From the Flight Deck to Healthcare: Why TeamSTEPPS is an Essential Blueprint for Patient Safety

The case for bringing team training into medicine is derived from the premise that medical care has become increasingly complex, and staff at all levels must work together to provide safe patient care. All specialties have separate training but are expected to work together as teams, often under extreme stress, with high stakes for errors and patient harm. These conditions are similar to those of an airline flight deck. (Baker et al., 2003a).  To address this issue, From the Flight Deck to Healthcare: Why TeamSTEPPS^® is an Essential Blueprint for Patient Safety discusses how integrating aviation-style communication and teamwork strategies into healthcare improves patient safety and the quality of care delivered.

Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) is a nationally recognized program developed by the U.S. Department of Defense (DoD) and the Agency for Healthcare Research and Quality (AHRQ). It focuses on improving team performance through the integration of standardized tools and communication events, supporting real-time patient safety awareness and effective information exchange for handoff, critical events, and advocacy. TeamSTEPPS was built from 25 years of research around culture transformation, teamwork, and team training (King et al., 2008). This article describes the evolution of this program from Crew Resource Management and other similar programs, the literature supporting TeamSTEPPS and improved patient outcomes and safety climate, and a case example of why this type of program is needed in healthcare.

Origins of TeamSTEPPS

After the Institute of Medicine (IOM) issued its report To Err is Human in 1999, President Clinton founded the Quality Interagency Coordination (QuIC) Task Force, made up of members from the Department(s) of Health and Human Services, Labor, Defense (DoD), and Veterans Affairs. Their goal was to develop recommendations to improve patient safety and decrease medical errors. Specific units were called out as high-risk areas- including Labor and Delivery, Emergency, Surgical, and Intensive Care - in which action was required to decrease the number of errors (Baker et al., 2003a). In response, a multiyear research project was funded by the U.S. DoD and the AHRQ. The output of this work was the development of TeamSTEPPS in 2006 (King et al., 2008).  

Research was reviewed from earlier training programs developed within the airline industry, and later integrated into medicine. CRM training was initiated in the early 1980’s within aviation to improve safety within the industry. The program structure includes 3-phases: knowledge, practice and evaluation, followed by recurrent training. It utilizes tools such as simulations, videos, and lectures, focusing on teamwork, communication, and the acquisition of specific skills and knowledge. Implementation of this program was shown to improve communication, safety attitudes, team coordination and error management (Baker et al., 2003a).

Early medical team training programs drew heavily on CRM core concepts and were pioneered in military and civilian hospitals in emergency rooms and by Anesthesia teams. The DoD funded programs in Army, Navy, and Air Force hospitals, including MedTeams^TM and Medical Team Management (MTM). The Air Force initiated MTM training due to a safety event involving a neurologically damaged newborn resulting from a breakdown in teamwork. The Anesthesia Crisis Resource Management (ACRM) training program took place at Stanford University School of Medicine and at the Palo Alto Veteran Affairs Medical Center (Baker et al., 2003a).  

Another early program was Dynamic Outcomes Management (DOM), based primarily on CRM and often taught by former pilots. It brought team training to healthcare, educating interdisciplinary teams in a classroom style using active learning strategies including discussion, role play, case studies, and knowledge evaluation (Baker et al., 2003b).  The research that came from these and other similar programs, along with expertise from national leaders in team training, health care, aviation, human factors science, and change facilitation, subsequently shaped the development of TeamSTEPPS (King et al., 2008).

TeamSTEPPS curriculum

TeamSTEPPS is a program comprised of evidence-based curriculum designed to improve team performance through the integration of standardized tools and communication events. Examples of team communication tools and events are provided below:

SBAR: Situation, Background, Assessment, Recommendation.

CUS: Advocacy tools (I am Concerned, I am Uncomfortable, this is a Safety issue).

Checkbacks & Callouts: Closed-loop communication to verify information.

Huddles & Debriefs: Scheduled meetings to plan and review care.

Two-Challenge Rule: Asking a question and then, if ignored, asking for more information to provide clarification.

Chain of Command: Clearly established pathway of who to call with patient safety concerns

These strategies support real-time patient safety awareness and effective information exchange on the front lines. The curriculum also builds psychological safety among the team, empowering all members to speak up about patient safety concerns and voice opinions and ideas without fear of negative repercussions (Agency for Healthcare Research and Quality, 2023). TeamSTEPPS is a foundational component in a comprehensive perinatal safety program.

