Association between implementation of a medical team training program and surgical mortality

JAMA

Volumn 304, Issue 15, 2010, Pages 1693-1700

  Neily, Julia ^a   Mills, Peter D ^a,b   Young Xu, Yinong ^a,b   Carney, Brian T ^a   West, Priscilla ^a   Berger, David H ^c   Mazzia, Lisa M ^a   Paull, Douglas E ^a   Bagian, James P ^a,d,e  

^a DEPARTMENT OF VETERANS AFFAIRS   (United States)

^b DARTMOUTH MEDICAL SCHOOL   (United States)

^c BAYLOR COLLEGE OF MEDICINE   (United States)

^d University of Texas Medical Branch School of Medicine   (United States)

^e Uniformed Services University of the Health Sciences and the Walter Reed National Military Medical Center   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

ARTICLE; HEALTH CARE QUALITY; MEDICAL EDUCATION; MEDICAL ERROR; OPERATING ROOM; OUTCOME ASSESSMENT; PATIENT SAFETY; PRIORITY JOURNAL; SURGICAL MORTALITY; SURGICAL RISK; SURGICAL TECHNIQUE; TOTAL QUALITY MANAGEMENT; CASE CONTROL STUDY; CLINICAL COMPETENCE; CLINICAL TRIAL; COHORT ANALYSIS; EDUCATION; HUMAN; MANPOWER; MORTALITY; MULTICENTER STUDY; OPERATING ROOM PERSONNEL; PATIENT CARE; PROPENSITY SCORE; PUBLIC HOSPITAL; RETROSPECTIVE STUDY; STANDARDS; STATISTICS AND NUMERICAL DATA; SURGERY; UNITED STATES;

CASE-CONTROL STUDIES; CLINICAL COMPETENCE; COHORT STUDIES; EDUCATION, MEDICAL, CONTINUING; HOSPITAL MORTALITY; HOSPITALS, VETERANS; HUMANS; OPERATING ROOM TECHNICIANS; OPERATING ROOMS; PATIENT CARE TEAM; PROPENSITY SCORE; RETROSPECTIVE STUDIES; SURGICAL PROCEDURES, OPERATIVE; UNITED STATES;

EID: 77958149840     PISSN: 00987484     EISSN: 15383598     Source Type: Journal    
DOI: 10.1001/jama.2010.1506     Document Type: Article

References (32)

