AORN Journal
Volume 86, Issue 6 , Pages 994-1011 , December 2007

A Team Training Program Using Human Factors to Enhance Patient Safety

  • David A. Marshall

      Affiliations

    • David A. Marshall, is the President and CEO of Safer Healthcare, Denver, CO.
  • ,
  • Danae A. Manus, MPA, RHIA

      Affiliations

    • Danae A. Manus, MPA, RHIA, is an independent health care consultant and instructional designer, San Francisco, CA.

References 

  1. