Patient Safety Update
Team Training a Success in Interventional Radiology
Interventional Radiology is concluding a year-long teamwork training program that enhanced communication among vascular interventional staff and improved patient safety. The Partners Radiology-led program, which kicked off late in 2006 at BWH and MGH, had two goals: to decrease errors by improving communication and teamwork and to improve staff perceptions of the safety climate.
At BWH, Radiology’s Richard Baum, MD, medical director, Rick Foley, MS, BSN, RN, nurse manager, and Carol Upson, chief radiologic technologist, served as the BWH steering committee. Eileen Bozadjian, RN, program manager for quality, who also served on the BWH and Partners steering committees, and Radiology nurse educator De’Ann McNamara, BS, RN, were trained as observers.
“They learned techniques to observe peer behaviors relating to communication and teamwork in the clinical environment,” Andrea Kelly, JD, RN, patient safety program manager for Partners, said.
In January 2007, the entire vascular interventional team of physicians, nurses, technologists and support staff completed a four-hour training session on communication and teamwork. After the training, McNamara and Bozadjian observed how well their colleagues communicated and worked together using the skills they had learned.
“The team training has broken down the traditional hierarchy and allowed the different professionals to function as a team for quality patient outcomes,” Foley said.
At BWH, the enhanced teamwork fostered an important improvement in patient safety. McNamara and Michael Stecker, MD, noticed that patients with lines sometimes were sent to the PACU without the lines being capped. “De’Ann and Mike joined together to form a post-procedure pause and created a checklist sticker to put on the charts of patients with lines as a reminder to staff,” Kelly said.
McNamara and Stecker published this work in the Journal of Vascular and Interventional Radiology to share BWH’s achievement of continued patient safety measures with others.
McNamara and Bozadjian also observed the Vascular Interventional Radiology team at MGH, and the two MGH observers did the same at BWH so the teams could share ideas and learn from each other.
Since then, MGH has adopted a BWH best practice: multidisciplinary morning rounds. Each morning, the entire BWH Interventional Radiology team gathers to go over the patient list and discuss any problems or issues. “It’s a great way to communicate and allow everyone to have a voice,” Kelly said.
Kelly is awaiting survey results to measure the impact of the team training program. “We surveyed staff prior to the training and then a year later,” she said. “It will be interesting to see the results of the recent survey because the first survey indicated that staffs’ original perceptions of safety were very good.”
The Partners team training program was the idea of Scott Gazelle, MD, MPH, PhD, director of Partners Radiology. He worked with Allen Frankel, MD, then director of Patient Safety for Partners, to create a program to span across IR suites in Partners hospitals. “Nothing like this had ever been done for radiology in any other health system,” Kelly said.
The programs are scheduled to roll out to Faulkner Hospital and North Shore Medical Center this March.
At BWH, team training is also underway in the Thoracic Operating Rooms and is being rolled out in the post-partum units and the NICU in the Connors Center for Women and Newborns. Perinatal staff completed the training in 2005.