TeamSTEPPS in obstetrics

The literature supports implementation of TeamSTEPPS alone or in combination with obstetric-specific training interventions in improving perinatal outcomes, safety climate, and reducing medical malpractice costs (Wagner et al., 2011; Riley et al., 2016; Budin et al., 2014; Pettker et al., 2009; Pettker et al., 2014).

A prospective study by Riley et al. (2016) included 342,754 deliveries across 14 hospitals in 12 states, in which three interventions were implemented over 4 years: standardized care processes (induction, augmentation, and vacuum bundles), multidisciplinary TeamSTEPPS training, and educational efforts combined with feedback. In-situ simulation training and electronic fetal monitoring education were included. Perinatal harm was measured with the adverse outcome index (AOI), defined as the number of delivered mothers or newborns with an adverse event, as a proportion of the total number of deliveries. This metric includes ten adverse events (ex. uterine rupture, maternal blood transfusion, maternal/neonatal death) in and around the birth process that are considered potentially modifiable with teamwork training. Results post-implementation demonstrated consistent use of the standardized care processes and a 14% reduction in perinatal harm, as measured in the AOI.

Wagner et al. (2012) describe the implementation of a perinatal safety program over a 2 yr. period at a large tertiary medical center, in which TeamSTEPPS combined with obstetric-specific standardized processes, simulation and education were introduced. Perinatal harm, measured with the modified adverse outcome index, was significantly reduced from 2% to 0.8% and maintained over a 2-year period. Significant decreases were also found in other markers of perinatal morbidity- return to the OR and birth trauma rates. Additionally, employees' perceptions of safety and patients' perceptions of staff working well together improved significantly.

Other studies have shown comparable outcomes in patient safety climate improvements and perceptions of teamwork after implementation of a team training program (Budin et al., 2014). TeamSTEPPS, as part of a comprehensive patient safety program, has also been shown to significantly decrease both obstetric claims and payments, in addition to reducing perinatal harm and improving safety climate (Pettker et al., 2014; Pettker et al., 2009).

Case example

Why do we need TeamSTEPPS in healthcare, especially in Labor and Delivery?  The following provides an example of how communication breakdowns can lead to near misses and patient harm.

A 25-year-old obese patient in labor required a category 1 (immediate) cesarean delivery. As the obstetric team was in a hurry to deliver the baby, the team huddle was rushed. The anesthesia care provider inserted a spinal needle swiftly and uneventfully. He injected hyperbaric bupivacaine 0.5% and the cesarean delivery was carried out uneventfully. A live baby girl was born with an Apgar score of 10 at 5 minutes. When the anesthesia care provider later opened the patient’s electronic health record, he discovered that the patient had received subcutaneous enoxaparin 40 mg four hours preoperatively. The obstetric team had not mentioned this information during the previous huddle.

Postoperatively, the patient was monitored closely and was found to have a dense, persistent motor and sensory block of the lower limbs at 6 to 8 hours after delivery. Thus, magnetic resonance imaging (MRI) of the lumbar spine was performed, which did not show any epidural hematoma. Over the next day, the dense sensory block gradually wore off, and the patient recovered without any permanent sensory or motor impairment (Curtin & Schloemerkemper, 2023, para 1).

In this scenario, the spinal procedure was contraindicated due to the recent dosing of enoxaparin, and increased the patient’s risk of complications including epidural bleeding and hematoma. Though there was a pre-cesarean huddle and time-out process in place, this was conducted in a rushed manner and review of pertinent medications did not occur. This reflects a missed opportunity to consider the recent anticoagulation in the treatment plan. Had effective and complete communication occurred at the pre-cesarean huddle and time-out, the anesthesiologist would have known about the enoxaparin and may have administered general anesthesia instead. This reinforces the need for proper preoperative and time-out processes to be followed, regardless of the level of urgency in procedure (Curtin & Schloemerkemper, 2023). It’s often in emergency cases, that minor slips can occur due to the rushed nature of events.

Cultural transformation on the front lines:

When conducted in a multidisciplinary manner, it is incredibly powerful to have everyone together hearing the same message.

