-01

The purpose of the study was to evaluate the impact of new pedestrian countermeasure installations on pedestrian safety to assist in informing future pedestrian safety initiatives. In order to address these objectives, the WMU team conducted a litera...

A Multiple Case Study Exploring Members' Perceptions of Threat Assessment Teams' Training and Resources at Two-Year Colleges

ERIC Educational Resources Information Center

Pendleton, Kristi A.

2017-01-01

Incorporating a qualitative approach, the purpose of this multiple case study dissertation was: 1) to explore the perceptions of threat assessment teams on campus safety; 2) to study the challenges and barriers two-year colleges experience in relation to the threat assessment team process; and 3) to describe how the teams' perceptions of risk may…

NASA/Navy Benchmarking Exchange (NNBE). Volume 1. Interim Report. Navy Submarine Program Safety Assurance

NASA Technical Reports Server (NTRS)

2002-01-01

The NASA/Navy Benchmarking Exchange (NNBE) was undertaken to identify practices and procedures and to share lessons learned in the Navy's submarine and NASA's human space flight programs. The NNBE focus is on safety and mission assurance policies, processes, accountability, and control measures. This report is an interim summary of activity conducted through October 2002, and it coincides with completion of the first phase of a two-phase fact-finding effort.In August 2002, a team was formed, co-chaired by senior representatives from the NASA Office of Safety and Mission Assurance and the NAVSEA 92Q Submarine Safety and Quality Assurance Division. The team closely examined the two elements of submarine safety (SUBSAFE) certification: (1) new design/construction (initial certification) and (2) maintenance and modernization (sustaining certification), with a focus on: (1) Management and Organization, (2) Safety Requirements (technical and administrative), (3) Implementation Processes, (4) Compliance Verification Processes, and (5) Certification Processes.

'Achieving ensemble': communication in orthopaedic surgical teams and the development of situation awareness--an observational study using live videotaped examples.

PubMed

Bleakley, Alan; Allard, Jon; Hobbs, Adrian

2013-03-01

Focused dialogue, as good communication between practitioners, offers a condition of possibility for development of high levels of situation awareness in surgical teams. This has been termed "achieving ensemble". Situation awareness grasps what is happening in time and space with regard to one's own unfolding work in relation to that of colleagues, and is necessary to maintain patient safety throughout a surgical list. We refined a typology, initially developed for use in studying the dynamics of teams in aviation safety, of 10 kinds of communication within two broad areas: 'Reports', or authoritative acts of communication setting up a monological or authoritative climate; and 'Requests', or facilitative acts of communication setting up a dialogical or participatory climate. We systematically mapped how orthopaedic surgical teams use verbal communication through analysis of videotaped operations using the typology. We asked: 'do orthopaedic surgical teams set up the conditions of possibility for the emergence of situation awareness through effective communication?' We found that orthopaedic surgical teams tend to produce monological rather than dialogical climates. Dialogue increases with more complex cases, but in routine work, communication levels are depressed and one-way, influenced by surgeons working within a traditionally hierarchical and authoritative culture. We suggest that such a monological climate inhibits development of situation awareness and then compromises patient safety. The same teams, however, generate potentially rich educational climates through exchange of profession-specific knowledge and skills, and we suggest that where technical skill exchange is good, non-technical or interpersonal communication skill levels can follow.

The Role of Knowledge Brokers: Lessons from a Community Based Research Study of Cultural Safety in Relation to People Who Use Drugs

ERIC Educational Resources Information Center

McCall, Jane; Mollison, Ashley; Browne, Annette; Parker, Joanne; Pauly, Bernie

2017-01-01

The study explored cultural safety as a strategy to address the stigma of substance use in acute care settings. Two research team members took on the role of knowledge brokers (KBs) in order to liaise between the research team and two distinct research advisory groups: one with people who use drugs and the other nurses. The KBs were instrumental…

'It's a cultural expectation...' The pressure on medical trainees to work independently in clinical practice.

PubMed

Kennedy, Tara J T; Regehr, Glenn; Baker, G Ross; Lingard, Lorelei A

2009-07-01

Medical trainees demonstrate a reluctance to ask for help unless they believe it is absolutely necessary, a situation which could impact on the safety of patients. This study aimed to develop a theoretical exploration of the pressure on medical trainees to be independent and to generate theory-based approaches to the implications for patient safety of this pressure towards independent working. In Phase 1, 88 teaching team members from internal and emergency medicine were observed during clinical activities (216 hours), and 65 participants completed brief interviews. In Phase 2, 36 in-depth interviews were conducted using video vignettes. Data collection and analysis employed grounded theory methodology. Participants conceived that the pressure towards independence in clinical work originated in trainees' desire to lay claim to the identity of a doctor (as a member of a group of autonomous high achievers), and in organisational issues such as heavy workloads and constant evaluations. The identity and organisational issues related to the pressure towards independence were explored through the lenses of established theories from education and psychology. Consideration of Lave and Wenger's situated learning theory suggests that giving attention to the 'independent doctor' ideal, through measures such as involving trainees when their supervisors ask for help, could impact the safety of teaching team practice. Amalberti et al.'s migration model explains how pressures to maximise productivity and individual gain may cause teaching teams to migrate beyond the boundaries of safe practice and suggests that managing triggers (such as workload and high-stakes evaluations) for violations of safe practice might improve safety. Implementation and evaluation of these theory-based approaches to the safety of teaching team practice would contribute to a better understanding of the links between trainee independence and patient safety.

Effects of a Workplace Intervention Targeting Psychosocial Risk Factors on Safety and Health Outcomes

PubMed Central

Hammer, Leslie B.; Truxillo, Donald M.; Bodner, Todd; Rineer, Jennifer; Pytlovany, Amy C.; Richman, Amy

2015-01-01

The goal of this study was to test the effectiveness of a workplace intervention targeting work-life stress and safety-related psychosocial risk factors on health and safety outcomes. Data were collected over time using a randomized control trial design with 264 construction workers employed in an urban municipal department. The intervention involved family- and safety-supportive supervisor behavior training (computer-based), followed by two weeks of behavior tracking and a four-hour, facilitated team effectiveness session including supervisors and employees. A significant positive intervention effect was found for an objective measure of blood pressure at the 12-month follow-up. However, no significant intervention results were found for self-reported general health, safety participation, or safety compliance. These findings suggest that an intervention focused on supervisor support training and a team effectiveness process for planning and problem solving should be further refined and utilized in order to improve employee health with additional research on the beneficial effects on worker safety. PMID:26557703

Understanding Human Autonomy Teaming Through Applications

NASA Technical Reports Server (NTRS)

Aponso, B.; Stallmann, Summer; Lachter, Joel; Shively, Jay; Benton, J.; Kaneshige, John; Mumaw, Randy; Feary, Michael

2017-01-01

This presentation describes the development and demonstration of human autonomy teaming technologies for improving aviation safety and efficiency during nominal and off-nominal operations by developing and validating increasingly autonomous systems concepts, technologies, and procedures.

A Team, Case-based Examination and Its Impact on Student Performance in a Patient Safety and Informatics Course

PubMed Central

Etheridge, Kierstan; DeLellis, Teresa

2017-01-01

Objective. To describe the redesigned assessment plan for a patient safety and informatics course and assess student pharmacist performance and perceptions. Methods. The final examination of a patient safety course was redesigned from traditional multiple choice and short answer to team-based, open-ended, and case-based. Faculty for each class session developed higher level activities, focused on developing key skills or attitudes deemed essential for practice, for a progressive patient case consisting of nine activities. Student performance and perceptions were analyzed with pre- and post-surveys using 5-point scales. Results. Mean performance on the examination was 93.6%; median scores for each assessed course outcome ranged from 90% to 100%. Eighty-five percent of students completed both surveys. Confidence performing skills and demonstrating attitudes improved for each item on post-survey compared with pre-survey. Eighty-one percent of students indicated the experience of taking the examination was beneficial for their professional development. Conclusion. A team, case-based examination was associated with high student performance and improved self-confidence in performing medication safety-related skills. PMID:28970618

Training and action for patient safety: embedding interprofessional education for patient safety within an improvement methodology.

PubMed

Slater, Beverley L; Lawton, Rebecca; Armitage, Gerry; Bibby, John; Wright, John

2012-01-01

Despite an explosion of interest in improving safety and reducing error in health care, one important aspect of patient safety that has received little attention is a systematic approach to education and training for the whole health care workforce. This article describes an evaluation of an innovative multiprofessional, team-based training program that embeds patient safety within quality improvement methods. Kirkpatrick's "levels of evaluation" model was adopted to evaluate the program in health organizations across one city in the north of England. Questionnaires were used to assess reaction of participants to the program (Level 1). Improvements in patient safety knowledge and patient safety culture (Level 2) were assessed using a 12-item multiple-choice questionnaire and a culture questionnaire. Interviews and project-specific quantitative measurements were used to assess changes in professional practice and patient outcomes (Levels 3 and 4). All aspects of the program were positively received by participants. Few participants completed the MCQ at both time points, but those who did showed improvement in knowledge. There were some small but significant improvements in patient safety culture. Interviews revealed a number of additional benefits beyond the specific problems addressed. Most importantly, 8 of the 11 teams showed improvements in patient safety practices and/or outcomes. This program is an example of interprofessional education in practice and demonstrates that team-based learning using quality improvement methods is feasible and can be effective in improving patient safety, but requires time and space for participants. Alignment with continuing education arrangements could support mainstream adoption of this approach within organizations. Copyright © 2012 The Alliance for Continuing Education in the Health Professions, the Society for Academic Continuing Medical Education, and the Council on CME, Association for Hospital Medical Education.

Patient safety reporting systems: sustained quality improvement using a multidisciplinary team and "good catch" awards.

PubMed

Herzer, Kurt R; Mirrer, Meredith; Xie, Yanjun; Steppan, Jochen; Li, Matthew; Jung, Clinton; Cover, Renee; Doyle, Peter A; Mark, Lynette J

2012-08-01

Since 1999, hospitals have made substantial commitments to health care quality and patient safety through individual initiatives of executive leadership involvement in quality, investments in safety culture, education and training for medical students and residents in quality and safety, the creation of patient safety committees, and implementation of patient safety reporting systems. At the Weinberg Surgical Suite at The Johns Hopkins Hospital (Baltimore), a 16-operating-room inpatient/outpatient cancer center, a patient safety reporting process was developed to maximize the usefulness of the reports and the long-term sustainability of quality improvements arising from them. A six-phase framework was created incorporating UHC's Patient Safety Net (PSN): Identify, report, analyze, mitigate, reward, and follow up. Unique features of this process included a multidisciplinary team to review reports, mitigate hazards, educate and empower providers, recognize the identifying/reporting individuals or groups with "Good Catch" awards, and follow up to determine if quality improvements were sustained over time. Good Catch awards have been given in recognition of 29 patient safety hazards identified since 2008; in each of these cases, an initiative was developed to mitigate the original hazard. Twenty-five (86%) of the associated quality improvements have been sustained. Two Good Catch award-winning projects--vials of heparin with an unusually high concentration of the drug that posed a potential overdose hazard and a rapid infusion device that resisted practitioner control--are described in detail. A multidisciplinary team's analysis and mitigation of hazards identified in a patient safety reporting process entailed positive recognition with a Good Catch award, education of practitioners, and long-term follow-up.

[Determinants in an occupational health and safety program implementation].

PubMed

Chaves, Sonia Cristina Lima; Santana, Vilma Sousa; de Leão, Inez Cristina Martins; de Santana, Jusiene Nogueira; de Almeida Lacerda, Lívia Maria Aragão

2009-03-01

To identify predictors for the degree to which a program that integrates occupational health surveillance with labor safety, and involves occupational health/safety specialists, company management, and employees, is implemented. This ecological study evaluated companies implementing the occupational health and safety program (OHSP) proposed by the state of Bahia's regional department of Serviço Social da Indústria (Social Services for Industry, SESI) during the 2005-2006 cycle. The companies that participated were randomly selected. Data were collected through interviews with key contacts within the companies and from technical reports issued by SESI. Multiple linear regression was used to identify factors related to the company, employee, occupational/safety specialist, and any subdimensions that might promote OHSP implementation. Of the 78 companies selected (3 384 employees), the degree to which OHSP was implemented was "advanced" in 24.4%, "intermediate" in 53.8%, and "initial" in 19.3%. Company-related, employee-related and specialist-related factors were positively associated with OHSP implementation (P < 0.001). The most important factor overall was the program's financial autonomy (beta = 4.40; P < 0.001). Bivariate analysis revealed that the degree of implementation was associated with the employees' level of health/safety knowledge (beta = 1.58; P < 0.05) and training (beta = 0.40; P < 0.001) and with communication between the occupational safety team (beta = 1.89; P < 0.01) and the health team (beta = 0.58; P < 0.05). These findings remained unchanged after adjustment for levels of education among managers and employees, salary/wages, company size, and risk. The time and resources available for employees to dedicate to occupational health and safety, the integration and reinforcement of employee and manager training programs, and improved relationship between occupational health and safety teams may contribute to the success of health and safety promotion efforts among employees.

Total Quality Management and the System Safety Secretary

NASA Technical Reports Server (NTRS)

Elliott, Suzan E.

1993-01-01

The system safety secretary is a valuable member of the system safety team. As downsizing occurs to meet economic constraints, the Total Quality Management (TQM) approach is frequently adopted as a formula for success and, in some cases, for survival.

Interprofessional Education in Neonatal Care.

PubMed

Kenner, Carole

2016-01-01

Interprofessional education is not a new concept. Yet, the operationalization of interprofessional education with related competencies for collaborative team-based practice in neonatal units is often difficult. Changes in healthcare with an emphasis on patient-focused care and the concern for patient safety and quality care are accelerating the need for more interprofessional education. This article briefly outlines the evolution of interprofessional education to support collaborative team-based practice and how that facilitates safety and quality care in neonatal units.

Supporting structures for team situation awareness and decision making: insights from four delivery suites.

PubMed

Mackintosh, Nicola; Berridge, Emma-Jane; Freeth, Della

2009-02-01

'Human factors' (non-technical skills such as communication and teamwork) have been strongly implicated in adverse events during labour and delivery. The importance of shared 'situation awareness' between team members is highlighted as a key factor in patient safety. Arising from an ethnographic study of safety culture in the delivery suites of four UK hospitals, the aim of this study is to describe the main mechanisms supporting team situation awareness (TSA) and examine contrasting configurations of supports. Stage I: 177 hours of lightly structured non-participant observation (sensitizing concepts: safety culture, non-technical skills, teamwork and decision making) analysed to identify a core organizing concept, main supporting categories and preliminary conceptual models. Stage II: (approximately 11 months after first observations) 104 hours of observation to test and elaborate stage I analyses. Handover, whiteboard use and a coordinator role emerged as the key processes facilitating work and team coordination. The interplay between these supporting processes and the contextual features of each site promoted or inhibited TSA. Three configurations of supports for TSA were evident. These are described. Context configurations of supporting mechanisms and artefacts influence TSA, with implications for the maintenance of patient safety on delivery suites. A balanced model of supports for TSA is commended. Examining contrasting configurations helps reveal how local mechanisms or organizational, environmental and temporal factors might be manipulated to improve TSA.

Treating the Football Athlete: Coaches' Perspective from the University of Michigan.

PubMed

Chung, Kevin C; Lark, Meghan E; Cederna, Paul S

2017-02-01

Although football is one of the most popular sports in America, its high injury incidence places concern on the injury prevention and safety of its players. This article investigates the perspectives of two National Collegiate Athletic Association Division 1 football coaches on promoting injury management and player safety while maintaining a highly competitive team. Through obtaining their coaching philosophy team management topics, effective strategies that contribute to a team culture prioritizing player well-being were identified. Interactions of football coaches with physicians and medical specialists are explored to highlight strengths that can optimize the care and treatment of football athletes. Copyright © 2016 Elsevier Inc. All rights reserved.

Treating the Football Athlete: Coaches’ perspective from the University of Michigan

PubMed Central

Chung, Kevin C.; Lark, Meghan E.; Cederna, Paul S.

2016-01-01

Synopsis Although football is one of the most popular sports in America, its high injury incidence places concern on the injury prevention and safety of its players. This article investigates the perspectives of two National Collegiate Athletic Association (NCAA) Division 1 football coaches on promoting injury management and player safety while maintaining a highly competitive team. Through obtaining their coaching philosophy on a wide range of team management topics, effective strategies that contribute to a team culture prioritizing player well-being were identified. Furthermore, the interactions of football coaches with physicians and medical specialists are explored to highlight collaborative strengths that can be used to optimize the care and treatment of football athletes. PMID:27886827

Simulation in the Executive Suite: Lessons Learned for Building Patient Safety Leadership.

PubMed

Rosen, Michael A; Goeschel, Christine A; Che, Xin-Xuan; Fawole, Joseph Oluyinka; Rees, Dianne; Curran, Rosemary; Gelinas, Lillee; Martin, Jessica N; Kosel, Keith C; Pronovost, Peter J; Weaver, Sallie J

2015-12-01

Simulation is a powerful learning tool for building individual and team competencies of frontline health care providers with demonstrable impact on performance. This article examines the impact of simulation in building strategic leadership competencies for patient safety and quality among executive leaders in health care organizations. We designed, implemented, and evaluated a simulation as part of a larger safety leadership network meeting for executive leaders. This simulation targeted knowledge competencies of governance priority, culture of continuous improvement, and internal transparency and feedback. Eight teams of leaders in health care organizations-a total of 55 participants-participated in a 4-hour session. Each team performed collectively as a new chief executive officer (CEO) tasked with a goal of rescuing a hospital with a failing safety record. Teams worked on a modifiable simulation board reflecting the current dysfunctional organizational structure of the simulated hospital. They assessed and redesigned accountability structures based on information acquired in encounter sessions with confederates playing the role of internal staff and external consultants. Data were analyzed, and results are presented as qualitative themes arising from the simulation exercise, participant reaction data, and performance during the simulation. Key findings include high degrees of variability in solutions developed for the dysfunctional hospital system and generally positive learner reactions to the simulation experience. This study illustrates the potential value of simulation as a mechanism for learning and strategy development for executive leaders grappling with patient safety issues. Future research should explore the cognitive or functional fidelity of organizational simulations and the use of custom scenarios for strategic planning.

Professional and interprofessional differences in electronic health records use and recognition of safety issues in critically ill patients

PubMed Central

Sakata, Knewton K.; Stephenson, Laurel S.; Mulanax, Ashley; Bierman, Jesse; Mcgrath, Karess; Scholl, Gretchen; McDougal, Adrienne; Bearden, David T.; Mohan, Vishnu; Gold, Jeffrey A.

2018-01-01

During interprofessional intensive care unit (ICU) rounds each member of the interprofessional team is responsible for gathering and interpreting information from the electronic health records (EHR) to facilitate effective team decision-making. This study was conducted to determine how each professional group reviews EHR data in preparation for rounds and their ability to identify patient safety issues. Twenty-five physicians, 29 nurses, and 20 pharmacists participated. Individual participants were given verbal and written sign-out and then asked to review a simulated record in our institution’s EHR, which contained 14 patient safety items. After reviewing the chart, subjects presented the patient and the number of safety items recognised was recorded. About 40%, 30%, and 26% of safety issues were recognised by physicians, nurses, and pharmacists, respectively (p = 0.0006) and no item recognised 100% of the time. There was little overlap between the three groups with only 50% of items predicted to be recognised 100% of the time by the team. Differential recognition was associated with marked differences in EHR use, with only 3/152 EHR screens utilised by all three groups and the majority of screens used exclusively only by one group. There were significant and non-overlapping differences in individual profession recognition of patient safety issues in the EHR. Preferential identification of safety issues by certain professional groups may be attributed to differences in EHR use. Future studies will be needed to determine if shared decision-making during rounds can improve recognition of safety issues. PMID:27341177

Challenging authority during a life-threatening crisis: the effect of operating theatre hierarchy.