1. Joint Commission. Joint Commission Sentinel Event. http://www. jointcommission.org/NR/rdonlyres/377FF7E7-F565-4D61-9FD2-593CA688135B /0/Statswithallfieldshidden31March2010.pdf. March 31, 2010. Accessed May 23, 2010.
2. Lingard L, Regehr G, Orser B, et al. Evaluation of a preoperative checklist and team briefing among surgeons, nurses, and anesthesiologists to reduce failures in communication. Arch Surg. 2008;143(1): 12-17.
3. Davenport DL, Henderson WG, Mosca CL, Khuri SF, Mentzer RM Jr. Risk-adjusted morbidity in teaching hospitals correlates with reported levels of communication and collaboration on surgical teams but not with scale measures of teamwork climate, safety climate, or working conditions. J Am Coll Surg. 2007; 205(6):778-784.
4. Leonard M, Graham S, Bonacum D. The human factor: the critical importance of effective teamwork and communication in providing safe care. Qual Saf Health Care. 2004;13(suppl 1):i85-i90.
5. Awad SS, Fagan SP, Bellows C, et al. Bridging the communication gap in the operating room with medical team training. Am J Surg. 2005;190(5):770-774.
6. Haynes AB, Weiser TG, Berry WR, et al; Safe Surgery Saves Lives Study Group. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009;360(5): 491-499.
7. Sorbero M, Farley D, Mattke S, Lovejoy S. Outcome Measures for Effective Teamwork in Inpatient Care. Santa Monica, CA: Rand Corp; 2008. http://www.rand.org/pubs/technical-reports/TR462. Accessed May 23, 2010.
8. Dunn EJ, Mills PD, Neily J, Crittenden MD, Carmack AL, Bagian JP. Medical team training: applying crew resource management in the Veterans Health Administration. Jt Comm J Qual Patient Saf. 2007; 33(6):317-325.
9. Paull DE, Mazzia LM, Izu BS, Neily J, Mills PD, Bagian JP. Predictors of successful implementation of preoperative briefings and postoperative debriefings after medical team training. Am J Surg. 2009;198(5): 675-678.
10. Musson D, Helmreich RL. Team training and resource management in health care: current issues and future directions. Harvard Health Policy Review. 2004; 5(1):25-35. http://www1.va.gov/vhapublications /ViewPublication.asp?pub-ID=1398. Accessed August 2, 2010.
11. Neily J, Mills PD, Lee P, et al. Medical Team Training and coaching in the Veterans Health Administration: assessment and impact on the first 32 facilities in the programme. Qual Saf Health Care. 2010; 19(4):360-364.
12. Khuri SF, Henderson WG, Daley J, et al; Principal Site Investigators of the Patient Safety in Surgery Study. The patient safety in surgery study: background, study design, and patient populations. J Am Coll Surg. 2007; 204(6):1089-1102.
13. Khuri SF, Daley J, Henderson W, et al. The National Veterans Administration Surgical Risk Study: risk adjustment for the comparative assessment of the quality of surgical care. J Am Coll Surg. 1995;180 (5):519-531.
14. Khuri SF, Daley J, Henderson W, et al; National VA Surgical Quality Improvement Program. The Department of Veterans Affairs' NSQIP: the first national, validated, outcome-based, risk-adjusted, and peer-controlled program for the measurement and enhancement of the quality of surgical care. Ann Surg. 1998;228(4):491-507.
15. Khuri SF. The NSQIP: a new frontier in surgery. Surgery. 2005;138(5):837-843.
16. The American College of Surgeons, National Surgical Quality Improvement Program. About ACS NSQIP: history of the ACS NSQIP. https://acsnsqip.org /main/about-history.asp. Accessed December 23, 2009.
17. Daley J, Khuri SF, Henderson W, et al. Risk adjustment of the postoperative morbidity rate for the comparative assessment of the quality of surgical care: results of the National Veterans Affairs Surgical Risk Study. J Am Coll Surg. 1997;185(4):328-340. (Pubitemid 27419190)
18. Szabo CR; Veterans Healthcare Administration National Leadership Board Human Resources Committee 2005 Facility Complexity Model 2005; August 9, 2005. http://www1.va.gov/vhapublications /ViewPublication.asp?pub-ID=1398. Accessed May 23, 2010.
19. West AN, Lee RE, Shambaugh-Miller MD, et al. Defining "rural" for veterans' healthcare planning [published online ahead of print June 17, 2010]. J Rural Health. http://onlinelibrary.wiley.com/doi/10.1111 /j.1748-0361.2010.00298.x/abstract. Accessed September 27, 2010.
20. Diggle PJ, Liang KY, Zeger SL. Analysis of Longitudinal Data. Oxford, England: Clarendon Press; 1996.
21. McCullagh P, Nelder JA. Generalized Linear Models. 2nd ed. London, UK: Chapman & Hall; 1989.
22. Rosenbaum PR, Rubin DB. The central role of the propensity score in observational studies for causal effects. Biometrika. 1983;70(1):41-55.
23. Rubin DB. Estimating causal effects from large data sets using propensity scores. Ann Intern Med. 1997; 127(8 pt 2):757-763.
24. Rosenbaum PR, Rubin DB. Reducing bias in observational studies using subclassification on the propensity score. J Am Stat Assoc. 1984;79:516-524.
25. Rosenbaum PR, Rubin DB. Constructing a control group using multivariate matched sampling methods that incorporate the propensity score. Am Stat. 1985;39:33-38.
26. Morey JC, Simon R, Jay GD, et al. Error reduction and performance improvement in the emergency department through formal teamwork training: evaluation results of the MedTeams project. Health Serv Res. 2002;37(6):1553-1581.
27. Williams KA, Rose WD, Simon R. Teamwork in emergency medical services. Air Med J. 1999;18 (4):149-153.
28. Grogan EL, Stiles RA, France DJ, et al. The impact of aviation-based teamwork training on the attitudes of health-care professionals. J Am Coll Surg. 2004;199(6):843-848.
29. DeFontes J, Subida S. Preoperative safety briefing project. Permanente Journal. 2004;8(2):21-27. http://xnet.kp.org/permanentejournal/spring04 /awardwin.html. Accessed September 29, 2010.
30. Makary MA, Mukherjee A, Sexton JB, et al. Operating room briefings and wrong-site surgery. J Am Coll Surg. 2007;204(2):236-243.
31. Pratt SD, Mann S, Salisbury M, et al. Impact of CRM-based training on obstetric outcomes and clinicians' patient safety attitudes. Jt Comm J Qual Patient Saf. 2007;33(12):720-725.
32. Neily J, Mills PD, Eldridge N, et al. Incorrect surgical procedures within and outside of the operating room. Arch Surg. 2009;144(11):1028-1034.