TeamSTEPPS:

• Breaks down the silos

• Allows for the sharing of different perspectives, which helps us to all get along better in practice

• Helps to create a learning community

• Takes deliberate work to bring the concepts into day-to-day practice and sustain the work

• Works when processes (time-outs, checklists, etc.) are performed rigorously, even in emergencies, to catch information or essential steps, that may slip through the cracks during high-stress moments

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References:

1. Agency for Healthcare Research and Quality. (2023, May). TeamSTEPPS 3.0 curriculum materials. U.S. Department of Health and Human Services. https://www.ahrq.gov/teamstepps-program/curriculum/index.html

2. Baker DP, Gustafson S, Beaubien J, Salas E, Barach P (2003a).  Medical teamwork and patient safety: The evidence-based relation. Washington, DC: American Institutes for Research.

3. Baker DP, Gustafson S, Beaubien JM, Salas E, Barach P (2003b). Medical team training programs. Advances in Patient Safety: Vol. 4

4. Budin, W. C., Gennaro, S., O’Connor, C., & Contratti, F. (2014). Sustainability of improvements in perinatal teamwork and safety climate. Journal of Nursing Care Quality, 29(4), 363–370. https://doi.org/10.1097/ncq.0000000000000067

5. Curtin, A., & Schloemerkemper, N. (2023, June 28). Hurried team huddle and poor communication: Unsafe practice during anesthesia for emergency cesarean delivery. Patient Safety Network. https://psnet.ahrq.gov/web-mm/hurried-team-huddle-and-poor-communication-unsafe-practice-during-anesthesia-emergency

6. Curtin, A., & Schloemerkemper, N. (2023, June 28). Hurried team huddle and poor communication: Unsafe practice during anesthesia for emergency cesarean delivery. Patient Safety Network. https://psnet.ahrq.gov/web-mm/hurried-team-huddle-and-poor-communication-unsafe-practice-during-anesthesia-emergency

7. King, H. B., Battles, J., Baker, D. P., Alonso, A., Salas, E., Webster, J., Toomey, L., & Salisbury, M. (2008). TeamSTEPPS™: Team strategies and tools to enhance performance and patient safety. In K. Henriksen, J. B. Battles, M. A. Keyes, & M. L. Grady (Eds.), Advances in patient safety: New directions and alternative approaches (Vol. 3: Performance and tools). Agency for Healthcare Research and Quality (US). https://www.ncbi.nlm.nih.gov/books/NBK43686/

8. Pettker, C. M., Thung, S. F., Norwitz, E. R., Buhimschi, C. S., Raab, C. A., Copel, J. A., Kuczynski, E., Lockwood, C. J., & Funai, E. F. (2009). Impact of a comprehensive patient safety strategy on obstetric adverse events. American Journal of Obstetrics and Gynecology, 200(5), 492.e1–492.e8. https://doi.org/10.1016/j.ajog.2009.01.022

9. Pettker, C. M., Thung, S. F., Lipkind, H. S., Illuzzi, J. L., Buhimschi, C. S., Raab, C. A., Copel, J. A., Lockwood, C. J., & Funai, E. F. (2014). A comprehensive obstetric patient safety program reduces liability claims and payments. American Journal of Obstetrics and Gynecology, 211(5), 488.e1–488.e8. https://doi.org/10.1016/j.ajog.2014.04.038 

10. Wagner, B., Meirowitz, N., Shah, J., Nanda, D., Reggio, L., Cohen, P., Britt, K., Kaufman, L., Walia, R., Bacote, C., Lesser, M. L., Pekmezaris, R., Fleischer, A., & Abrams, K. J. (2012). Comprehensive perinatal safety initiative to reduce adverse obstetric events. Journal for Healthcare Quality, 34(1), 6–15. https://doi.org/10.1111/j.1945-1474.2011.00134.x

About the Author: Jeanette Zocco, RN, is a passionate perinatal safety expert, writer, and entrepreneur dedicated to bridging the gap between healthcare quality protocols and bedside excellence. As the founder of the OB Neonatal Study Guide, she delivers evidence-based education and quality improvement tools designed to empower maternal-child health professionals. Discover her latest articles and resources at obneonatalstudyguide.com.

💡If you enjoyed this article, check out her comprehensive study guide book, Obstetric and Neonatal Quality and Safety (C-ONQS) Study Guide: A Practical Resource for Perinatal Nurses, available on Amazon!  Amazon_obneonatalstudyguide

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