PubMed

Sydor, D T; Bould, M D; Naik, V N; Burjorjee, J; Arzola, C; Hayter, M; Friedman, Z

2013-03-01

Effective operating theatre (OT) communication is important for team function and patient safety. Status asymmetry between team members may contribute to communication breakdown and threaten patient safety. We investigated how hierarchy in the OT team influences an anaesthesia trainee's ability to challenge an unethical decision by a consultant anaesthetist in a simulated crisis scenario. We prospectively randomized 49 postgraduate year (PGY) 2-5 anaesthesia trainees at two academic hospitals to participate in a videotaped simulated crisis scenario with a simulated OT team practicing either a hierarchical team structure (Group H) or a non-hierarchical team structure (Group NH). The scenario allowed trainees several opportunities to challenge their consultant anaesthetist when administering blood to a Jehovah's Witness. Three independent, blinded raters scored the performances using a modified advocacy-inquiry score (AIS). The primary outcome was the comparison of the best-response AIS between Groups H vs NH. Secondary outcomes included the comparison of best AIS by PGY and the percentage in each group that checked and administered blood. The AIS did not differ between the groups (P=0.832) but significantly improved from PGY2 to PGY5 (P=0.026). The rates of checking blood (92% vs 76%, P=0.082) and administering blood (62% vs 57%, P=0.721) were high in both groups but not significantly different between the groups. This study did not show a significant effect of OT team hierarchical structure on trainee's ability to challenge authority; however, the results are concerning. The challenges were suboptimal in quality and there was an alarming high rate of blood checking and administration in both groups. This may reflect lack of training in appropriately and effectively challenging authority within the formal curriculum with implications for patient safety.

A crew resource management program tailored to trauma resuscitation improves team behavior and communication.

PubMed

Hughes, K Michael; Benenson, Ronald S; Krichten, Amy E; Clancy, Keith D; Ryan, James Patrick; Hammond, Christopher

2014-09-01

Crew Resource Management (CRM) is a team-building communication process first implemented in the aviation industry to improve safety. It has been used in health care, particularly in surgical and intensive care settings, to improve team dynamics and reduce errors. We adapted a CRM process for implementation in the trauma resuscitation area. An interdisciplinary steering committee developed our CRM process to include a didactic classroom program based on a preimplementation survey of our trauma team members. Implementation with new cultural and process expectations followed. The Human Factors Attitude Survey and Communication and Teamwork Skills assessment tool were used to design, evaluate, and validate our CRM program. The initial trauma communication survey was completed by 160 team members (49% response). Twenty-five trauma resuscitations were observed and scored using Communication and Teamwork Skills. Areas of concern were identified and 324 staff completed our 3-hour CRM course during a 3-month period. After CRM training, 132 communication surveys and 38 Communication and Teamwork Skills observations were completed. In the post-CRM survey, respondents indicated improvement in accuracy of field to medical command information (p = 0.029); accuracy of emergency department medical command information to the resuscitation area (p = 0.002); and team leader identity, communication of plan, and role assignment (p = 0.001). After CRM training, staff were more likely to speak up when patient safety was a concern (p = 0.002). Crew Resource Management in the trauma resuscitation area enhances team dynamics, communication, and, ostensibly, patient safety. Philosophy and culture of CRM should be compulsory components of trauma programs and in resuscitation of injured patients. Copyright © 2014 American College of Surgeons. Published by Elsevier Inc. All rights reserved.

Development of an Integrated Team Training Design and Assessment Architecture to Support Adaptability in Healthcare Teams

DTIC Science & Technology

2017-10-01

to patient safety by addressing key methodological and conceptual gaps in healthcare simulation-based team training. The investigators are developing...primary outcome of Aim 1a is a conceptually and methodologically sound training design architecture that supports the development and integration of team...should be delivered. This subtask was delayed by approximately 1 month and is now completed. Completed Evaluation of existing experimental dataset to

A simulation model for determining the optimal size of emergency teams on call in the operating room at night.

PubMed

van Oostrum, Jeroen M; Van Houdenhoven, Mark; Vrielink, Manon M J; Klein, Jan; Hans, Erwin W; Klimek, Markus; Wullink, Gerhard; Steyerberg, Ewout W; Kazemier, Geert

2008-11-01

Hospitals that perform emergency surgery during the night (e.g., from 11:00 pm to 7:30 am) face decisions on optimal operating room (OR) staffing. Emergency patients need to be operated on within a predefined safety window to decrease morbidity and improve their chances of full recovery. We developed a process to determine the optimal OR team composition during the night, such that staffing costs are minimized, while providing adequate resources to start surgery within the safety interval. A discrete event simulation in combination with modeling of safety intervals was applied. Emergency surgery was allowed to be postponed safely. The model was tested using data from the main OR of Erasmus University Medical Center (Erasmus MC). Two outcome measures were calculated: violation of safety intervals and frequency with which OR and anesthesia nurses were called in from home. We used the following input data from Erasmus MC to estimate distributions of all relevant parameters in our model: arrival times of emergency patients, durations of surgical cases, length of stay in the postanesthesia care unit, and transportation times. In addition, surgeons and OR staff of Erasmus MC specified safety intervals. Reducing in-house team members from 9 to 5 increased the fraction of patients treated too late by 2.5% as compared to the baseline scenario. Substantially more OR and anesthesia nurses were called in from home when needed. The use of safety intervals benefits OR management during nights. Modeling of safety intervals substantially influences the number of emergency patients treated on time. Our case study showed that by modeling safety intervals and applying computer simulation, an OR can reduce its staff on call without jeopardizing patient safety.

Psychosocial safety climate, emotional exhaustion, and work injuries in healthcare workplaces.

PubMed

Zadow, Amy Jane; Dollard, Maureen Frances; Mclinton, Sarven Savia; Lawrence, Peter; Tuckey, Michelle Rae

2017-12-01

Preventing work injuries requires a clear understanding of how they occur, how they are recorded, and the accuracy of injury surveillance. Our innovation was to examine how psychosocial safety climate (PSC) influences the development of reported and unreported physical and psychological workplace injuries beyond (physical) safety climate, via the erosion of psychological health (emotional exhaustion). Self-report data (T2, 2013) from 214 hospital employees (18 teams) were linked at the team level to the hospital workplace injury register (T1, 2012; T2, 2013; and T3, 2014). Concordance between survey-reported and registered injury rates was low (36%), indicating that many injuries go unreported. Safety climate was the strongest predictor of T2 registered injury rates (controlling for T1); PSC and emotional exhaustion also played a role. Emotional exhaustion was the strongest predictor of survey-reported total injuries and underreporting. Multilevel analysis showed that low PSC, emanating from senior managers and transmitted through teams, was the origin of psychological health erosion (i.e., low emotional exhaustion), which culminated in greater self-reported work injuries and injury underreporting (both physical and psychological). These results underscore the need to consider, in theory and practice, a dual physical-psychosocial safety explanation of injury events and a psychosocial explanation of injury underreporting. Copyright © 2017 John Wiley & Sons, Ltd.

[Social network analysis: a method to improve safety in healthcare organizations].

PubMed

Marqués Sánchez, Pilar; González Pérez, Marta Eva; Agra Varela, Yolanda; Vega Núñez, Jorge; Pinto Carral, Arrate; Quiroga Sánchez, Enedina

2013-01-01

Patient safety depends on the culture of the healthcare organization involving relationships between professionals. This article proposes that the study of these relations should be conducted from a network perspective and using a methodology called Social Network Analysis (SNA). This methodology includes a set of mathematical constructs grounded in Graph Theory. With the SNA we can know aspects of the individual's position in the network (centrality) or cohesion among team members. Thus, the SNA allows to know aspects related to security such as the kind of links that can increase commitment among professionals, how to build those links, which nodes have more prestige in the team in generating confidence or collaborative network, which professionals serve as intermediaries between the subgroups of a team to transmit information or smooth conflicts, etc. Useful aspects in stablishing a safety culture. The SNA would analyze the relations among professionals, their level of communication to communicate errors and spontaneously seek help and coordination between departments to participate in projects that enhance safety. Thus, they related through a network, using the same language, a fact that helps to build a culture. In summary, we propose an approach to safety culture from a SNA perspective that would complement other commonly used methods.

Using in situ simulation to identify and resolve latent environmental threats to patient safety: case study involving operational changes in a labor and delivery ward.

PubMed

Hamman, William R; Beaudin-Seiler, Beth M; Beaubien, Jeffrey M; Gullickson, Amy M; Orizondo-Korotko, Krystyna; Gross, Amy C; Fuqua, Wayne; Lammers, Richard

2010-01-01

Since the publication of "To Err Is Human" in 1999, health care professionals have looked to high-reliability industries such as aviation for guidance on improving system safety. One of the most widely adopted aviation-derived approaches is simulation-based team training, also known as crew resource management training. In the health care domain, crew resource management training often takes place in custom-built simulation laboratories that are designed to replicate operating rooms or labor and delivery rooms. Unlike these traditional crew resource management training programs, "in situ simulation" occurs on actual patient care units, involves actual health care team members, and uses actual organization processes to train and assess team performance. During the past 24 months, our research team has conducted nearly 40 in situ simulations. In this article, we present the results from 1 such simulation: a patient who experienced a difficult labor that resulted in an emergency caesarian section and hysterectomy. During the simulation, a number of latent environmental threats to safety were identified. This article presents the latent threats and the steps that the hospital has taken to remedy them.

Tiger Team Assessment of the National Institute for Petroleum and Energy Research

DOE Office of Scientific and Technical Information (OSTI.GOV)

Not Available

1992-05-01

This report documents the Tiger Team Assessment of the National Institute for Petroleum and Energy Research (NIPER) and the Bartlesville Project Office (BPO) of the Department of Energy (DOE), co-located in Bartlesville, Oklahoma. The assessment investigated the status of the environmental, safety, and health (ES H) programs of the two organizations. The Tiger Team Assessment was conducted from April 6 to May 1, 1992, under the auspices of DOE's Office of Special Projects (OSP) in the Office of the Assistant Secretary for Environment, Safety and Health (EH). The assessment was comprehensive, encompassing environmental, safety, and health issues; management practices; qualitymore » assurance; and NIPER and BPO self-assessments. Compliance with Federal, state, and local regulations; DOE Orders; best management practices; and internal IITRI requirements was assessed. In addition, an evaluation was conducted of the adequacy and effectiveness of BPO and IITRI management of the ES H and self-assessment processes. The NIPER/BPO Tiger Team Assessment is part of a larger, comprehensive DOE Tiger Team Independent Assessment Program planned for DOE facilities. The objective of the initiative is to provide the Secretary with information on the compliance status of DOE facilities with regard to ES H requirements, root causes for noncompliance, adequacy of DOE and contractor ES H management programs, response actions to address the identified problem areas, and DOE-wide ES H compliance trends and root causes.« less

Tiger Team Assessment of the National Institute for Petroleum and Energy Research

DOE Office of Scientific and Technical Information (OSTI.GOV)

Not Available

1992-05-01

This report documents the Tiger Team Assessment of the National Institute for Petroleum and Energy Research (NIPER) and the Bartlesville Project Office (BPO) of the Department of Energy (DOE), co-located in Bartlesville, Oklahoma. The assessment investigated the status of the environmental, safety, and health (ES&H) programs of the two organizations. The Tiger Team Assessment was conducted from April 6 to May 1, 1992, under the auspices of DOE`s Office of Special Projects (OSP) in the Office of the Assistant Secretary for Environment, Safety and Health (EH). The assessment was comprehensive, encompassing environmental, safety, and health issues; management practices; quality assurance;more » and NIPER and BPO self-assessments. Compliance with Federal, state, and local regulations; DOE Orders; best management practices; and internal IITRI requirements was assessed. In addition, an evaluation was conducted of the adequacy and effectiveness of BPO and IITRI management of the ES&H and self-assessment processes. The NIPER/BPO Tiger Team Assessment is part of a larger, comprehensive DOE Tiger Team Independent Assessment Program planned for DOE facilities. The objective of the initiative is to provide the Secretary with information on the compliance status of DOE facilities with regard to ES&H requirements, root causes for noncompliance, adequacy of DOE and contractor ES&H management programs, response actions to address the identified problem areas, and DOE-wide ES&H compliance trends and root causes.« less

The science of teamwork: Progress, reflections, and the road ahead.

PubMed

Salas, Eduardo; Reyes, Denise L; McDaniel, Susan H

2018-01-01

We need teams in nearly every aspect of our lives (e.g., hospitals, schools, flight decks, nuclear power plants, oil rigs, the military, and corporate offices). Nearly a century of psychological science has uncovered extensive knowledge about team-related processes and outcomes. In this article, we draw from the reviews and articles of this special issue to identify 10 key reflections that have arisen in the team literature, briefly summarized here. Team researchers have developed many theories surrounding the multilayered aspects of teams, such that now we have a solid theoretical basis for teams. We have recognized that the collective is often stronger than the individual, initiating the shift from individual tasks to team tasks. All teams are not created equal, so it is important to consider the context to understand relevant team dynamics and outcomes, but sometimes teams performing in different contexts are more similar than not. It is critical to have teamwork-supportive organizational conditions and environments where psychological safety can flourish and be a mechanism to resolve conflicts, ensure safety, mitigate errors, learn, and improve performance. There are also helpful teamwork competencies that can increase effectiveness across teams or tasks that have been identified (e.g., coordination, communication, and adaptability). Even if a team is made up of experts, it can still fail if they do not know how to cooperate, coordinate, and communicate well together. To ensure the improvement and maintenance of effective team functioning, the organization must implement team development interventions and evaluate relevant team outcomes with robust diagnostic measurement. We conclude with 3 main directions for scientists to expand upon in the future: (a) address issues with technology to make further improvements in team assessment, (b) learn more about multiteam systems, and (c) bridge the gap between theory and practice. In summary, the science of teams has made substantial progress but still has plenty of room for advancement. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Probing Aircraft Flight Test Hazard Mitigation for the Alternative Fuel Effects on Contrails & Cruise Emissions (ACCESS) Research Team

NASA Technical Reports Server (NTRS)

Kelly, Michael J.

2013-01-01

The Alternative Fuel Effects on Contrails & Cruise Emissions (ACCESS) Project Integration Manager requested in July 2012 that the NASA Engineering and Safety Center (NESC) form a team to independently assess aircraft structural failure hazards associated with the ACCESS experiment and to identify potential flight test hazard mitigations to ensure flight safety. The ACCESS Project Integration Manager subsequently requested that the assessment scope be focused predominantly on structural failure risks to the aircraft empennage raft empennage.

Examining Variation in Mental Models of Influence and Leadership Among Nursing Leaders and Direct Care Nurses.

PubMed

Weaver, Sallie J; Mossburg, Sarah E; Pillari, MarieSarah; Kent, Paula S; Daugherty Biddison, Elizabeth Lee

This study explored similarities and differences in the views on team membership and leadership held by nurses in formal unit leadership positions and direct care nurses. We used a mixed-methods approach and a maximum variance sampling strategy, sampling from units with both high and low safety behaviors and safety culture scores. We identified several key differences in mental models of care team membership and leadership between formal leaders and direct care nurses that warrant further exploration.

Applying successfully proven measures in roadway safety to reduce harmful collisions in SC.

DOT National Transportation Integrated Search

2017-06-06

The overall goal of this research was to identify proven successful safety programs used in other states and assess the potential for safety improvement if similar programs were implemented in South Carolina. The research team not only sought out eng...

Participatory research and service-learning among farmers, health professional students, and experts: an agromedicine approach to farm safety and health.

PubMed

Guin, Susan M; Wheat, John R; Allinder, Russell S; Fanucchi, Gary J; Wiggins, Oscar S; Johnson, Gwendolyn J

2012-01-01

Agromedicine developments in Alabama rest heavily on the interest and support of the farm community. Participatory approaches have been advocated in order to impact the safety and health of farms. The University of Alabama Agromedicine Research Team, working closely with and guided by farmers, places emphasis on identifying areas of farmer concern related to agricultural health and safety and on developing jointly with the farmers plans to address their concerns. Agricultural extension agents were key to developing the trust relationships among farmers, health professionals, and extension personnel required for these successful agricultural safety and health developments. In this article the authors describe how the research team engaged farmers in participatory research to develop service learning activities for graduate students studying Agricultural Safety and Health at The University of Alabama. Accepting farmers' active role in research processes creates an environment that is favorable to change, while providing farmers reassurance that their health and safety is of utmost importance to the researchers.

Surgical team member assessment of the safety of surgery practice in 38 South Carolina hospitals.

PubMed

Singer, Sara J; Jiang, Wei; Huang, Lyen C; Gibbons, Lorri; Kiang, Mathew V; Edmondson, Lizabeth; Gawande, Atul A; Berry, William R

2015-06-01

We assessed surgical team member perceptions of multiple dimensions of safe surgical practice in 38 South Carolina hospitals participating in a statewide initiative to implement surgical safety checklists. Primary data were collected using a novel 35-item survey. We calculated the percentage of 1,852 respondents with strongly positive, positive, and neutral/negative responses about the safety of surgical practice, compared results by hospital and professional discipline, and examined how readiness, teamwork, and adherence related to staff perception of care quality. Overall, 78% of responses were positive about surgical safety at respondent's hospitals, but in each survey dimension, from 16% to 40% of responses were neutral/negative, suggesting significant opportunity to improve surgical safety. Respondents not reporting they would feel safe being treated in their operating rooms varied from 0% to 57% among hospitals. Surgeons responded more positively than nonsurgeons. Readiness, teamwork, and practice adherence related directly to staff perceptions of patient safety (p < .001). © The Author(s) 2015.

Environmental health and safety independent investigation of the in situ vitrification melt expulsion at the Oak Ridge National Laboratory, Oak Ridge, Tennessee

DOE Office of Scientific and Technical Information (OSTI.GOV)

NONE

At about 6:12 pm, EDT on April 21, 1996, steam and molten material were expelled from Pit 1 in situ vitrification (ISV) project at the Oak Ridge National Laboratory (ORNL). At the request of the director of the Environmental Restoration (ER) Division, Department of Energy Oak Ridge Operations (DOE ORO), an independent investigation team was established on April 26, 1996. This team was tasked to determine the facts related to the ORNL Pit 1 melt expulsion event (MEE) in the areas of environment safety and health concerns such as the adequacy of the ISV safety systems; operational control restrictions; emergencymore » response planning/execution; and readiness review, and report the investigation team findings within 45 days from the date of incident. These requirements were stated in the letter of appointment presented in Appendix A of this report. This investigation did not address the physical causes of the MEE. A separate investigation was conducted by ISV project personnel to determine the causes of the melt expulsion and the extent of the effects of this phenomenon. In response to this event, occurrence report ORO-LMES-X10ENVRES-1996-0006 (Appendix B) was filed. The investigation team did not address the occurrence reporting or event notification process. The project personnel (project team) examined the physical evidence at Pit 1 ISV site (e.g., the ejected melt material and the ISV hood), reviewed documents such as the site- specific health and safety plan (HASP), and interviewed personnel involved in the event and/or the project. A listing of the personnel interviewed and evidence reviewed is provided in Appendix C.« less

Observation of behavioural markers of non-technical skills in the operating room and their relationship to intra-operative incidents.

PubMed

Siu, Joey; Maran, Nikki; Paterson-Brown, Simon

2016-06-01

The importance of non-technical skills in improving surgical safety and performance is now well recognised. Better understanding is needed of the impact that non-technical skills of the multi-disciplinary theatre team have on intra-operative incidents in the operating room (OR) using structured theatre-based assessment. The interaction of non-technical skills that influence surgical safety of the OR team will be explored and made more transparent. Between May-August 2013, a range of procedures in general and vascular surgery in the Royal Infirmary of Edinburgh were performed. Non-technical skills behavioural markers and associated intra-operative incidents were recorded using established behavioural marking systems (NOTSS, ANTS and SPLINTS). Adherence to the surgical safety checklist was also observed. A total of 51 procedures were observed, with 90 recorded incidents - 57 of which were considered avoidable. Poor situational awareness was a common area for surgeons and anaesthetists leading to most intra-operative incidents. Poor communication and teamwork across the whole OR team had a generally large impact on intra-operative incidents. Leadership was shown to be an essential set of skills for the surgeons as demonstrated by the high correlation of poor leadership with intra-operative incidents. Team-working and management skills appeared to be especially important for anaesthetists in the recovery from an intra-operative incident. A significant number of avoidable incidents occur during operative procedures. These can all be linked to failures in non-technical skills. Better training of both individual and team in non-technical skills is needed in order to improve patient safety in the operating room. Copyright © 2014 Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. Published by Elsevier Ltd. All rights reserved.

Simulation-based multiprofessional obstetric anaesthesia training conducted in situ versus off-site leads to similar individual and team outcomes: a randomised educational trial.

PubMed

Sørensen, Jette Led; van der Vleuten, Cees; Rosthøj, Susanne; Østergaard, Doris; LeBlanc, Vicki; Johansen, Marianne; Ekelund, Kim; Starkopf, Liis; Lindschou, Jane; Gluud, Christian; Weikop, Pia; Ottesen, Bent

2015-10-06

To investigate the effect of in situ simulation (ISS) versus off-site simulation (OSS) on knowledge, patient safety attitude, stress, motivation, perceptions of simulation, team performance and organisational impact. Investigator-initiated single-centre randomised superiority educational trial. Obstetrics and anaesthesiology departments, Rigshospitalet, University of Copenhagen, Denmark. 100 participants in teams of 10, comprising midwives, specialised midwives, auxiliary nurses, nurse anaesthetists, operating theatre nurses, and consultant doctors and trainees in obstetrics and anaesthesiology. Two multiprofessional simulations (clinical management of an emergency caesarean section and a postpartum haemorrhage scenario) were conducted in teams of 10 in the ISS versus the OSS setting. Knowledge assessed by a multiple choice question test. Individual outcomes: scores on the Safety Attitudes Questionnaire, stress measurements (State-Trait Anxiety Inventory, cognitive appraisal and salivary cortisol), Intrinsic Motivation Inventory and perceptions of simulations. Team outcome: video assessment of team performance. Organisational impact: suggestions for organisational changes. The trial was conducted from April to June 2013. No differences between the two groups were found for the multiple choice question test, patient safety attitude, stress measurements, motivation or the evaluation of the simulations. The participants in the ISS group scored the authenticity of the simulation significantly higher than did the participants in the OSS group. Expert video assessment of team performance showed no differences between the ISS versus the OSS group. The ISS group provided more ideas and suggestions for changes at the organisational level. In this randomised trial, no significant differences were found regarding knowledge, patient safety attitude, motivation or stress measurements when comparing ISS versus OSS. Although participant perception of the authenticity of ISS versus OSS differed significantly, there were no differences in other outcomes between the groups except that the ISS group generated more suggestions for organisational changes. NCT01792674. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

Action research, simulation, team communication, and bringing the tacit into voice society for simulation in healthcare.

PubMed

Forsythe, Lydia

2009-01-01

In healthcare, professionals usually function in a time-constrained paradigm because of the nature of care delivery functions and the acute patient populations usually in need of emergent and urgent care. This leaves little, if no time for team reflection, or team processing as a collaborative action. Simulation can be used to create a safe space as a structure for recognition and innovation to continue to develop a culture of safety for healthcare delivery and patient care. To create and develop a safe space, three qualitative modified action research institutional review board-approved studies were developed using simulation to explore team communication as an unfolding in the acute care environment of the operating room. An action heuristic was used for data collection by capturing the participants' narratives in the form of collaborative recall and reflection to standardize task, process, and language. During the qualitative simulations, the team participants identified and changed multiple tasks, process, and language items. The simulations contributed to positive changes for task and efficiencies, team interactions, and overall functionality of the team. The studies demonstrated that simulation can be used in healthcare to define safe spaces to practice, reflect, and develop collaborative relationships, which contribute to the realization of a culture of safety.

The Johns Hopkins Hospital: identifying and addressing risks and safety issues.

PubMed

Paine, Lori A; Baker, David R; Rosenstein, Beryl; Pronovost, Peter J

2004-10-01

At The Johns Hopkins Hospital (JHH), a culture of safety refers to the presence of characteristics such as the belief that harm is untenable and the use of a systems approach to analyzing safety issues. The leadership of JHH provides strategic planning guidance for safety and improvement initiatives, involves the patient safety committee in capital investment allocation decisions and in designing and planning new hospital facilities, and ensures that safety and quality head the agenda of board-of-trustees meetings. Although JHH takes a systems approach, structures such as monitoring staff behavior trends are used to hold people accountable for job performance. JHH encountered three major hurdles in implementing and sustaining a culture of safety. First, JHH's decentralized organizational structure contributes to a silo effect that limits the spread of ideas, practices, and culture. JHH intends to create an internal collaborative of departmental safety initiatives to foster opportunities for units to share ideas and results. Second, in response to the challenge of encouraging teams to think and act in an interdisciplinary fashion, communication and teamwork training are being used to enhance the effectiveness of interdisciplinary teams. Further development of valid and meaningful safety-related measurement and data collection methodologies is JHH's largest remaining challenge.

Training and Action for Patient Safety: Embedding Interprofessional Education for Patient Safety within an Improvement Methodology

ERIC Educational Resources Information Center

Slater, Beverley L.; Lawton, Rebecca; Armitage, Gerry; Bibby, John; Wright, John

2012-01-01

Introduction: Despite an explosion of interest in improving safety and reducing error in health care, one important aspect of patient safety that has received little attention is a systematic approach to education and training for the whole health care workforce. This article describes an evaluation of an innovative multiprofessional, team-based…

Psychometric Support for an Abbreviated Version of the California School Climate and Safety Survey

ERIC Educational Resources Information Center

Rebelez, Jennica L.; Furlong, Michael J.

2013-01-01

The California School Climate and Safety Survey-Short Form (CSCSS-SF) was developed as a streamlined version (54 items) of the original CSCSS (102 items) for school safety teams to gather information regarding student perceptions of campus climate, safety, and experience of victimization. Using a longitudinal dataset, this study implemented…

78 FR 21715 - Sexual Assault Prevention and Response (SAPR) Program Procedures

Federal Register 2010, 2011, 2012, 2013, 2014

2013-04-11

... high-risk team to monitor cases where the sexual assault victim's life and safety may be in jeopardy... in Military Rule of Evidence 514. (9) Requires the execution of a high-risk team to monitor cases...

Primary care emergency team training in situ means learning in real context

PubMed Central

Brandstorp, Helen; Halvorsen, Peder A.; Sterud, Birgitte; Haugland, Bjørgun; Kirkengen, Anna Luise

2016-01-01

Objective The purpose of our study was to explore the local learning processes and to improve in situ team training in the primary care emergency teams with a focus on interaction. Design, setting and subjects As participating observers, we investigated locally organised trainings of teams constituted ad hoc, involving nurses, paramedics and general practitioners, in rural Norway. Subsequently, we facilitated focus discussions with local participants. We investigated what kinds of issues the participants chose to elaborate in these learning situations, why they did so, and whether and how local conditions improved during the course of three and a half years. In addition, we applied learning theories to explore and challenge our own and the local participants’ understanding of team training. Results In situ team training was experienced as challenging, engaging, and enabling. In the training sessions and later focus groups, the participants discussed a wide range of topics constitutive for learning in a sociocultural perspective, and topics constitutive for patient safety culture. The participants expanded the types of training sites, themes and the structures for participation, improved their understanding of communication and developed local procedures. The flexible structure of the model mirrors the complexity of medicine and provides space for the participants’ own sense of responsibility. Conclusion Challenging, monthly in situ team trainings organised by local health personnel facilitate many types of learning. The flexible training model provides space for the participants’ own sense of responsibility and priorities. Outcomes involve social and structural improvements, including a sustainable culture of patient safety. Key Points Challenging, monthly in situ team trainings, organised by local health personnel, facilitate many types of learning.The flexible structure of the training model mirrors the complexity of medicine and the realism of the simulation sessions.Providing room for the participants’ own priorities and sense of responsibility allows for improvement on several levels.The participants demonstrated a consistent, long-term motivation to strengthen safety, both for their patients and for themselves. PMID:27442268

Primary care emergency team training in situ means learning in real context.

PubMed

Brandstorp, Helen; Halvorsen, Peder A; Sterud, Birgitte; Haugland, Bjørgun; Kirkengen, Anna Luise

2016-09-01

The purpose of our study was to explore the local learning processes and to improve in situ team training in the primary care emergency teams with a focus on interaction. As participating observers, we investigated locally organised trainings of teams constituted ad hoc, involving nurses, paramedics and general practitioners, in rural Norway. Subsequently, we facilitated focus discussions with local participants. We investigated what kinds of issues the participants chose to elaborate in these learning situations, why they did so, and whether and how local conditions improved during the course of three and a half years. In addition, we applied learning theories to explore and challenge our own and the local participants' understanding of team training. In situ team training was experienced as challenging, engaging, and enabling. In the training sessions and later focus groups, the participants discussed a wide range of topics constitutive for learning in a sociocultural perspective, and topics constitutive for patient safety culture. The participants expanded the types of training sites, themes and the structures for participation, improved their understanding of communication and developed local procedures. The flexible structure of the model mirrors the complexity of medicine and provides space for the participants' own sense of responsibility. Challenging, monthly in situ team trainings organised by local health personnel facilitate many types of learning. The flexible training model provides space for the participants' own sense of responsibility and priorities. Outcomes involve social and structural improvements, including a sustainable culture of patient safety. KEY POINTS Challenging, monthly in situ team trainings, organised by local health personnel, facilitate many types of learning. The flexible structure of the training model mirrors the complexity of medicine and the realism of the simulation sessions. Providing room for the participants' own priorities and sense of responsibility allows for improvement on several levels. The participants demonstrated a consistent, long-term motivation to strengthen safety, both for their patients and for themselves.

Improving Health Care Quality and Patient Safety Through Peer-to-Peer Assessment: Demonstration Project in Two Academic Medical Centers.

PubMed

Mort, Elizabeth; Bruckel, Jeffrey; Donelan, Karen; Paine, Lori; Rosen, Michael; Thompson, David; Weaver, Sallie; Yagoda, Daniel; Pronovost, Peter

Despite decades of investment in patient safety, unintentional patient harm remains a major challenge in the health care industry. Peer-to-peer assessment in the nuclear industry has been shown to reduce harm. The study team's goal was to pilot and assess the feasibility of this approach in health care. The team developed tools and piloted a peer-to-peer assessment at 2 academic hospitals: Massachusetts General Hospital and Johns Hopkins Hospital. The assessment evaluated both the institutions' organizational approach to quality and safety as well as their approach to reducing 2 specific areas of patient harm. Site visits were completed and consisted of semistructured interviews with institutional leaders and clinical staff as well as direct patient observations using audit tools. Reports with recommendations were well received and each institution has developed improvement plans. The study team believes that peer-to-peer assessment in health care has promise and warrants consideration for wider adoption.

Patient Safety Reporting Systems: Sustained Quality Improvement Using a Multidisciplinary Team and “Good Catch” Awards

PubMed Central

Herzer, Kurt R.; Mirrer, Meredith; Xie, Yanjun; Steppan, Jochen; Li, Matthew; Jung, Clinton; Cover, Renee; Doyle, Peter A.; Mark, Lynette J.

2014-01-01

Background Since 1999, hospitals have made substantial commitments to healthcare quality and patient safety through individual initiatives of executive leadership involvement in quality, investments in safety culture, education and training for medical students and residents in quality and safety, the creation of patient safety committees, and implementation of patient safety reporting systems. Cohesive quality and safety approaches have become comprehensive programs to identify and mitigate hazards that could harm patients. This article moves to the next level with an intense refocusing of attention on one of the individual components of a comprehensive program--the patient safety reporting system—with a goal of maximized usefulness of the reports and long-term sustainability of quality improvements arising from them. Methods A six-phase framework was developed to deal with patient safety hazards: identify, report, analyze, mitigate, reward, and follow up. Unique features of this process included a multidisciplinary team to review reports, mitigate hazards, educate and empower providers, recognize the identifying/reporting individuals or groups with “Good Catch” awards, and follow up to determine if quality improvements were sustained over time. Results To date, 29 patient safety hazards have gone through this process with “Good Catch” awards being granted at our institution. These awards were presented at various times over the past 4 years since the process began in 2008. Follow-up revealed that 86% of the associated quality improvements have been sustained over time since the awards were given. We present the details of two of these “Good Catch” awards: vials of heparin with an unusually high concentration of the drug that posed a potential overdose hazard and a rapid infusion device that resisted practitioner control. Conclusion A multidisciplinary team's analysis and mitigation of hazards identified in a patient safety reporting system, positive recognition with a “Good Catch” award, education of practitioners, and long-term follow-up resulted in an outcome of sustained quality improvement initiatives. PMID:22946251

The interplay between teamwork, clinicians' emotional exhaustion, and clinician-rated patient safety: a longitudinal study.

PubMed

Welp, Annalena; Meier, Laurenz L; Manser, Tanja

2016-04-19

Effectively managing patient safety and clinicians' emotional exhaustion are important goals of healthcare organizations. Previous cross-sectional studies showed that teamwork is associated with both. However, causal relationships between all three constructs have not yet been investigated. Moreover, the role of different dimensions of teamwork in relation to emotional exhaustion and patient safety is unclear. The current study focused on the long-term development of teamwork, emotional exhaustion, and patient safety in interprofessional intensive care teams by exploring causal relationships between these constructs. A secondary objective was to disentangle the effects of interpersonal and cognitive-behavioral teamwork. We employed a longitudinal study design. Participants were 2100 nurses and physicians working in 55 intensive care units. They answered an online questionnaire on interpersonal and cognitive-behavioral aspects of teamwork, emotional exhaustion, and patient safety at three time points with a 3-month lag. Data were analyzed with cross-lagged structural equation modeling. We controlled for professional role. Analyses showed that emotional exhaustion had a lagged effect on interpersonal teamwork. Furthermore, interpersonal and cognitive-behavioral teamwork mutually influenced each other. Finally, cognitive-behavioral teamwork predicted clinician-rated patient safety. The current study shows that the interrelations between teamwork, clinician burnout, and clinician-rated patient safety unfold over time. Interpersonal and cognitive-behavioral teamwork play specific roles in a process leading from clinician emotional exhaustion to decreased clinician-rated patient safety. Emotionally exhausted clinicians are less able to engage in positive interpersonal teamwork, which might set in motion a vicious cycle: negative interpersonal team interactions negatively affect cognitive-behavioral teamwork and vice versa. Ultimately, ineffective cognitive-behavioral teamwork negatively impacts clinician-rated patient safety. Thus, reducing clinician emotional exhaustion is an important prerequisite of managing teamwork and patient safety. From a practical point of view, team-based interventions targeting patient safety are less likely to be effective when clinicians are emotionally exhausted.

Workflow Enhancement (WE) Improves Safety in Radiation Oncology: Putting the WE and Team Together

DOE Office of Scientific and Technical Information (OSTI.GOV)

Chao, Samuel T., E-mail: chaos@ccf.org; Rose Ella Burkhardt Brain Tumor and Neuro-oncology Center, Cleveland Clinic, Cleveland, Ohio; Meier, Tim

Purpose: To review the impact of a workflow enhancement (WE) team in reducing treatment errors that reach patients within radiation oncology. Methods and Materials: It was determined that flaws in our workflow and processes resulted in errors reaching the patient. The process improvement team (PIT) was developed in 2010 to reduce errors and was later modified in 2012 into the current WE team. Workflow issues and solutions were discussed in PIT and WE team meetings. Due to tensions within PIT that resulted in employee dissatisfaction, there was a 6-month hiatus between the end of PIT and initiation of the renamed/redesigned WEmore » team. In addition to the PIT/WE team forms, the department had separate incident forms to document treatment errors reaching the patient. These incident forms are rapidly reviewed and monitored by our departmental and institutional quality and safety groups, reflecting how seriously these forms are treated. The number of these incident forms was compared before and after instituting the WE team. Results: When PIT was disbanded, a number of errors seemed to occur in succession, requiring reinstitution and redesign of this team, rebranded the WE team. Interestingly, the number of incident forms per patient visits did not change when comparing 6 months during the PIT, 6 months during the hiatus, and the first 6 months after instituting the WE team (P=.85). However, 6 to 12 months after instituting the WE team, the number of incident forms per patient visits decreased (P=.028). After the WE team, employee satisfaction and commitment to quality increased as demonstrated by Gallup surveys, suggesting a correlation to the WE team. Conclusions: A team focused on addressing workflow and improving processes can reduce the number of errors reaching the patient. Time is necessary before a reduction in errors reaching patients will be seen.« less

Qualitative evaluation of the Safety and Improvement in Primary Care (SIPC) pilot collaborative in Scotland: perceptions and experiences of participating care teams.

PubMed

Bowie, Paul; Halley, Lyn; Blamey, Avril; Gillies, Jill; Houston, Neil

2016-01-29

To explore general practitioner (GP) team perceptions and experiences of participating in a large-scale safety and improvement pilot programme to develop and test a range of interventions that were largely new to this setting. Qualitative study using semistructured interviews. Data were analysed thematically. Purposive sample of multiprofessional study participants from 11 GP teams based in 3 Scottish National Health Service (NHS) Boards. 27 participants were interviewed. 3 themes were generated: (1) programme experiences and benefits, for example, a majority of participants referred to gaining new theoretical and experiential safety knowledge (such as how unreliable evidence-based care can be) and skills (such as how to search electronic records for undetected risks) related to the programme interventions; (2) improvements to patient care systems, for example, improvements in care systems reliability using care bundles were reported by many, but this was an evolving process strongly dependent on closer working arrangements between clinical and administrative staff; (3) the utility of the programme improvement interventions, for example, mixed views and experiences of participating in the safety climate survey and meeting to reflect on the feedback report provided were apparent. Initial theories on the utilisation and potential impact of some interventions were refined based on evidence. The pilot was positively received with many practices reporting improvements in safety systems, team working and communications with colleagues and patients. Barriers and facilitators were identified related to how interventions were used as the programme evolved, while other challenges around spreading implementation beyond this pilot were highlighted. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

Qualitative evaluation of the Safety and Improvement in Primary Care (SIPC) pilot collaborative in Scotland: perceptions and experiences of participating care teams

PubMed Central

Bowie, Paul; Halley, Lyn; Blamey, Avril; Gillies, Jill; Houston, Neil

2016-01-01

Objectives To explore general practitioner (GP) team perceptions and experiences of participating in a large-scale safety and improvement pilot programme to develop and test a range of interventions that were largely new to this setting. Design Qualitative study using semistructured interviews. Data were analysed thematically. Subjects and setting Purposive sample of multiprofessional study participants from 11 GP teams based in 3 Scottish National Health Service (NHS) Boards. Results 27 participants were interviewed. 3 themes were generated: (1) programme experiences and benefits, for example, a majority of participants referred to gaining new theoretical and experiential safety knowledge (such as how unreliable evidence-based care can be) and skills (such as how to search electronic records for undetected risks) related to the programme interventions; (2) improvements to patient care systems, for example, improvements in care systems reliability using care bundles were reported by many, but this was an evolving process strongly dependent on closer working arrangements between clinical and administrative staff; (3) the utility of the programme improvement interventions, for example, mixed views and experiences of participating in the safety climate survey and meeting to reflect on the feedback report provided were apparent. Initial theories on the utilisation and potential impact of some interventions were refined based on evidence. Conclusions The pilot was positively received with many practices reporting improvements in safety systems, team working and communications with colleagues and patients. Barriers and facilitators were identified related to how interventions were used as the programme evolved, while other challenges around spreading implementation beyond this pilot were highlighted. PMID:26826149

Developing a Practical and Sustainable Faculty Development Program With a Focus on Teaching Quality Improvement and Patient Safety: An Alliance for Independent Academic Medical Centers National Initiative III Project.

PubMed

Rodrigue, Christopher; Seoane, Leonardo; Gala, Rajiv B; Piazza, Janice; Amedee, Ronald G

2012-01-01

Teaching the next generation of physicians requires more than traditional teaching models. The Accreditation Council for Graduate Medical Education's Next Accreditation System places considerable emphasis on developing a learning environment that fosters resident education in quality improvement and patient safety. The goal of this project was to develop a comprehensive and sustainable faculty development program with a focus on teaching quality improvement and patient safety. A multidisciplinary team representing all stakeholders in graduate medical education developed a validated survey to assess faculty and house officer baseline perceptions of their experience with faculty development opportunities, quality improvement tools and training, and resident participation in quality improvement and patient safety programs at our institution. We then developed a curriculum to address these 3 areas. Our pilot survey revealed a need for a comprehensive program to teach faculty and residents the art of teaching. Two other areas of need are (1) regular resident participation in quality improvement and patient safety efforts and (2) effective tools for developing skills and habits to analyze practices using quality improvement methods. Resident and faculty pairs in 17 Ochsner training programs developed and began quality improvement projects while completing the first learning module. Resident and faculty teams also have been working on the patient safety modules and incorporating aspects of patient safety into their individual work environments. Our team's goal is to develop a sustainable and manageable faculty development program that includes modules addressing quality improvement and patient safety in accordance with Accreditation Council for Graduate Medical Education accreditation requirements.

Preventing food poisoning

MedlinePlus

... US Food & Drug Administration. 4 basic steps to food safety at home. www.fda.gov/downloads/forconsumers/byaudience/ ... and the A.D.A.M. Editorial team. Food Safety Read more NIH MedlinePlus Magazine Read more Health ...

Enhanced Time Out: An Improved Communication Process.

PubMed

Nelson, Patricia E

2017-06-01

An enhanced time out is an improved communication process initiated to prevent such surgical errors as wrong-site, wrong-procedure, or wrong-patient surgery. The enhanced time out at my facility mandates participation from all members of the surgical team and requires designated members to respond to specified time out elements on the surgical safety checklist. The enhanced time out incorporated at my facility expands upon the safety measures from the World Health Organization's surgical safety checklist and ensures that all personnel involved in a surgical intervention perform a final check of relevant information. Initiating the enhanced time out at my facility was intended to improve communication and teamwork among surgical team members and provide a highly reliable safety process to prevent wrong-site, wrong-procedure, and wrong-patient surgery. Copyright © 2017 AORN, Inc. Published by Elsevier Inc. All rights reserved.

Factors influencing mine rescue team behaviors.

PubMed

Jansky, Jacqueline H; Kowalski-Trakofler, K M; Brnich, M J; Vaught, C

2016-01-01

A focus group study of the first moments in an underground mine emergency response was conducted by the National Institute for Occupational Safety and Health (NIOSH), Office for Mine Safety and Health Research. Participants in the study included mine rescue team members, team trainers, mine officials, state mining personnel, and individual mine managers. A subset of the data consists of responses from participants with mine rescue backgrounds. These responses were noticeably different from those given by on-site emergency personnel who were at the mine and involved with decisions made during the first moments of an event. As a result, mine rescue team behavior data were separated in the analysis and are reported in this article. By considering the responses from mine rescue team members and trainers, it was possible to sort the data and identify seven key areas of importance to them. On the basis of the responses from the focus group participants with a mine rescue background, the authors concluded that accurate and complete information and a unity of purpose among all command center personnel are two of the key conditions needed for an effective mine rescue operation.

Development of a rapid response plan for intraoperative emergencies: the Circulate, Scrub, and Technical Assistance Team.

PubMed

Earle, David; Betti, Diane; Scala, Emilia

2017-01-01

Unplanned intraoperative events are inevitable and cause stress and inefficiency among staff. We believe that developing a technical rapid response team with explicitly defined, narrow roles would reduce the amount of chaos during such emergencies. This article provides a detailed description of the development and implementation of such a program. In-situ simulation of an intraoperative emergency was used for a formal assessment of the current practice. Debriefing sessions identified areas of improvement and solicited solutions. A multidisciplinary working group then developed and implemented the technical rapid response team based on the needs assessment. The program was designed to create a Circulating, Scrubbing, and Technical Assistance Team that helps with equipment, supplies, anesthesia, and communication. We anticipate the program will foster a culture of safety, and promote positive relationships and attitudes of the entire multidisciplinary team. In the future, research regarding patient outcomes and staff satisfaction and safety attitudes may help provide objective evidence of the benefits of the program. Copyright © 2016 Elsevier Inc. All rights reserved.

30 CFR 49.14 - [Reserved

Code of Federal Regulations, 2011 CFR

2011-07-01

... 30 Mineral Resources 1 2011-07-01 2011-07-01 false [Reserved] 49.14 Section 49.14 Mineral Resources MINE SAFETY AND HEALTH ADMINISTRATION, DEPARTMENT OF LABOR EDUCATION AND TRAINING MINE RESCUE TEAMS Mine Rescue Teams for Underground Coal Mines § 49.14 [Reserved] ...

30 CFR 49.14 - [Reserved

Code of Federal Regulations, 2013 CFR

2013-07-01

... 30 Mineral Resources 1 2013-07-01 2013-07-01 false [Reserved] 49.14 Section 49.14 Mineral Resources MINE SAFETY AND HEALTH ADMINISTRATION, DEPARTMENT OF LABOR EDUCATION AND TRAINING MINE RESCUE TEAMS Mine Rescue Teams for Underground Coal Mines § 49.14 [Reserved] ...

30 CFR 49.14 - [Reserved

Code of Federal Regulations, 2010 CFR

2010-07-01

... 30 Mineral Resources 1 2010-07-01 2010-07-01 false [Reserved] 49.14 Section 49.14 Mineral Resources MINE SAFETY AND HEALTH ADMINISTRATION, DEPARTMENT OF LABOR EDUCATION AND TRAINING MINE RESCUE TEAMS Mine Rescue Teams for Underground Coal Mines § 49.14 [Reserved] ...

30 CFR 49.14 - [Reserved

Code of Federal Regulations, 2012 CFR

2012-07-01

... 30 Mineral Resources 1 2012-07-01 2012-07-01 false [Reserved] 49.14 Section 49.14 Mineral Resources MINE SAFETY AND HEALTH ADMINISTRATION, DEPARTMENT OF LABOR EDUCATION AND TRAINING MINE RESCUE TEAMS Mine Rescue Teams for Underground Coal Mines § 49.14 [Reserved] ...

30 CFR 49.14 - [Reserved

Code of Federal Regulations, 2014 CFR

2014-07-01

... 30 Mineral Resources 1 2014-07-01 2014-07-01 false [Reserved] 49.14 Section 49.14 Mineral Resources MINE SAFETY AND HEALTH ADMINISTRATION, DEPARTMENT OF LABOR EDUCATION AND TRAINING MINE RESCUE TEAMS Mine Rescue Teams for Underground Coal Mines § 49.14 [Reserved] ...

Maximizing Team Performance: The Critical Role of the Nurse Leader.

PubMed

Manges, Kirstin; Scott-Cawiezell, Jill; Ward, Marcia M

2017-01-01

Facilitating team development is challenging, yet critical for ongoing improvement across healthcare settings. The purpose of this exemplary case study is to examine the role of nurse leaders in facilitating the development of a high-performing Change Team in implementing a patient safety initiative (TeamSTEPPs) using the Tuckman Model of Group Development as a guiding framework. The case study is the synthesis of 2.5 years of critical access hospital key informant interviews (n = 50). Critical juncture points related to team development and key nurse leader actions are analyzed, suggesting that nurse leaders are essential to maximize clinical teams' performance. © 2016 Wiley Periodicals, Inc.

Effects of perioperative briefing and debriefing on patient safety: a prospective intervention study

PubMed Central

Leong, Katharina Brigitte Margarethe Siew Lan; Hanskamp-Sebregts, Mirelle; van der Wal, Raymond A; Wolff, Andre P

2017-01-01

Objectives This study was carried out to improve patient safety in the operating theatre by the introduction of perioperative briefing and debriefing, which focused on an optimal collaboration between surgical team members. Design A prospective intervention study with one pretest and two post-test measurements: 1 month before and 4 months and 2.5 years after the implementation of perioperative briefing and debriefing, respectively. Setting Operating theatres of a tertiary care hospital with 875 beds in the Netherlands. Participants All members of five surgical teams participated in the perioperative briefing and debriefing. Intervention The implementation of perioperative briefing and debriefing from July 2012 to January 2014. Primary and secondary outcomes The primary outcome was changes in the team climate, measured by the Team Climate Inventory. Secondary outcomes were the experiences of surgical teams with perioperative briefing and debriefing, measured with a structured questionnaire, and the duration of the briefings, measured by an independent observer. Results Two and a half years after the introduction of perioperative briefing and debriefing, the team climate increased statistically significant (p≤0.05). Members of the five surgical teams strongly agreed with the positive influence of perioperative briefing and debriefing on clear agreements and reminding one another of the agreements of the day. They perceived a higher efficiency of the surgical programme with more operations starting on time and less unexpectedly long operation time. The perioperative briefing took less than 4 min to conduct. Conclusions Perioperative briefing and debriefing improved the team climate of surgical teams and the efficiency of their work within the operating theatre with acceptable duration per briefing. Surgical teams with alternating team compositions have the most benefit of briefing and debriefing. PMID:29247103

The National Shipbuilding Research Program. Ergonomic Study of Shipbuilding and Repair

DTIC Science & Technology

2000-10-09

syndrome, tendinitis , epicondylitis, bicipital tendinitis , rotator cuff tendinitis , disorders due to repetitive trauma, repetitive motion syndrome...Health & Safety is peer of all other managing directors. Ex. Mandatory safety rotation of two months in safety patrol group for all workers. Ex...Mandatory safety rotation of two months in safety patrol group for all workers. Ex. Each team reviews each work-related injury for cause and prevention

Tiger Team Assessment of the Los Alamos National Laboratory

DOE Office of Scientific and Technical Information (OSTI.GOV)

Not Available

1991-11-01

The purpose of the safety and health assessment was to determine the effectiveness of representative safety and health programs at the Los Alamos National Laboratory (LANL). Within the safety and health programs at LANL, performance was assessed in the following technical areas: Organization and Administration, Quality Verification, Operations, Maintenance, Training and Certification, Auxiliary Systems, Emergency Preparedness, Technical Support, Packaging and Transportation, Nuclear Criticality Safety, Security/Safety Interface, Experimental Activities, Site/Facility Safety Review, Radiological Protection, Personnel Protection, Worker Safety and Health (OSHA) Compliance, Fire Protection, Aviation Safety, Explosives Safety, Natural Phenomena, and Medical Services.

Identification of Vehicle Health Assurance Related Trends

NASA Technical Reports Server (NTRS)

Phojanamongkolkij, Nipa; Evans, Joni K.; Barr, Lawrence C.; Leone, Karen M.; Reveley, Mary S.

2014-01-01

Trend analysis in aviation as related to vehicle health management (VHM) was performed by reviewing the most current statistical and prognostics data available from the National Transportation Safety Board (NTSB) accident, the Federal Aviation Administration (FAA) incident, and the NASA Aviation Safety Reporting System (ASRS) incident datasets. In addition, future directions in aviation technology related to VHM research areas were assessed through the Commercial Aviation Safety Team (CAST) Safety Enhancements Reserved for Future Implementations (SERFIs), the National Transportation Safety Board (NTSB) Most-Wanted List and recent open safety recommendations, the National Research Council (NRC) Decadal Survey of Civil Aeronautics, and the Future Aviation Safety Team (FAST) areas of change. Future research direction in the VHM research areas is evidently strong as seen from recent research solicitations from the Naval Air Systems Command (NAVAIR), and VHM-related technologies actively being developed by aviation industry leaders, including GE, Boeing, Airbus, and UTC Aerospace Systems. Given the highly complex VHM systems, modifications can be made in the future so that the Vehicle Systems Safety Technology Project (VSST) technical challenges address inadequate maintenance crew's trainings and skills, and the certification methods of such systems as recommended by the NTSB, NRC, and FAST areas of change.

Mine Improvement and New Emergency Response Act of 2006. Public Law 109-236, S2803

DOE Office of Scientific and Technical Information (OSTI.GOV)

NONE

2006-06-15

This Act may be cited as the 'Mine Improvement and New Emergency Response Act of 2006' or the 'MINER Act'. It amends the Federal Mine Safety and Health Act of 1977 to improve the safety of mines and mining. The Act requires operators of underground coal mines to improve accident preparedness. The legislation requires mining companies to develop an emergency response plan specific to each mine they operate, and requires that every mine has at least two rescue teams located within one hour. S. 2803 also limits the legal liability of rescue team members and the companies that employ them.more » The act increases both civil and criminal penalties for violations of federal mining safety standards and gives the Mine Safety and Health Administration (MSHA) the ability to temporarily close a mine that fails to pay the penalties or fines. In addition, the act calls for several studies into ways to enhance mine safety, as well as the establishment of a new office within the National Institute for Occupational Safety and Health devoted to improving mine safety. Finally, the legislation establishes new scholarship and grant programs devoted to training individuals with respect to mine safety.« less

Transforming communication and safety culture in intrapartum care: a multi-organization blueprint.

PubMed

Lyndon, Audrey; Johnson, M Christina; Bingham, Debra; Napolitano, Peter G; Joseph, Gerald; Maxfield, David G; O'Keeffe, Daniel F

2015-01-01

Effective, patient-centered communication facilitates interception and correction of potentially harmful conditions and errors. All team members, including women, their families, physicians, midwives, nurses, and support staff, have a role in identifying the potential for harm during labor and birth. However, the results of collaborative research studies conducted by organizations that represent professionals who care for women during labor and birth indicate that health care providers may frequently witness, but may not always report, problems with safety or clinical performance. Some of these health care providers felt resigned to the continuation of such problems and fearful of retribution if they tried to address them. Speaking up to address safety and quality concerns is a dynamic social process. Every team member must feel empowered to speak up about concerns without fear of put-downs, retribution, or receiving poor-quality care. Patient safety requires mutual accountability: individuals, teams, health care facilities, and professional associations have a shared responsibility for creating and sustaining environments of mutual respect and engaging in highly reliable perinatal care. Defects in human factors, communication, and leadership have been the leading contributors to sentinel events in perinatal care for more than a decade. Organizational commitment and executive leadership are essential to creating an environment that proactively supports safety and quality. The problem is well-known; the time for action is now. © 2015 by the American College of Obstetricians and Gynecologists.

Transforming communication and safety culture in intrapartum care: a multi-organization blueprint.

PubMed

Lyndon, Audrey; Johnson, M Christina; Bingham, Debra; Napolitano, Peter G; Joseph, Gerald; Maxfield, David G; OʼKeeffe, Daniel F

2015-05-01

Effective, patient-centered communication facilitates interception and correction of potentially harmful conditions and errors. All team members, including women, their families, physicians, midwives, nurses, and support staff, have a role in identifying the potential for harm during labor and birth. However, the results of collaborative research studies conducted by organizations that represent professionals who care for women during labor and birth indicate that health care providers may frequently witness, but may not always report, problems with safety or clinical performance. Some of these health care providers felt resigned to the continuation of such problems and fearful of retribution if they tried to address them. Speaking up to address safety and quality concerns is a dynamic social process. Every team member must feel empowered to speak up about concerns without fear of put-downs, retribution, or receiving poor-quality care. Patient safety requires mutual accountability: individuals, teams, health care facilities, and professional associations have a shared responsibility for creating and sustaining environments of mutual respect and engaging in highly reliable perinatal care. Defects in human factors, communication, and leadership have been the leading contributors to sentinel events in perinatal care for more than a decade. Organizational commitment and executive leadership are essential to creating an environment that proactively supports safety and quality. The problem is well-known; the time for action is now.

Transforming communication and safety culture in intrapartum care: a multi-organization blueprint.

PubMed

Lyndon, Audrey; Johnson, M Christina; Bingham, Debra; Napolitano, Peter G; Joseph, Gerald; Maxfield, David G; O'Keeffe, Daniel F

2015-01-01

Effective, patient-centered communication facilitates interception and correction of potentially harmful conditions and errors. All team members, including women, their families, physicians, midwives, nurses, and support staff, have roles in identifying the potential for harm during labor and birth. However, the results of collaborative research studies conducted by organizations that represent professionals who care for women during labor and birth indicate that health care providers may frequently witness, but may not always report, problems with safety or clinical performance. Some of these health care providers felt resigned to the continuation of such problems and fearful of retribution if they tried to address them. Speaking up to address safety and quality concerns is a dynamic social process. Every team member must feel empowered to speak up about concerns without fear of put-downs, retribution, or receiving poor-quality care. Patient safety requires mutual accountability: individuals, teams, health care facilities, and professional associations have a shared responsibility for creating and sustaining environments of mutual respect and engaging in highly reliable perinatal care. Defects in human factors, communication, and leadership have been the leading contributors to sentinel events in perinatal care for more than a decade. Organizational commitment and executive leadership are essential to creating an environment that proactively supports safety and quality. The problem is well-known; the time for action is now. © 2015 AWHONN, the Association of Women's Health, Obstetric and Neonatal Nurses.

Simulated settings; powerful arenas for learning patient safety practices and facilitating transference to clinical practice. A mixed method study.

PubMed

Reime, Marit Hegg; Johnsgaard, Tone; Kvam, Fred Ivan; Aarflot, Morten; Breivik, Marit; Engeberg, Janecke Merethe; Brattebø, Guttorm

2016-11-01

Poor teamwork is an important factor in the occurrence of critical incidents because of a lack of non-technical skills. Team training can be a key to prevent these incidents. The purpose of this study was to explore the experience of nursing and medical students after a simulation-based interprofessional team training (SBITT) course and its impact on professional and patient safety practices, using a concurrent mixed-method design. The participants (n = 262) were organized into 44 interprofessional teams. The results showed that two training sequences the same day improved overall team performance. Making mistakes during SBITT appeared to improve the quality of patient care once the students returned to clinical practice as it made the students more vigilant. Furthermore, the video-assisted oral debriefing provided an opportunity to strengthen interprofessional teamwork and share situational awareness. SBITT gave the students an opportunity to practice clinical reasoning skills and to share professional knowledge. The students conveyed the importance of learning to speak up to ensure safe patient practices. Simulated settings seem to be powerful arenas for learning patient safety practices and facilitating transference of this awareness to clinical practice. Copyright © 2016 Elsevier Ltd. All rights reserved.

Interdisciplinary Team Huddles for Fetal Heart Rate Tracing Review.

PubMed

Thompson, Lisa; Krening, Cynthia; Parrett, Dolores

2018-06-01

To address an increase in unexpected poor outcomes in term neonates, our team developed a goal of high reliability and improved fetal safety in the culture of the Labor and Delivery nursing department. We implemented interdisciplinary reviews of fetal heart rate, along with a Category II fetal heart rate management algorithm and a fetal heart rate assessment rapid response alert to call for unscheduled reviews when needed. Enhanced communication between nurses and other clinicians supported an interdisciplinary approach to fetal safety, and we observed an improvement in health outcomes for term neonates. We share our experience with the intention of making our methods available to any labor and delivery unit team committed to safe, high-quality care and service excellence. Copyright © 2018 AWHONN. Published by Elsevier Inc. All rights reserved.

Design Development Test and Evaluation (DDT and E) Considerations for Safe and Reliable Human Rated Spacecraft Systems

NASA Technical Reports Server (NTRS)

Miller, James; Leggett, Jay; Kramer-White, Julie

2008-01-01

A team directed by the NASA Engineering and Safety Center (NESC) collected methodologies for how best to develop safe and reliable human rated systems and how to identify the drivers that provide the basis for assessing safety and reliability. The team also identified techniques, methodologies, and best practices to assure that NASA can develop safe and reliable human rated systems. The results are drawn from a wide variety of resources, from experts involved with the space program since its inception to the best-practices espoused in contemporary engineering doctrine. This report focuses on safety and reliability considerations and does not duplicate or update any existing references. Neither does it intend to replace existing standards and policy.

Teams, tribes and patient safety: overcoming barriers to effective teamwork in healthcare.

PubMed

Weller, Jennifer; Boyd, Matt; Cumin, David

2014-03-01

Modern healthcare is delivered by multidisciplinary, distributed healthcare teams who rely on effective teamwork and communication to ensure effective and safe patient care. However, we know that there is an unacceptable rate of unintended patient harm, and much of this is attributed to failures in communication between health professionals. The extensive literature on teams has identified shared mental models, mutual respect and trust and closed-loop communication as the underpinning conditions required for effective teams. However, a number of challenges exist in the healthcare environment. We explore these in a framework of educational, psychological and organisational challenges to the development of effective healthcare teams. Educational interventions can promote a better understanding of the principles of teamwork, help staff understand each other's roles and perspectives, and help develop specific communication strategies, but may not be sufficient on their own. Psychological barriers, such as professional silos and hierarchies, and organisational barriers such as geographically distributed teams, can increase the chance of communication failures with the potential for patient harm. We propose a seven-step plan to overcome the barriers to effective team communication that incorporates education, psychological and organisational strategies. Recent evidence suggests that improvement in teamwork in healthcare can lead to significant gains in patient safety, measured against efficiency of care, complication rate and mortality. Interventions to improve teamwork in healthcare may be the next major advance in patient outcomes.

The complexity of team training: what we have learned from aviation and its applications to medicine

PubMed Central

Hamman, W

2004-01-01

Errors in health care that compromise patient safety are tied to latent failures in the structure and function of systems. Teams of people perform most care delivered today, yet training often remains focused on individual responsibilities. Training programmes for all healthcare workers need to increase the educational experience of working in interdisciplinary teams. The complexities of team training require a multifunctional (systems) approach, which crosses organisational divisions to allow communication, accountability, and creation and maintenance of interdisciplinary teams. This report identifies challenges for medical education in performing the research, identifying performance measurements, and modifying educational curricula for the advancement of interdisciplinary teams, based on the complexity of team training identified in commercial aviation. PMID:15465959

What are the critical success factors for team training in health care?

PubMed

Salas, Eduardo; Almeida, Sandra A; Salisbury, Mary; King, Heidi; Lazzara, Elizabeth H; Lyons, Rebecca; Wilson, Katherine A; Almeida, Paula A; McQuillan, Robert

2009-08-01

Ineffective communication among medical teams is a leading cause of preventable patient harm throughout the health care system. A growing body of literature indicates that medical teamwork improves the quality, safety, and cost-effectiveness of health care delivery, and expectations for teamwork in health care have increased. Yet few health care professions' curricula include teamwork training, and few medical practices integrate teamwork principles. Because of this knowledge gap, growing numbers of health care systems are requiring staff to participate in formal teamwork training programs. Seven evidence-based, practical, systematic success factors for preparing, implementing, and sustaining a team training and performance improvement initiative were identified. Each success factor is accompanied by tips for deployment and a real-world example of application. (1) Align team training objectives and safety aims with organizational goals, (2) provide organizational support for the team training initiative, (3) get frontline care leaders on board, (4) prepare the environment and trainees for team training, (5) determine required resources and time commitment and ensure their availability, (6) facilitate application of trained teamwork skills on the job; and (7) measure the effectiveness of the team training program. Although decades of research in other high-risk organizations have clearly demonstrated that properly designed team training programs can improve team performance, success is highly dependent on organizational factors such as leadership support, learning climate, and commitment to data-driven change. Before engaging in a teamwork training initiative, health care organizations should have a clear understanding of these factors and the strategies for their establishment.

29 CFR 541.203 - Administrative exemption examples.

Code of Federal Regulations, 2014 CFR

2014-07-01

... administrative exemption. (c) An employee who leads a team of other employees assigned to complete major projects... the employee does not have direct supervisory responsibility over the other employees on the team. (d... or safety, building or construction, health or sanitation, environmental or soils specialists and...

29 CFR 541.203 - Administrative exemption examples.

Code of Federal Regulations, 2011 CFR

2011-07-01

... administrative exemption. (c) An employee who leads a team of other employees assigned to complete major projects... the employee does not have direct supervisory responsibility over the other employees on the team. (d... or safety, building or construction, health or sanitation, environmental or soils specialists and...

Aviation Safety Issues Database

NASA Technical Reports Server (NTRS)

Morello, Samuel A.; Ricks, Wendell R.

2009-01-01

The aviation safety issues database was instrumental in the refinement and substantiation of the National Aviation Safety Strategic Plan (NASSP). The issues database is a comprehensive set of issues from an extremely broad base of aviation functions, personnel, and vehicle categories, both nationally and internationally. Several aviation safety stakeholders such as the Commercial Aviation Safety Team (CAST) have already used the database. This broader interest was the genesis to making the database publically accessible and writing this report.

Smartphones let surgeons know WhatsApp: an analysis of communication in emergency surgical teams.

PubMed

Johnston, Maximilian J; King, Dominic; Arora, Sonal; Behar, Nebil; Athanasiou, Thanos; Sevdalis, Nick; Darzi, Ara

2015-01-01

Outdated communication technologies in healthcare can place patient safety at risk. This study aimed to evaluate implementation of the WhatsApp messaging service within emergency surgical teams. A prospective mixed-methods study was conducted in a London hospital. All emergency surgery team members (n = 40) used WhatsApp for communication for 19 weeks. The initiator and receiver of communication were compared for response times and communication types. Safety events were reported using direct quotations. More than 1,100 hours of communication pertaining to 636 patients were recorded, generating 1,495 communication events. The attending initiated the most instruction-giving communication, whereas interns asked the most clinical questions (P < .001). The resident was the speediest responder to communication compared to the intern and attending (P < .001). The participants felt that WhatsApp helped flatten the hierarchy within the team. WhatsApp represents a safe, efficient communication technology. This study lays the foundations for quality improvement innovations delivered over smartphones. Copyright © 2015 Elsevier Inc. All rights reserved.

The health team and the safety of the mother-baby binomial during labor and birth.

PubMed

Dornfeld, Dinara; Rubim Pedro, Eva Neri

2015-01-01

Describe the performance of the health care team regarding the safety of both mother and baby during labor and birth. Qualitative, descriptive, exploratory study. The subjects were: obstetricians, residents in Obstetrics, pediatricians, nurses, and nursing technicians. The observation technique was used for data collection in a public hospital, between March and July 2010. The data was subjected to thematic content analysis. CEP-GHC (No. 10/001). Data analysis revealed the themes: empathic support, woman's companion, skin-to-skin contact (SSC), and birth environment. The team promoted safe care through empathic support for women and appreciation and respect for the escort. In relation to SSC and the enabling environment for the reception of the newborn, efforts are still needed for these practices to be configured in secure care circumstances. The Nurse played a differential role in the team for the realization of safe care, because she was predominant in supporting women and promoting CPP.

Implementation of Recommendations from the One System Comparative Evaluation of the Hanford Tank Farms and Waste Treatment Plant Safety Bases

DOE Office of Scientific and Technical Information (OSTI.GOV)

Garrett, Richard L.; Niemi, Belinda J.; Paik, Ingle K.

2013-11-07

A Comparative Evaluation was conducted for One System Integrated Project Team to compare the safety bases for the Hanford Waste Treatment and Immobilization Plant Project (WTP) and Tank Operations Contract (TOC) (i.e., Tank Farms) by an Expert Review Team. The evaluation had an overarching purpose to facilitate effective integration between WTP and TOC safety bases. It was to provide One System management with an objective evaluation of identified differences in safety basis process requirements, guidance, direction, procedures, and products (including safety controls, key safety basis inputs and assumptions, and consequence calculation methodologies) between WTP and TOC. The evaluation identified 25more » recommendations (Opportunities for Integration). The resolution of these recommendations resulted in 16 implementation plans. The completion of these implementation plans will help ensure consistent safety bases for WTP and TOC along with consistent safety basis processes. procedures, and analyses. and should increase the likelihood of a successful startup of the WTP. This early integration will result in long-term cost savings and significant operational improvements. In addition, the implementation plans lead to the development of eight new safety analysis methodologies that can be used at other U.S. Department of Energy (US DOE) complex sites where URS Corporation is involved.« less

Implementing instructions for KSC systems and safety training

NASA Technical Reports Server (NTRS)

1973-01-01

The requirements for the safety training program are reported for KSC including transportation, inspection, checkout operations, maintenance of launch vehicles, spacecraft, ground support equipment, and launch teams. The responsibilities and mechanics for implementing the program are outlined.

Enhancing team learning in nursing teams through beliefs about interpersonal context.

PubMed

Ortega, Aída; Sánchez-Manzanares, Miriam; Gil, Francisco; Rico, Ramón

2013-01-01

This article is a report of a study that examines the relationship between team-level learning and performance in nursing teams, and the role of beliefs about the interpersonal context in this relationship. Over recent years, there has been an increasing interest in the learning processes of work teams. Researchers have investigated the impact of team learning on team performance, and the enabling conditions for this learning. However, team learning in nursing teams has been largely ignored. A cross-sectional field survey design was used. The sample comprises a total of 468 healthcare professionals working in 89 nursing teams at different public hospitals throughout Spain. Members of nursing teams participated voluntarily by completing a confidential individual questionnaire. Team supervisors evaluated nursing teams' performance. Data were collected over 2007-2008. The results show a mediating effect of team learning on the relationship between beliefs about interpersonal context (psychological safety, perceived task interdependence, and group potency) and team performance. Our findings suggest that beliefs about interpersonal context and team learning are important to effective nursing team performance. © 2012 Blackwell Publishing Ltd.

Effectiveness of the surgical safety checklist in correcting errors: a literature review applying Reason's Swiss cheese model.

PubMed

Collins, Susan J; Newhouse, Robin; Porter, Jody; Talsma, AkkeNeel

2014-07-01

Approximately 2,700 patients are harmed by wrong-site surgery each year. The World Health Organization created the surgical safety checklist to reduce the incidence of wrong-site surgery. A project team conducted a narrative review of the literature to determine the effectiveness of the surgical safety checklist in correcting and preventing errors in the OR. Team members used Swiss cheese model of error by Reason to analyze the findings. Analysis of results indicated the effectiveness of the surgical checklist in reducing the incidence of wrong-site surgeries and other medical errors; however, checklists alone will not prevent all errors. Successful implementation requires perioperative stakeholders to understand the nature of errors, recognize the complex dynamic between systems and individuals, and create a just culture that encourages a shared vision of patient safety. Copyright © 2014 AORN, Inc. Published by Elsevier Inc. All rights reserved.

Implementing a pediatric surgical safety checklist in the OR and beyond.

PubMed

Norton, Elizabeth K; Rangel, Shawn J

2010-07-01

An international study about implementation of the World Health Organization Surgical Safety Checklist showed that use of the checklist reduced complication and death rates in adult surgical patients. Clinicians at Children's Hospital Boston, Massachusetts, modified the Surgical Safety Checklist for pediatric populations. We pilot tested the Pediatric Surgical Safety Checklist and created a large checklist poster for each OR to allow the entire surgical team to view the checklist simultaneously and to promote shared responsibility for conducting the time out. Results of the pilot test showed improvements in teamwork, communication, and adherence to process measures. Parallel efforts were made in other areas of the hospital where invasive procedures are performed. Compliance with the checklist at our facility has been good, and team members have expressed satisfaction with the flow and content of the checklist. Copyright (c) 2010 AORN, Inc. Published by Elsevier Inc. All rights reserved.

Design and evaluation of simulation scenarios for a program introducing patient safety, teamwork, safety leadership, and simulation to healthcare leaders and managers.

PubMed

Cooper, Jeffrey B; Singer, Sara J; Hayes, Jennifer; Sales, Michael; Vogt, Jay W; Raemer, Daniel; Meyer, Gregg S

2011-08-01

We developed a training program to introduce managers and informal leaders of healthcare organizations to key concepts of teamwork, safety leadership, and simulation to motivate them to act as leaders to improve safety within their sphere of influence. This report describes the simulation scenario and debriefing that are core elements of that program. Twelve teams of clinician and nonclinician managers were selected from a larger set of volunteers to participate in a 1-day, multielement training program. Two simulation exercises were developed: one for teams of nonclinicians and the other for clinicians or mixed groups. The scenarios represented two different clinical situations, each designed to engage participants in discussions of their safety leadership and teamwork issues immediately after the experience. In the scenarios for nonclinicians, participants conducted an anesthetic induction and then managed an ethical situation. The scenario for clinicians simulated a consulting visit to an emergency room that evolved into a problem-solving challenge. Participants in this scenario had a limited time to prepare advice for hospital leadership on how to improve observed safety and cultural deficiencies. Debriefings after both types of scenarios were conducted using principles of "debriefing with good judgment." We assessed the relevance and impact of the program by analyzing participant reactions to the simulation through transcript data and facilitator observations as well as a postcourse questionnaire. The teams generally reported positive perceptions of the relevance and quality of the simulation with varying types and degrees of impact on their leadership and teamwork behaviors. These kinds of clinical simulation exercises can be used to teach healthcare leaders and managers safety leadership and teamwork skills and behaviors.

High-reliability emergency response teams in the hospital: improving quality and safety using in situ simulation training.

PubMed

Wheeler, Derek S; Geis, Gary; Mack, Elizabeth H; LeMaster, Tom; Patterson, Mary D

2013-06-01

In situ simulation training is a team-based training technique conducted on actual patient care units using equipment and resources from that unit, and involving actual members of the healthcare team. We describe our experience with in situ simulation training in a major children's medical centre. In situ simulations were conducted using standardised scenarios approximately twice per month on inpatient hospital units on a rotating basis. Simulations were scheduled so that each unit participated in at least two in situ simulations per year. Simulations were conducted on a revolving schedule alternating on the day and night shifts and were unannounced. Scenarios were preselected to maximise the educational experience, and frequently involved clinical deterioration to cardiopulmonary arrest. We performed 64 of the scheduled 112 (57%) in situ simulations on all shifts and all units over 21 months. We identified 134 latent safety threats and knowledge gaps during these in situ simulations, which we categorised as medication, equipment, and/or resource/system threats. Identification of these errors resulted in modification of systems to reduce the risk of error. In situ simulations also provided a method to reinforce teamwork behaviours, such as the use of assertive statements, role clarity, performance of frequent updating, development of a shared mental model, performance of independent double checks of high-risk medicines, and overcoming authority gradients between team members. Participants stated that the training programme was effective and did not disrupt patient care. In situ simulations can identify latent safety threats, identify knowledge gaps, and reinforce teamwork behaviours when used as part of an organisation-wide safety programme.

Making time for learning-oriented leadership in multidisciplinary hospital management groups.

PubMed

Singer, Sara J; Hayes, Jennifer E; Gray, Garry C; Kiang, Mathew V

2015-01-01

Although the clinical requirements of health care delivery imply the need for interdisciplinary management teams to work together to promote frontline learning, such interdisciplinary, learning-oriented leadership is atypical. We designed this study to identify behaviors enabling groups of diverse managers to perform as learning-oriented leadership teams on behalf of quality and safety. We randomly selected 12 of 24 intact groups of hospital managers from one hospital to participate in a Safety Leadership Team Training program. We collected primary data from March 2008 to February 2010 including pre- and post-staff surveys, multiple interviews, observations, and archival data from management groups. We examined the level and trend in frontline perceptions of managers' learning-oriented leadership following the intervention and ability of management groups to achieve objectives on targeted improvement projects. Among the 12 intervention groups, we identified higher- and lower-performing intervention groups and behaviors that enabled higher performers to work together more successfully. Management groups that achieved more of their performance goals and whose staff perceived more and greater improvement in their learning-oriented leadership after participation in Safety Leadership Team Training invested in structures that created learning capacity and conscientiously practiced prescribed learning-oriented management and problem-solving behaviors. They made the time to do these things because they envisioned the benefits of learning, valued the opportunity to learn, and maintained an environment of mutual respect and psychological safety within their group. Learning in management groups requires vision of what learning can accomplish; will to explore, practice, and build learning capacity; and mutual respect that sustains a learning environment.

How 3 rural safety net clinics integrate care for patients: a qualitative case study.

PubMed

Derrett, Sarah; Gunter, Kathryn E; Nocon, Robert S; Quinn, Michael T; Coleman, Katie; Daniel, Donna M; Wagner, Edward H; Chin, Marshall H

2014-11-01

Integrated care focuses on care coordination and patient centeredness. Integrated care supports continuity of care over time, with care that is coordinated within and between settings and is responsive to patients' needs. Currently, little is known about care integration for rural patients. To examine challenges to care integration in rural safety net clinics and strategies to address these challenges. Qualitative case study. Thirty-six providers and staff from 3 rural clinics in the Safety Net Medical Home Initiative. Interviews were analyzed using the framework method with themes organized within 3 constructs: Team Coordination and Empanelment, External Coordination and Partnerships, and Patient-centered and Community-centered Care. Participants described challenges common to safety net clinics, including limited access to specialists for Medicaid and uninsured patients, difficulty communicating with external providers, and payment models with limited support for care integration activities. Rurality compounded these challenges. Respondents reported benefits of empanelment and team-based care, and leveraged local resources to support care for patients. Rural clinics diversified roles within teams, shared responsibility for patient care, and colocated providers, as strategies to support care integration. Care integration was supported by 2 fundamental changes to organize and deliver care to patients-(1) empanelment with a designated group of patients being cared for by a provider; and (2) a multidisciplinary team able to address rural issues. New funding and organizational initiatives of the Affordable Care Act may help to further improve care integration, although additional solutions may be necessary to address particular needs of rural communities.

Review of Issues Associated with Safe Operation and Management of the Space Shuttle Program

NASA Technical Reports Server (NTRS)

Johnstone, Paul M.; Blomberg, Richard D.; Gleghorn, George J.; Krone, Norris J.; Voltz, Richard A.; Dunn, Robert F.; Donlan, Charles J.; Kauderer, Bernard M.; Brill, Yvonne C.; Englar, Kenneth G.;

These College Teams Go Sky-High Competing for a Championship.

ERIC Educational Resources Information Center

Monaghan, Peter

1986-01-01

The National Collegiate Flying Association's annual national competition in flight skills and safety involves competition among flight-trained college students and teams in precision landing with and without engines, cross-country navigation, flight-computer accuracy, message drops, preflight inspection proficiency, and aircraft recognition. (MSE)

Effective communication and teamwork promotes patient safety.

PubMed

Gluyas, Heather

2015-08-05

Teamwork requires co-operation, co-ordination and communication between members of a team to achieve desired outcomes. In industries with a high degree of risk, such as health care, effective teamwork has been shown to achieve team goals successfully and efficiently, with fewer errors. This article introduces behaviours that support communication, co-operation and co-ordination in teams. The central role of communication in enabling co-operation and co-ordination is explored. A human factors perspective is used to examine tools to improve communication and identify barriers to effective team communication in health care.

29 CFR 1910.410 - Qualifications of dive team.

Code of Federal Regulations, 2010 CFR

2010-07-01

... Labor Regulations Relating to Labor (Continued) OCCUPATIONAL SAFETY AND HEALTH ADMINISTRATION, DEPARTMENT OF LABOR OCCUPATIONAL SAFETY AND HEALTH STANDARDS Commercial Diving Operations Personnel... control the exposure of others to hyperbaric conditions shall be trained in diving-related physics and...

Innovative contracting practices for ITS : task E : final report

DOT National Transportation Integrated Search

1999-07-01

The Peer Exchange is a process adopted by the Office of Motor Carrier and Highway Safety in which teams of professionals, representing state and federal government and private industry, identify effective commercial motor vehicle safety findings for ...

Capital Beltway update : Beltway user focus groups

DOT National Transportation Integrated Search

1998-04-01

Author's abstract: The Capital Beltway is 64 miles of roadway surrounding Washington, D.C. The Capital Beltway Safety Team, led by officials from Maryland and Virginia, was formed to address safety issues on this urban interstate highway. This report...

Safety Awareness & Communications Internship

NASA Technical Reports Server (NTRS)

Jefferson, Zanani

2015-01-01

The projects that I have worked on during my internships were updating the JSC Safety & Health Action Team JSAT Employee Guidebook, conducting a JSC mishap case study, preparing for JSC Today Close Call success stories, and assisting with event planning and awareness.

Integrated vehicle-based safety systems : first annual report

DOT National Transportation Integrated Search

2007-10-01

The IVBSS (Integrated Vehicle-Based Safety Systems) program is a four-year, two phase cooperative research program being conducted by an industry team led by the University of Michigan Transportation Research Institute (UMTRI). The program began in N...

Update from C3RS lessons learned team : safety culture and trend analysis.

DOT National Transportation Integrated Search

2014-07-01

The Federal Railroad Administration (FRA) believes that, in addition to process and technology innovations, human-factors-based solutions can significantly contribute to improving safety in the railroad industry. To test this assumption, FRA implemen...

Integrated Safety Analysis Teams

NASA Technical Reports Server (NTRS)

Wetherholt, Jonathan C.

2008-01-01

Today's complex systems require understanding beyond one person s capability to comprehend. Each system requires a team to divide the system into understandable subsystems which can then be analyzed with an Integrated Hazard Analysis. The team must have both specific experiences and diversity of experience. Safety experience and system understanding are not always manifested in one individual. Group dynamics make the difference between success and failure as well as the difference between a difficult task and a rewarding experience. There are examples in the news which demonstrate the need to connect the pieces of a system into a complete picture. The Columbia disaster is now a standard example of a low consequence hazard in one part of the system; the External Tank is a catastrophic hazard cause for a companion subsystem, the Space Shuttle Orbiter. The interaction between the hardware, the manufacturing process, the handling, and the operations contributed to the problem. Each of these had analysis performed, but who constituted the team which integrated this analysis together? This paper will explore some of the methods used for dividing up a complex system; and how one integration team has analyzed the parts. How this analysis has been documented in one particular launch space vehicle case will also be discussed.

Collective leadership and safety cultures (Co-Lead): protocol for a mixed-methods pilot evaluation of the impact of a co-designed collective leadership intervention on team performance and safety culture in a hospital group in Ireland.

PubMed

McAuliffe, Eilish; De Brún, Aoife; Ward, Marie; O'Shea, Marie; Cunningham, Una; O'Donovan, Róisín; McGinley, Sinead; Fitzsimons, John; Corrigan, Siobhán; McDonald, Nick

2017-11-03

There is accumulating evidence implicating the role of leadership in system failures that have resulted in a range of errors in healthcare, from misdiagnoses to failures to recognise and respond to patient deterioration. This has led to concerns about traditional hierarchical leadership structures and created an interest in the development of collective ways of working that distribute leadership roles and responsibilities across team members. Such collective leadership approaches have been associated with improved team performance and staff engagement. This research seeks to improve our understanding of collective leadership by addressing two specific issues: (1) Does collective leadership emerge organically (and in what forms) in a newly networked structure? and (2) Is it possible to design and implement collective leadership interventions that enable teams to collectively improve team performance and patient safety? The first phase will include a social network analysis, using an online survey and semistructured interviews at three time points over 12 months, to document the frequency of contact and collaboration between senior hospital management staff in a recently configured hospital group. This study will explore how the network of 11 hospitals is operating and will assess whether collective leadership emerges organically. Second, collective leadership interventions will be co-designed during a series of workshops with healthcare staff, researchers and patient representatives, and then implemented and evaluated with four healthcare teams within the hospital network. A mixed-methods evaluation will explore the impact of the intervention on team effectiveness and team performance indicators to assess whether the intervention is suitable for wider roll-out and evaluation across the hospital group. Favourable ethical opinion has been received from the University College Dublin Research Ethics Committee (HREC-LS-16-116397/LS-16-20). Results will be disseminated via publication in peer-reviewed journals, national and international conferences, and to relevant stakeholders and interest groups. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Does team training work? Principles for health care.

PubMed

Salas, Eduardo; DiazGranados, Deborah; Weaver, Sallie J; King, Heidi

2008-11-01

Teamwork is integral to a working environment conducive to patient safety and care. Team training is one methodology designed to equip team members with the competencies necessary for optimizing teamwork. There is evidence of team training's effectiveness in highly complex and dynamic work environments, such as aviation and health care. However, most quantitative evaluations of training do not offer any insight into the actual reasons why, how, and when team training is effective. To address this gap in understanding, and to provide guidance for members of the health care community interested in implementing team training programs, this article presents both quantitative results and a specific qualitative review and content analysis of team training implemented in health care. Based on this review, we offer eight evidence-based principles for effective planning, implementation, and evaluation of team training programs specific to health care.

We Are Going to Name Names and Call You Out! Improving the Team in the Academic Operating Room Environment.

PubMed

Bodor, Richard; Nguyen, Brian J; Broder, Kevin

2017-05-01

Communication failures between multidisciplinary teams can impact efficiency, performance, and morale. Academic operating rooms (ORs) often have surgical, anesthesia, and nursing teams, each teaching multiple trainees. Incorrectly identifying name and "rank" (postgraduate year [PGY]) of resident trainees can disrupt performance evaluations and team morale and even potentially impair delivery of quality care when miscommunication errors proliferate. Our OR-based survey asked 50 participants (18 surgeons, 14 anesthesiologists, and 18 nursing members), to recall basic identification data including provider names and PGY levels from their recent collaborating OR teams. Participants also weighed in on the importance of using accurate "names and ranks" for all OR participants. Each service reliably knew their own team members' names and rank. However, surgery and anesthesia teams displayed decreased knowledge about their lower level trainees, whereas nursing teams performed best, identifying all level nurses present. Deficits occurred whenever participants tried recalling basic identifying data about contributors from any other collaborating team. Typically, misidentified participants were lower level PGY residents working on other teams' services. All survey respondents desired improving systems to better remember "names and ranks" identifications among OR participants, citing both safety and team morale benefits. Many fail to know the names and ranks of contributors among members of different OR teams. Even our most reliable nursing team was inconsistent at identification information from collaborating practitioners. Despite universally acknowledged benefits, participants rarely learned basic background identification data beyond their own team. Those surveyed all desired improving identifications with suggestions including sterile name and rank tags and proper notification of entry and exit from the OR. Because successful collaborations require appropriate level task delegations, participants believed knowing a resident's name and rank is important not only for team bonding but also for safety. Academia furthermore demands fair performance evaluations, and displaying them clearly improves recall. Refining our own identified gaps in OR communications may demonstrate improved teamwork and safer task delegations and perhaps even stimulate other performance benefits for academic ORs.

Fundamentals of quality and safety in diagnostic radiology.

PubMed

Bruno, Michael A; Nagy, Paul

2014-12-01

The most fundamental aspects of quality and safety in radiology are reviewed, including a brief history of the quality and safety movement as applied to radiology, the overarching considerations of organizational culture, team building, choosing appropriate goals and metrics, and the radiologist's quality "tool kit." Copyright © 2014 American College of Radiology. Published by Elsevier Inc. All rights reserved.

Improving Student Concern for Safety in a Production Technology Lab through the Use of Teambuilding.

ERIC Educational Resources Information Center

Lacina, Dale Robert

The effectiveness of team building as a strategy for improving students' concern for safety in a production technology laboratory was examined in a study involving a group of grade 9 and 10 production technology students from an urban, lower-middle-class community in western Illinois. Students' safety test scores, teacher checklists, and…

Using Co-Design to Develop a Collective Leadership Intervention for Healthcare Teams to Improve Safety Culture.

PubMed

Ward, Marie E; De Brún, Aoife; Beirne, Deirdre; Conway, Clare; Cunningham, Una; English, Alan; Fitzsimons, John; Furlong, Eileen; Kane, Yvonne; Kelly, Alan; McDonnell, Sinéad; McGinley, Sinead; Monaghan, Brenda; Myler, Ann; Nolan, Emer; O'Donovan, Róisín; O'Shea, Marie; Shuhaiber, Arwa; McAuliffe, Eilish

2018-06-05

While co-design methods are becoming more popular in healthcare; there is a gap within the peer-reviewed literature on how to do co-design in practice. This paper addresses this gap by delineating the approach taken in the co-design of a collective leadership intervention to improve healthcare team performance and patient safety culture. Over the course of six workshops healthcare staff, patient representatives and advocates, and health systems researchers collaboratively co-designed the intervention. The inputs to the process, exercises and activities that took place during the workshops and the outputs of the workshops are described. The co-design method, while challenging at times, had many benefits including grounding the intervention in the real-world experiences of healthcare teams. Implications of the method for health systems research are discussed.

Report of the Shuttle Processing Review Team

NASA Technical Reports Server (NTRS)

1993-01-01

The intent of this report is to summarize the assessment of the shuttle processing operations at the Kennedy Space Center (KSC) as requested by the NASA Administrator. He requested a team reaffirmation that safety is the number one priority and review operations to ensure confidence in the shuttle processing procedures at KSC.

Creating a Campus Based Community Emergency Response Team (CERT)

ERIC Educational Resources Information Center

Connolly, Maureen

2012-01-01

This article provides the reader with information regarding forming a community emergency response team (CERT) at a community college. College public safety departments are efficient entities in ordinary times. However, recent events at community colleges across the country have shown that there have been situations where their capabilities have…

15 CFR 270.205 - Reports.

Code of Federal Regulations, 2013 CFR

2013-01-01

... 15 Commerce and Foreign Trade 1 2013-01-01 2013-01-01 false Reports. 270.205 Section 270.205... SAFETY TEAMS Investigations § 270.205 Reports. (a) Not later than 90 days after completing an investigation, a Team shall issue a public report which includes: (1) An analysis of the likely technical cause...

15 CFR 270.205 - Reports.

Code of Federal Regulations, 2014 CFR

2014-01-01

... 15 Commerce and Foreign Trade 1 2014-01-01 2014-01-01 false Reports. 270.205 Section 270.205... SAFETY TEAMS Investigations § 270.205 Reports. (a) Not later than 90 days after completing an investigation, a Team shall issue a public report which includes: (1) An analysis of the likely technical cause...

15 CFR 270.205 - Reports.

Code of Federal Regulations, 2011 CFR

2011-01-01

... 15 Commerce and Foreign Trade 1 2011-01-01 2011-01-01 false Reports. 270.205 Section 270.205... SAFETY TEAMS Investigations § 270.205 Reports. (a) Not later than 90 days after completing an investigation, a Team shall issue a public report which includes: (1) An analysis of the likely technical cause...

30 CFR 49.5 - Mine rescue station.

Code of Federal Regulations, 2012 CFR

2012-07-01

... 30 Mineral Resources 1 2012-07-01 2012-07-01 false Mine rescue station. 49.5 Section 49.5 Mineral Resources MINE SAFETY AND HEALTH ADMINISTRATION, DEPARTMENT OF LABOR EDUCATION AND TRAINING MINE RESCUE TEAMS Mine Rescue Teams for Underground Metal and Nonmetal Mines § 49.5 Mine rescue station. (a) Except...

30 CFR 49.15 - Mine rescue station.

Code of Federal Regulations, 2013 CFR

2013-07-01

... 30 Mineral Resources 1 2013-07-01 2013-07-01 false Mine rescue station. 49.15 Section 49.15 Mineral Resources MINE SAFETY AND HEALTH ADMINISTRATION, DEPARTMENT OF LABOR EDUCATION AND TRAINING MINE RESCUE TEAMS Mine Rescue Teams for Underground Coal Mines § 49.15 Mine rescue station. (a) Every operator...

30 CFR 49.15 - Mine rescue station.

Code of Federal Regulations, 2011 CFR

2011-07-01

... 30 Mineral Resources 1 2011-07-01 2011-07-01 false Mine rescue station. 49.15 Section 49.15 Mineral Resources MINE SAFETY AND HEALTH ADMINISTRATION, DEPARTMENT OF LABOR EDUCATION AND TRAINING MINE RESCUE TEAMS Mine Rescue Teams for Underground Coal Mines § 49.15 Mine rescue station. (a) Every operator...

30 CFR 49.4 - Alternative mine rescue capability for special mining conditions.

Code of Federal Regulations, 2014 CFR

2014-07-01

... 30 Mineral Resources 1 2014-07-01 2014-07-01 false Alternative mine rescue capability for special mining conditions. 49.4 Section 49.4 Mineral Resources MINE SAFETY AND HEALTH ADMINISTRATION, DEPARTMENT OF LABOR EDUCATION AND TRAINING MINE RESCUE TEAMS Mine Rescue Teams for Underground Metal and...

30 CFR 49.5 - Mine rescue station.

Code of Federal Regulations, 2013 CFR

2013-07-01

... 30 Mineral Resources 1 2013-07-01 2013-07-01 false Mine rescue station. 49.5 Section 49.5 Mineral Resources MINE SAFETY AND HEALTH ADMINISTRATION, DEPARTMENT OF LABOR EDUCATION AND TRAINING MINE RESCUE TEAMS Mine Rescue Teams for Underground Metal and Nonmetal Mines § 49.5 Mine rescue station. (a) Except...

30 CFR 49.1 - Purpose and scope.

Code of Federal Regulations, 2014 CFR

2014-07-01

... 30 Mineral Resources 1 2014-07-01 2014-07-01 false Purpose and scope. 49.1 Section 49.1 Mineral Resources MINE SAFETY AND HEALTH ADMINISTRATION, DEPARTMENT OF LABOR EDUCATION AND TRAINING MINE RESCUE TEAMS Mine Rescue Teams for Underground Metal and Nonmetal Mines § 49.1 Purpose and scope. This part...

30 CFR 49.15 - Mine rescue station.

Code of Federal Regulations, 2012 CFR

2012-07-01

... 30 Mineral Resources 1 2012-07-01 2012-07-01 false Mine rescue station. 49.15 Section 49.15 Mineral Resources MINE SAFETY AND HEALTH ADMINISTRATION, DEPARTMENT OF LABOR EDUCATION AND TRAINING MINE RESCUE TEAMS Mine Rescue Teams for Underground Coal Mines § 49.15 Mine rescue station. (a) Every operator...

30 CFR 49.5 - Mine rescue station.

Code of Federal Regulations, 2014 CFR

2014-07-01

... 30 Mineral Resources 1 2014-07-01 2014-07-01 false Mine rescue station. 49.5 Section 49.5 Mineral Resources MINE SAFETY AND HEALTH ADMINISTRATION, DEPARTMENT OF LABOR EDUCATION AND TRAINING MINE RESCUE TEAMS Mine Rescue Teams for Underground Metal and Nonmetal Mines § 49.5 Mine rescue station. (a) Except...

30 CFR 49.15 - Mine rescue station.

Code of Federal Regulations, 2014 CFR

2014-07-01

... 30 Mineral Resources 1 2014-07-01 2014-07-01 false Mine rescue station. 49.15 Section 49.15 Mineral Resources MINE SAFETY AND HEALTH ADMINISTRATION, DEPARTMENT OF LABOR EDUCATION AND TRAINING MINE RESCUE TEAMS Mine Rescue Teams for Underground Coal Mines § 49.15 Mine rescue station. (a) Every operator...

30 CFR 49.4 - Alternative mine rescue capability for special mining conditions.

Code of Federal Regulations, 2012 CFR

2012-07-01

... 30 Mineral Resources 1 2012-07-01 2012-07-01 false Alternative mine rescue capability for special mining conditions. 49.4 Section 49.4 Mineral Resources MINE SAFETY AND HEALTH ADMINISTRATION, DEPARTMENT OF LABOR EDUCATION AND TRAINING MINE RESCUE TEAMS Mine Rescue Teams for Underground Metal and...

30 CFR 49.4 - Alternative mine rescue capability for special mining conditions.

Code of Federal Regulations, 2013 CFR

2013-07-01

... 30 Mineral Resources 1 2013-07-01 2013-07-01 false Alternative mine rescue capability for special mining conditions. 49.4 Section 49.4 Mineral Resources MINE SAFETY AND HEALTH ADMINISTRATION, DEPARTMENT OF LABOR EDUCATION AND TRAINING MINE RESCUE TEAMS Mine Rescue Teams for Underground Metal and...

30 CFR 49.1 - Purpose and scope.

Code of Federal Regulations, 2012 CFR

2012-07-01

... 30 Mineral Resources 1 2012-07-01 2012-07-01 false Purpose and scope. 49.1 Section 49.1 Mineral Resources MINE SAFETY AND HEALTH ADMINISTRATION, DEPARTMENT OF LABOR EDUCATION AND TRAINING MINE RESCUE TEAMS Mine Rescue Teams for Underground Metal and Nonmetal Mines § 49.1 Purpose and scope. This part...

30 CFR 49.15 - Mine rescue station.

Code of Federal Regulations, 2010 CFR

2010-07-01

... 30 Mineral Resources 1 2010-07-01 2010-07-01 false Mine rescue station. 49.15 Section 49.15 Mineral Resources MINE SAFETY AND HEALTH ADMINISTRATION, DEPARTMENT OF LABOR EDUCATION AND TRAINING MINE RESCUE TEAMS Mine Rescue Teams for Underground Coal Mines § 49.15 Mine rescue station. (a) Every operator...

30 CFR 49.1 - Purpose and scope.

Code of Federal Regulations, 2013 CFR

2013-07-01

... 30 Mineral Resources 1 2013-07-01 2013-07-01 false Purpose and scope. 49.1 Section 49.1 Mineral Resources MINE SAFETY AND HEALTH ADMINISTRATION, DEPARTMENT OF LABOR EDUCATION AND TRAINING MINE RESCUE TEAMS Mine Rescue Teams for Underground Metal and Nonmetal Mines § 49.1 Purpose and scope. This part...

FHWA Study Tour for Pedestrian and Bicyclist Safety in England, Germany, and The Netherlands

DOT National Transportation Integrated Search

1994-10-01

This report documents the findings of a U.S. study team that visited England, The Netherlands, and Germany. The trip sponsored by the Federal Highway Administration was taken September 3-19, 1993. Members of the study team also spent one day in Basel...

Probing Aircraft Flight Test Hazard Mitigation for the Alternative Fuel Effects on Contrails and Cruise Emissions (ACCESS) Research Team . Volume 2; Appendices

NASA Technical Reports Server (NTRS)

Kelly, Michael J.

2013-01-01

The Alternative Fuel Effects on Contrails and Cruise Emissions (ACCESS) Project Integration Manager requested in July 2012 that the NASA Engineering and Safety Center (NESC) form a team to independently assess aircraft structural failure hazards associated with the ACCESS experiment and to identify potential flight test hazard mitigations to ensure flight safety. The ACCESS Project Integration Manager subsequently requested that the assessment scope be focused predominantly on structural failure risks to the aircraft empennage (horizontal and vertical tail). This report contains the Appendices to Volume I.

Collective autonomy and absenteeism within work teams: a team motivation approach.

PubMed

Rousseau, Vincent; Aubé, Caroline

2013-01-01

This study investigates the role of collective autonomy in regard to team absenteeism by considering team potency as a motivational mediator and task routineness as a moderator. The sample consists of 90 work teams (327 members and 90 immediate superiors) drawn from a public safety organization. Results of structural equation modeling indicate that the relationships between collective autonomy and two indicators of team absenteeism (i.e., absence frequency and time lost) are mediated by team potency. Specifically, collective autonomy is positively related to team potency which in turn is negatively related to team absenteeism. Furthermore, results of hierarchical regression analyses show that task routineness moderates the relationships between collective autonomy and the two indicators of team absenteeism such that these relationships are stronger when the level of task routineness is low. On the whole, this study points out that collective autonomy may exercise a motivational effect on attendance at work within teams, but this effect is contingent on task routineness.

A practical guide to failure mode and effects analysis in health care: making the most of the team and its meetings.

PubMed

Ashley, Laura; Armitage, Gerry; Neary, Maria; Hollingsworth, Gillian

2010-08-01

Failure Mode and Effects Analysis (FMEA) is a proactive risk assessment tool used to identify potential vulnerabilities in complex, high-risk processes and to generate remedial actions before the processes result in adverse events. FMEA is increasingly used to proactively assess and improve the safety of complex health care processes such as drug administration and blood transfusion. A central feature of FMEA is that it is undertaken by a multidisciplinary team, and because it entails numerous analytical steps, it takes a series of several meetings. Composing a team of busy health care professionals with the appropriate knowledge, skill mix, and logistical availability for regular meetings is, however, a serious challenge. Despite this, information and advice on FMEA team assembly and meetings scheduling are scarce and diffuse and often presented without the accompanying rationale. Assemble an eight-member team composed of clinically active health care staff, from every profession involved in delivery of the process-and who regularly perform it; staff from a range of seniority levels; outsider(s) to the process-and perhaps even to health care; a leader (and facilitator); and researchers. Plan for 10-15 hours of team meeting time for first-time, narrowly defined FMEAs, scheduled as four to six meetings lasting 2 to 3 hours each, spaced weekly to biweekly. Meet in a venue that seats the team around one table and is off the hospital floor but within its grounds. FMEA, generally acknowledged to be a useful addition to the patient safety toolkit, is a meticulous and time- and resource-intensive methodology, and its successful completion is highly dependent on the team members' aptitude and on the facility's and team members' commitment to hold regular, productive meetings.

Reflexive journaling on emotional research topics: ethical issues for team researchers.

PubMed

Malacrida, Claudia

2007-12-01

Traditional epistemological concerns in qualitative research focus on the effects of researchers' values and emotions on choices of research topics, power relations with research participants, and the influence of researcher standpoints on data collection and analysis. However, the research process also affects the researchers' values, emotions, and standpoints. Drawing on reflexive journal entries of assistant researchers involved in emotionally demanding team research, this article explores issues of emotional fallout for research team members, the implications of hierarchical power imbalances on research teams, and the importance of providing ethical opportunities for reflexive writing about the challenges of doing emotional research. Such reflexive approaches ensure the emotional safety of research team members and foster opportunities for emancipatory consciousness among research team members.

The Development of Project Orion Ground Safety Requirements

NASA Technical Reports Server (NTRS)

Kirkpatrick, Paul; Condzella, Bill; Williams, Jeff

2011-01-01

In spite of a very compressed schedule, Project Orion's AFT safety team was able to pull together a comprehensive set of ground safety requirements using existing requirements and subject matter experts. These requirements will serve as the basis for the design of GSE and ground operations. Using the above lessons as a roadmap, new Projects can produce the same results. A rigorous set of ground safety requirements is required to assure ground support equipment (GSE) and associated flight hardware ground operations are conducted safety

The Impact of System Factors on Quality and Safety in Arterial Surgery: A Systematic Review.

PubMed

Lear, R; Godfrey, A D; Riga, C; Norton, C; Vincent, C; Bicknell, C D

2017-07-01

A systems approach to patient safety proposes that a wide range of factors contribute to surgical outcome, yet the impact of team, work environment, and organisational factors, is not fully understood in arterial surgery. The aim of this systematic review is to summarize and discuss what is already known about the impact of system factors on quality and safety in arterial surgery. A systematic review of original research papers in English using MEDLINE, Embase, PsycINFO, and Cochrane databases, was performed according to PRISMA guidelines. Independent reviewers selected papers according to strict inclusion and exclusion criteria, and using predefined data fields, extracted relevant data on team, work environment, and organisational factors, and measures of quality and/or safety, in arterial procedures. Twelve papers met the selection criteria. Study endpoints were not consistent between papers, and most failed to report their clinical significance. A variety of tools were used to measure team skills in five papers; only one paper measured the relationship between team factors and patient outcomes. Two papers reported that equipment failures were common and had a significant impact on operating room efficiency. The influence of hospital characteristics on failure-to-rescue rates was tested in one large study, although their conclusions were limited to the American Medicare population. Five papers implemented changes in the patient pathway, but most studies failed to account for potential confounding variables. A small number of heterogenous studies have evaluated the relationship between system factors and quality or safety in arterial surgery. There is some evidence of an association between system factors and patient outcomes, but there is more work to be done to fully understand this relationship. Future research would benefit from consistency in definitions, the use of validated assessment tools, measurement of clinically relevant endpoints, and adherence to national reporting guidelines. Crown Copyright © 2017. Published by Elsevier Ltd. All rights reserved.

Recommendations for safety planning, data collection, evaluation and reporting during drug, biologic and vaccine development: a report of the safety planning, evaluation, and reporting team.

PubMed

Crowe, Brenda J; Xia, H Amy; Berlin, Jesse A; Watson, Douglas J; Shi, Hongliang; Lin, Stephen L; Kuebler, Juergen; Schriver, Robert C; Santanello, Nancy C; Rochester, George; Porter, Jane B; Oster, Manfred; Mehrotra, Devan V; Li, Zhengqing; King, Eileen C; Harpur, Ernest S; Hall, David B

2009-10-01

The Safety Planning, Evaluation and Reporting Team (SPERT) was formed in 2006 by the Pharmaceutical Research and Manufacturers of America. SPERT's goal was to propose a pharmaceutical industry standard for safety planning, data collection, evaluation, and reporting, beginning with planning first-in-human studies and continuing through the planning of the post-product-approval period. SPERT's recommendations are based on our review of relevant literature and on consensus reached in our discussions. An important recommendation is that sponsors create a Program Safety Analysis Plan early in development. We also give recommendations for the planning of repeated, cumulative meta-analyses of the safety data obtained from the studies conducted within the development program. These include clear definitions of adverse events of special interest and standardization of many aspects of data collection and study design. We describe a 3-tier system for signal detection and analysis of adverse events and highlight proposals for reducing "false positive" safety findings. We recommend that sponsors review the aggregated safety data on a regular and ongoing basis throughout the development program, rather than waiting until the time of submission. We recognize that there may be other valid approaches. The proactive approach we advocate has the potential to benefit patients and health care providers by providing more comprehensive safety information at the time of new product marketing and beyond.

Applying Failure Modes, Effects, And Criticality Analysis And Human Reliability Analysis Techniques To Improve Safety Design Of Work Process In Singapore Armed Forces

DTIC Science & Technology

2016-09-01

an instituted safety program that utilizes a generic risk assessment method involving the 5-M (Mission, Man, Machine , Medium and Management) factor...the Safety core value is hinged upon three key principles—(1) each soldier has a crucial part to play, by adopting safety as a core value and making...it a way of life in his unit; (2) safety is an integral part of training, operations and mission success, and (3) safety is an individual, team and

Behavior based safety. A different way of looking at an old problem.

PubMed

Haney, L; Anderson, M

1999-09-01

1. The occupational and environmental health nurse role in behavioral safety initiatives can very to include: serving as a leader, change agent, collaborator with safety professionals, consultant, team participant, educator, coach, and supporter to employees and management. 2. Behavior based safety and health initiatives add to existing knowledge and techniques for improving the health and safety of workers. 3. Behavior based safety relies on employee involvement and places a strong emphasis on observation, measurement, feedback, positive reinforcement, and evaluation. It focuses on identification of system improvements and prevention.

White Paper on Factors of Safety

NASA Technical Reports Server (NTRS)

Raju, Ivatury; Stadler, John; Kramer-White, Jule; Piascik, Robert

2012-01-01

Following the Columbia Accident Investigation Board (CAIB) Report, the "Diaz Team" identified CAIB Report elements with Agency-wide applicability. The "Diaz Report", A Renewed Commitment To Excellence, generated an action to "Review current policies and waivers on safety factors". This document addresses this action.

Safety and operations of hydrogen fuel infrastructure in northern climates : a collaborative complex systems approach.

DOT National Transportation Integrated Search

2010-10-07

"This project examined the safety and operation of hydrogen (H2) fueling system infrastructure in : northern climates. A multidisciplinary team lead by the University of Vermont (UVM), : combined with investigators from Zhejiang and Tsinghua Universi...

Hazardous material transportation safety and security field operational test final evaluation plan : executive summary

DOT National Transportation Integrated Search

2003-03-17

The purpose of this effort is to independently evaluate the Battelle Operational Test Team to test methods for leveraging technology and operations to improve HAZMAT transport security, safety, and operational efficiency. As such, the preceding techn...

A systems engineering initiative for NASA's space communications

NASA Technical Reports Server (NTRS)

Hornstein, Rhoda S.; Hei, Donald J., Jr.; Kelly, Angelita C.; Lightfoot, Patricia C.; Bell, Holland T.; Cureton-Snead, Izeller E.; Hurd, William J.; Scales, Charles H.

1993-01-01

In addition to but separate from the Red and Blue Teams commissioned by the NASA Administrator, NASA's Associate Administrator for Space Communications commissioned a Blue Team to review the Office of Space Communications (Code O) Core Program and determine how the program could be conducted faster, better, and cheaper, without compromising safety. Since there was no corresponding Red Team for the Code O Blue Team, the Blue Team assumed a Red Team independent attitude and challenged the status quo. The Blue Team process and results are summarized. The Associate Administrator for Space Communications subsequently convened a special management session to discuss the significance and implications of the Blue Team's report and to lay the groundwork and teamwork for the next steps, including the transition from engineering systems to systems engineering. The methodology and progress toward realizing the Code O Family vision and accomplishing the systems engineering initiative for NASA's space communications are presented.

Softball Games Bring NCI and Leidos Biomed Employees Together | Poster

Cancer.gov

NCI and Leidos Biomed employees took to the fields at Nallin Pond for the third annual slow-pitch softball games on August 26. The series attracted 54 employees who were divided into four teams, Red, Blue, Gray, and White, and they were cheered on by about 40 enthusiastic spectators. In the first set of games, the Gray team defeated the Blue team, 15–8, and the White team pulled out a win against the Red team, 17–15. After a brief rest, the two winning teams and the two losing teams faced each other in a second set of games. On Field 1, the “winners” match-up of the Gray and White teams was a nail biter, with a close score throughout the game. Daylight was a factor, however, and the team captains decided to call the game for safety reasons. With a lead of 15 to 13, the Gray team was declared the overall winner.

Interdisciplinary collaboration to maintain a culture of safety in a labor and delivery setting.

PubMed

Burke, Carol; Grobman, William; Miller, Deborah

2013-01-01

A culture of safety is a growing movement in obstetrical healthcare quality and management. Patient-centered and safe care is a primary priority for all healthcare workers, with communication and teamwork central to achieving optimal maternal health outcomes. A mandatory educational program was developed and implemented by physicians and nurses to sustain awareness and compliance to current protocols within a large university-based hospital. A didactic portion reviewing shoulder dystocia, operative vaginal delivery, obstetric hemorrhage, and fetal monitoring escalation was combined with a simulation session. The simulation was a fetal bradycardia activating the decision to perform an operative vaginal delivery complicated by a shoulder dystocia. More than 370 members of the healthcare team participated including obstetricians, midwives, the anesthesia team, and nurses. Success of the program was measured by an evaluation tool and comparing results from a prior safety questionnaire. Ninety-seven percent rated the program as excellent, and the response to a question on perception of overall grade on patient safety measured by the Agency for Healthcare Research and Quality safety survey demonstrated a significant improvement in the score (P = .003) following the program.

Matrix Game Methodology - Support to V2010 Olympic Marine Security Planners

DTIC Science & Technology

2011-02-01

OMOC was called the Integrated Safety /Security Matrix Game – Marine III, and was held 16-17 June 2009. This was the most extensive and complex of...Protection Matrix Game Marine Two .................................................. 12 3.3 Integrated Safety /Security Matrix Game – Marine III...Integrated Safety /Security Matrix Game – Marine III Scenarios........................... 53 ISSMG Marine III – Team Groupings

30 CFR 49.40 - Requirements for large coal mines.

Code of Federal Regulations, 2011 CFR

2011-07-01

... 30 Mineral Resources 1 2011-07-01 2011-07-01 false Requirements for large coal mines. 49.40 Section 49.40 Mineral Resources MINE SAFETY AND HEALTH ADMINISTRATION, DEPARTMENT OF LABOR EDUCATION AND TRAINING MINE RESCUE TEAMS Mine Rescue Teams for Underground Coal Mines § 49.40 Requirements for large coal...

30 CFR 49.40 - Requirements for large coal mines.

Code of Federal Regulations, 2012 CFR

2012-07-01

... 30 Mineral Resources 1 2012-07-01 2012-07-01 false Requirements for large coal mines. 49.40 Section 49.40 Mineral Resources MINE SAFETY AND HEALTH ADMINISTRATION, DEPARTMENT OF LABOR EDUCATION AND TRAINING MINE RESCUE TEAMS Mine Rescue Teams for Underground Coal Mines § 49.40 Requirements for large coal...

30 CFR 49.30 - Requirements for small coal mines.

Code of Federal Regulations, 2012 CFR

2012-07-01

... 30 Mineral Resources 1 2012-07-01 2012-07-01 false Requirements for small coal mines. 49.30 Section 49.30 Mineral Resources MINE SAFETY AND HEALTH ADMINISTRATION, DEPARTMENT OF LABOR EDUCATION AND TRAINING MINE RESCUE TEAMS Mine Rescue Teams for Underground Coal Mines § 49.30 Requirements for small coal...

30 CFR 49.40 - Requirements for large coal mines.

Code of Federal Regulations, 2013 CFR

2013-07-01

... 30 Mineral Resources 1 2013-07-01 2013-07-01 false Requirements for large coal mines. 49.40 Section 49.40 Mineral Resources MINE SAFETY AND HEALTH ADMINISTRATION, DEPARTMENT OF LABOR EDUCATION AND TRAINING MINE RESCUE TEAMS Mine Rescue Teams for Underground Coal Mines § 49.40 Requirements for large coal...

30 CFR 49.30 - Requirements for small coal mines.

Code of Federal Regulations, 2013 CFR

2013-07-01

... 30 Mineral Resources 1 2013-07-01 2013-07-01 false Requirements for small coal mines. 49.30 Section 49.30 Mineral Resources MINE SAFETY AND HEALTH ADMINISTRATION, DEPARTMENT OF LABOR EDUCATION AND TRAINING MINE RESCUE TEAMS Mine Rescue Teams for Underground Coal Mines § 49.30 Requirements for small coal...

30 CFR 49.40 - Requirements for large coal mines.

Code of Federal Regulations, 2010 CFR

2010-07-01

... 30 Mineral Resources 1 2010-07-01 2010-07-01 false Requirements for large coal mines. 49.40 Section 49.40 Mineral Resources MINE SAFETY AND HEALTH ADMINISTRATION, DEPARTMENT OF LABOR EDUCATION AND TRAINING MINE RESCUE TEAMS Mine Rescue Teams for Underground Coal Mines § 49.40 Requirements for large coal...

30 CFR 49.40 - Requirements for large coal mines.

Code of Federal Regulations, 2014 CFR

2014-07-01

... 30 Mineral Resources 1 2014-07-01 2014-07-01 false Requirements for large coal mines. 49.40 Section 49.40 Mineral Resources MINE SAFETY AND HEALTH ADMINISTRATION, DEPARTMENT OF LABOR EDUCATION AND TRAINING MINE RESCUE TEAMS Mine Rescue Teams for Underground Coal Mines § 49.40 Requirements for large coal...

30 CFR 49.30 - Requirements for small coal mines.

Code of Federal Regulations, 2010 CFR

2010-07-01

... 30 Mineral Resources 1 2010-07-01 2010-07-01 false Requirements for small coal mines. 49.30 Section 49.30 Mineral Resources MINE SAFETY AND HEALTH ADMINISTRATION, DEPARTMENT OF LABOR EDUCATION AND TRAINING MINE RESCUE TEAMS Mine Rescue Teams for Underground Coal Mines § 49.30 Requirements for small coal...

30 CFR 49.30 - Requirements for small coal mines.

Code of Federal Regulations, 2011 CFR

2011-07-01

... 30 Mineral Resources 1 2011-07-01 2011-07-01 false Requirements for small coal mines. 49.30 Section 49.30 Mineral Resources MINE SAFETY AND HEALTH ADMINISTRATION, DEPARTMENT OF LABOR EDUCATION AND TRAINING MINE RESCUE TEAMS Mine Rescue Teams for Underground Coal Mines § 49.30 Requirements for small coal...

30 CFR 49.30 - Requirements for small coal mines.

Code of Federal Regulations, 2014 CFR

2014-07-01

... 30 Mineral Resources 1 2014-07-01 2014-07-01 false Requirements for small coal mines. 49.30 Section 49.30 Mineral Resources MINE SAFETY AND HEALTH ADMINISTRATION, DEPARTMENT OF LABOR EDUCATION AND TRAINING MINE RESCUE TEAMS Mine Rescue Teams for Underground Coal Mines § 49.30 Requirements for small coal...

Development and Validation of Performance Assessment Tools for Interprofessional Communication and Teamwork (PACT)

ERIC Educational Resources Information Center

Chiu, Chia-Ju

2014-01-01

Background: Medical errors caused by breakdowns in teamwork and interprofessional communication contribute to many deaths in the United States each year. Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS®) is an evidence-based teamwork system developed to improve communication and teamwork skills among health care…

Chemicals in Schools: Solutions for Healthy School Environments. K-12 Schools

ERIC Educational Resources Information Center

US Environmental Protection Agency, 2006

2006-01-01

School leaders play a pivotal role in keeping schools safe from chemical accidents. Readers of this brochure can help schools develop a chemical cleanout and prevention program and assemble a team of teachers, facilities staff, and administrators with technical expertise to assess chemical safety issues and set policy. Some important team roles…

Van Accidents Raise Questions about Teams' Safety on the Road.

ERIC Educational Resources Information Center

Willdorf, Nina

2000-01-01

Examines factors involved in the greater numbers of traffic accidents as college sports teams travel more frequently and further to compete in intercollegiate events. Suggests that athletes in non-income-generating sports and/or in lower divisions of the National Collegiate Athletic Association are at greater risk because they are more likely to…

78 FR 14912 - International Aviation Safety Assessment (IASA) Program Change

Federal Register 2010, 2011, 2012, 2013, 2014

2013-03-08

...; and Public Expectations of IASA Categories Removal of Inactive Countries Under the IASA program, the... can put a U.S. carrier code on its flights. Public Expectations of IASA Category Ratings Members of... by a team consisting of a team leader and at least one expert in operations, maintenance, and...

STORC safety initiative: a multicentre survey on preparedness & confidence in obstetric emergencies.

PubMed

Guise, Jeanne-Marie; Segel, Sally Y; Larison, Kristine; M Jump, Sarah; Constable, Marion; Li, Hong; Osterweil, Patricia; Dieter Zimmer

2010-12-01

Patient safety is a national and international priority. The purpose of this study was to understand clinicians' perceptions of teamwork during obstetric emergencies in clinical practice, to examine factors associated with confidence in responding to obstetric emergencies and to evaluate perceptions about the value of team training to improve preparedness. An anonymous survey was administered to all clinical staff members who respond to obstetric emergencies in seven Oregon hospitals from June 2006 to August 2006. 614 clinical staff (74.5%) responded. While over 90% felt confident that the appropriate clinical staff would respond to emergencies, more than half reported that other clinical staff members were confused about their role during emergencies. Over 84% were confident that emergency drills or simulation-based team training would improve performance. Clinical staff who respond to obstetric emergencies in their practice reported feeling confident that the qualified personnel would respond to an emergency; however, they were less confident that the responders would perform well as a team. They reported that simulation and team training may improve their preparedness and confidence in responding to emergencies.

Critical roles of orthopaedic surgeon leadership in healthcare systems to improve orthopaedic surgical patient safety.

PubMed

Kuo, Calvin C; Robb, William J

2013-06-01

The prevention of medical and surgical harm remains an important public health problem despite increased awareness and implementation of safety programs. Successful introduction and maintenance of surgical safety programs require both surgeon leadership and collaborative surgeon-hospital alignment. Documentation of success of such surgical safety programs in orthopaedic practice is limited. We describe the scope of orthopaedic surgical patient safety issues, define critical elements of orthopaedic surgical safety, and outline leadership roles for orthopaedic surgeons needed to establish and sustain a culture of safety in contemporary healthcare systems. We identified the most common causes of preventable surgical harm based on adverse and sentinel surgical events reported to The Joint Commission. A comprehensive literature review through a MEDLINE(®) database search (January 1982 through April 2012) to identify pertinent orthopaedic surgical safety articles found 14 articles. Where gaps in orthopaedic literature were identified, the review was supplemented by 22 nonorthopaedic surgical references. Our final review included 36 articles. Six important surgical safety program elements needed to eliminate preventable surgical harm were identified: (1) effective surgical team communication, (2) proper informed consent, (3) implementation and regular use of surgical checklists, (4) proper surgical site/procedure identification, (5) reduction of surgical team distractions, and (6) routine surgical data collection and analysis to improve the safety and quality of surgical patient care. Successful surgical safety programs require a culture of safety supported by all six key surgical safety program elements, active surgeon champions, and collaborative hospital and/or administrative support designed to enhance surgical safety and improve surgical patient outcomes. Further research measuring improvements from such surgical safety systems in orthopaedic care is needed.

Why patients need leaders: introducing a ward safety checklist

PubMed Central

Amin, Yogen; Grewcock, Dave; Andrews, Steve; Halligan, Aidan

2012-01-01

The safety and consistency of the care given to hospital inpatients has recently become a particular political and public concern. The traditional ‘ward round’ presents an obvious opportunity for systematically and collectively ensuring that proper standards of care are being achieved for individual patients. This paper describes the design and implementation of a ‘ward safety checklist’ that defines a set of potential risk factors that should be checked on a daily basis, and offers multidisciplinary teams a number of prompts for sharing and clarifying information between themselves, and with the patient, during a round. The concept of the checklist and the desire to improve ward rounds were well received in many teams, but the barriers to adoption were informative about the current culture on many inpatient wards. Although the ‘multidisciplinary ward round’ is widely accepted as good practice, the medical and nursing staff in many teams are failing to coordinate their workloads well enough to make multidisciplinary rounds a working reality. ‘Nursing’ and ‘medical’ care on the ward have become ‘de-coupled’ and the potential consequences for patient safety and good communication are largely self-evident. This problem is further complicated by a medical culture which values the primacy of clinical autonomy and as a result can be resistant to perceived attempts to ‘systematize’ medical care through instruments such as checklists. PMID:22977047

NASA System Safety Framework and Concepts for Implementation

NASA Technical Reports Server (NTRS)

Dezfuli, Homayoon

2012-01-01

This report has been developed by the National Aeronautics and Space Administration (NASA) Human Exploration and Operations Mission Directorate (HEOMD) Risk Management team knowledge capture forums.. This document provides a point-in-time, cumulative, summary of actionable key lessons learned in safety framework and concepts.

An Interprofessional Course Using Human Patient Simulation to Teach Patient Safety and Teamwork Skills

PubMed Central

McCulloh, Russell; Dyer, Carla; Gregory, Gretchen; Higbee, Dena

2012-01-01

Objectives. To assess the effectiveness of human patient simulation to teach patient safety, team-building skills, and the value of interprofessional collaboration to pharmacy students. Design. Five scenarios simulating semi-urgent situations that required interprofessional collaboration were developed. Groups of 10 to 12 health professions students that included 1 to 2 pharmacy students evaluated patients while addressing patient safety hazards. Assessment. Pharmacy students’ scores on 8 of 30 items on a post-simulation survey of knowledge, skills, and attitudes improved over pre-simulation scores. Students’ scores on 3 of 10 items on a team building and interprofessional communications survey also improved after participating in the simulation exercise. Over 90% of students reported that simulation increased their understanding of professional roles and the importance of interprofessional communication. Conclusions. Simulation training provided an opportunity to improve pharmacy students’ ability to recognize and react to patient safety concerns and enhanced their interprofessional collaboration and communication skills. PMID:22611280

[Establishment of model of traditional Chinese medicine injections post-marketing safety monitoring].

PubMed

Guo, Xin-E; Zhao, Yu-Bin; Xie, Yan-Ming; Zhao, Li-Cai; Li, Yan-Feng; Hao, Zhe

2013-09-01

To establish a nurse based post-marketing safety surveillance model for traditional Chinese medicine injections (TCMIs). A TCMIs safety monitoring team and a research hospital team engaged in the research, monitoring processes, and quality control processes were established, in order to achieve comprehensive, timely, accurate and real-time access to research data, to eliminate errors in data collection. A triage system involving a study nurse, as the first point of contact, clinicians and clinical pharmacists was set up in a TCM hospital. Following the specified workflow involving labeling of TCM injections and using improved monitoring forms it was found that there were no missing reports at the ratio of error was zero. A research nurse as the first and main point of contact in post-marketing safety monitoring of TCM as part of a triage model, ensures that research data collected has the characteristics of authenticity, accuracy, timeliness, integrity, and eliminate errors during the process of data collection. Hospital based monitoring is a robust and operable process.

Educating future leaders in patient safety

PubMed Central

Leotsakos, Agnès; Ardolino, Antonella; Cheung, Ronny; Zheng, Hao; Barraclough, Bruce; Walton, Merrilyn

2014-01-01

Education of health care professionals has given little attention to patient safety, resulting in limited understanding of the nature of risk in health care and the importance of strengthening systems. The World Health Organization developed the Patient Safety Curriculum Guide: Multiprofessional Edition to accelerate the incorporation of patient safety teaching into higher educational curricula. The World Health Organization Curriculum Guide uses a health system-focused, team-dependent approach, which impacts all health care professionals and students learning in an integrated way about how to operate within a culture of safety. The guide is pertinent in the context of global educational reforms and growing recognition of the need to introduce patient safety into health care professionals’ curricula. The guide helps to advance patient safety education worldwide in five ways. First, it addresses the variety of opportunities and contexts in which health care educators teach, and provides practical recommendations to learning. Second, it recommends shared learning by students of different professions, thus enhancing student capacity to work together effectively in multidisciplinary teams. Third, it provides guidance on a range of teaching methods and pedagogical activities to ensure that students understand that patient safety is a practical science teaching them to act in evidence-based ways to reduce patient risk. Fourth, it encourages supportive teaching and learning, emphasizing the need to establishing teaching environments in which students feel comfortable to learn and practice patient safety. Finally, it helps educators incorporate patient safety topics across all areas of clinical practice. PMID:25285012

Improving staff perception of a safety climate with crew resource management training.

PubMed

Kuy, SreyRam; Romero, Ramon A L

2017-06-01

Communication failure is one of the top root causes in patient safety adverse events. Crew resource management (CRM) is a team building communication process intended to improve patient safety by improving team dynamics. First, to describe implementation of CRM in a Veterans Affair (VA) surgical service. Second, to assess whether staff CRM training is related to improvement in staff perception of a safety climate. Mandatory CRM training was implemented for all surgical service staff at a VA Hospital at 0 and 12 mo. Safety climate questionnaires were completed by operating room staff at a baseline, 6 and 12 mo after the initial CRM training. Participants reported improvement on all 27 points on the safety climate questionnaire at 6 mo compared with the baseline. At 12 mo, there was sustained improvement in 23 of the 27 areas. This is the first published report about the effect of CRM training on staff perception of a safety climate in a VA surgical service. We demonstrate that CRM training can be successfully implemented widespread in a surgical program. Overall, there was improvement in 100% of areas assessed on the safety climate questionnaire at 6 mo after CRM training. By 1 y, this improvement was sustained in 23 of 27 areas, with the areas of greatest improvement being the performance of briefings, collaboration between nurses and doctors, valuing nursing input, knowledge about patient safety, and institutional promotion of a patient safety climate. Published by Elsevier Inc.

ATV Engineering Support Team Safety Console Preparation for the Johannes Kepler Mission

NASA Astrophysics Data System (ADS)

Chase, R.; Oliefka, L.

2010-09-01

This paper describes the improvements to be implemented in the Safety console position of the Engineering Support Team(EST) at the Automated Transfer Vehicle(ATV) Control Centre(ATV-CC) for the upcoming ATV Johannes Kepler mission. The ATV missions to the International Space Station are monitored and controlled from the ATV-CC in Toulouse, France. The commanding of ATV is performed by the Vehicle Engineering Team(VET) in the main control room under authority of the Flight Director. The EST performs a monitoring function in a room beside the main control room. One of the EST positions is the Safety console, which is staffed by safety engineers from ESA and the industrial prime contractor, Astrium. The function of the Safety console is to check whether the hazard controls are available throughout the mission as required by the Hazard Reports approved by the ISS Safety Review Panel. Safety console preparation activities were limited prior to the first ATV mission due to schedule constraints, and the safety engineers involved have been working to improve the readiness for ATV 2. The following steps have been taken or are in process, and will be described in this paper: • review of the implementation of Operations Control Agreement Documents(OCADs) that record the way operational hazard controls are performed to meet the needs of the Hazard Reports(typically in Flight Rules and Crew Procedures), • crosscheck of operational control needs and implementations with respect to ATV's first flight observations and post flight evaluations, with a view to identifying additional, obsolete or revised operational hazard controls, • participation in the Flight Rule review and update process carried out between missions, • participation in the assessment of anomalies observed during the first ATV mission, to ensure that any impacts are addressed in the ATV 2 safety documentation, • preparation of a Safety console handbook to provide lists of important safety aspects to be monitored at various stages of the mission, including links to relevant Hazard Reports, Flight Rules, and supporting documentation, • participation to training courses conducted in the frame of the ATV Training Academy(ATAC), and provision of courses related to safety for the other members of the VET and EST, • participation to simulations conducted at ATV-CC, including off-nominal cases. The result of these activities will be an improved level of readiness for the ATV 2 mission.

Quality Improvement in Surgery Combining Lean Improvement Methods with Teamwork Training: A Controlled Before-After Study

PubMed Central

Robertson, Eleanor; Morgan, Lauren; New, Steve; Pickering, Sharon; Hadi, Mohammed; Collins, Gary; Rivero Arias, Oliver; Griffin, Damian; McCulloch, Peter

2015-01-01

Background To investigate the effectiveness of combining teamwork training and lean process improvement, two distinct approaches to improving surgical safety. We conducted a controlled interrupted time series study in a specialist UK Orthopaedic hospital incorporating a plastic surgery team (which received the intervention) and an Orthopaedic theatre team acting as a control. Study Design We used a 3 month intervention with 3 months data collection period before and after it. A combined teamwork training and lean process improvement intervention was delivered by an experienced specialist team. Before and after the intervention we evaluated team non-technical skills using NOTECHS II, technical performance using the glitch rate and WHO checklist compliance using a simple 3 point scale. We recorded complication rate, readmission rate and length of hospital stay data for 6 months before and after the intervention. Results In the active group, but not the control group, full compliance with WHO Time Out (T/O) increased from 14 to 71% (p = 0.032), Sign Out attempt rate (S/O) increased from 0% to 50% (p<0.001) and Oxford NOTECHS II scores increased after the intervention (P = 0.058). Glitch rate decreased in the active group and increased in the control group (p = 0.001). Complications and length of stay appeared to rise in the control group and fall in the active group. Conclusions Combining teamwork training and systems improvement enhanced both technical and non-technical operating team process measures, and were associated with a trend to better safety outcome measures in a controlled study comparison. We suggest that approaches which address both system and culture dimensions of safety may prove valuable in reducing risks to patients. PMID:26381643

Addressing Dual Patient and Staff Safety Through A Team-Based Standardized Patient Simulation for Agitation Management in the Emergency Department.

PubMed

Wong, Ambrose H; Auerbach, Marc A; Ruppel, Halley; Crispino, Lauren J; Rosenberg, Alana; Iennaco, Joanne D; Vaca, Federico E

2018-06-01

Emergency departments (EDs) have seen harm rise for both patients and health workers from an increasing rate of agitation events. Team effectiveness during care of this population is particularly challenging because fear of physical harm leads to competing interests. Simulation is frequently employed to improve teamwork in medical resuscitations but has not yet been reported to address team-based behavioral emergency care. As part of a larger investigation of agitated patient care, we designed this secondary study to examine the impact of an interprofessional standardized patient simulation for ED agitation management. We used a mixed-methods approach with emergency medicine resident and attending physicians, Physician Assistants (PAs) and Advanced Practice Registered Nurses (APRNs), ED nurses, technicians, and security officers at two hospital sites. After a simulated agitated patient encounter, we conducted uniprofessional and interprofessional focus groups. We undertook structured thematic analysis using a grounded theory approach. Quantitative data consisted of responses to the KidSIM Questionnaire addressing teamwork and simulation-based learning attitudes before and after each session. We reached data saturation with 57 participants. KidSIM scores revealed significant improvements in attitudes toward relevance of simulation, opportunities for interprofessional education, and situation awareness, as well as four of six questions for roles/responsibilities. Two broad themes emerged from the focus groups: (1) a team-based agitated patient simulation addressed dual safety of staff and patients simultaneously and (2) the experience fostered interprofessional discovery and cooperation in agitation management. A team-based simulated agitated patient encounter highlighted the need to consider the dual safety of staff and patients while facilitating interprofessional dialog and learning. Our findings suggest that simulation may be effective to enhance teamwork in behavioral emergency care.

Study protocol for a framework analysis using video review to identify latent safety threats: trauma resuscitation using in situ simulation team training (TRUST)

PubMed Central

Petrosoniak, Andrew; Pinkney, Sonia; Hicks, Christopher; White, Kari; Almeida, Ana Paula Siquiera Silva; Campbell, Douglas; McGowan, Melissa; Gray, Alice; Trbovich, Patricia

2016-01-01

Introduction Errors in trauma resuscitation are common and have been attributed to breakdowns in the coordination of system elements (eg, tools/technology, physical environment and layout, individual skills/knowledge, team interaction). These breakdowns are triggered by unique circumstances and may go unrecognised by trauma team members or hospital administrators; they can be described as latent safety threats (LSTs). Retrospective approaches to identifying LSTs (ie, after they occur) are likely to be incomplete and prone to bias. To date, prospective studies have not used video review as the primary mechanism to identify any and all LSTs in trauma resuscitation. Methods and analysis A series of 12 unannounced in situ simulations (ISS) will be conducted to prospectively identify LSTs at a level 1 Canadian trauma centre (over 800 dedicated trauma team activations annually). 4 scenarios have already been designed as part of this protocol based on 5 recurring themes found in the hospital's mortality and morbidity process. The actual trauma team will be activated to participate in the study. Each simulation will be audio/video recorded from 4 different camera angles and transcribed to conduct a framework analysis. Video reviewers will code the videos deductively based on a priori themes of LSTs identified from the literature, and/or inductively based on the events occurring in the simulation. LSTs will be prioritised to target interventions in future work. Ethics and dissemination Institutional research ethics approval has been acquired (SMH REB #15-046). Results will be published in peer-reviewed journals and presented at relevant conferences. Findings will also be presented to key institutional stakeholders to inform mitigation strategies for improved patient safety. PMID:27821600

Teamwork and team training in the ICU: where do the similarities with aviation end?

PubMed

Reader, Tom W; Cuthbertson, Brian H

2011-01-01

The aviation industry has made significant progress in identifying the skills and behaviors that result in effective teamwork. Its conceptualization of teamwork, development of training programs, and design of assessment tools are highly relevant to the intensive care unit (ICU). Team skills are important for maintaining safety in both domains, as multidisciplinary teams must work effectively under highly complex, stressful, and uncertain conditions. However, there are substantial differences in the nature of work and structure of teams in the ICU in comparison with those in aviation. While intensive care medicine may wish to use the advances made by the aviation industry for conceptualizing team skills and implementing team training programs, interventions must be tailored to the highly specific demands of the ICU.

Teamwork and team training in the ICU: Where do the similarities with aviation end?

PubMed Central

2011-01-01

The aviation industry has made significant progress in identifying the skills and behaviors that result in effective teamwork. Its conceptualization of teamwork, development of training programs, and design of assessment tools are highly relevant to the intensive care unit (ICU). Team skills are important for maintaining safety in both domains, as multidisciplinary teams must work effectively under highly complex, stressful, and uncertain conditions. However, there are substantial differences in the nature of work and structure of teams in the ICU in comparison with those in aviation. While intensive care medicine may wish to use the advances made by the aviation industry for conceptualizing team skills and implementing team training programs, interventions must be tailored to the highly specific demands of the ICU. PMID:22136283

KSC-2011-1050

NASA Image and Video Library

2011-01-07

CAPE CANAVERAL, Fla. -- In the Launch Control Center at NASA's Kennedy Space Center in Florida, United Space Alliance Safety Engineer Dwayne Thompson, left, and NASA Safety Engineer Dallas McCarter rehearse procedures for the liftoff of space shuttle Discovery's final mission with other STS-133 launch team members in Firing Room 4. The team at Kennedy also participated in launch simulations with personnel at NASA's Johnson Space Center in Houston. Discovery's next launch opportunity to the International Space Station on the STS-133 mission is planned for no earlier than Feb. 24. For more information on STS-133, visit www.nasa.gov/mission_pages/shuttle/shuttlemissions/sts133/. Photo credit: NASA/Kim Shiflett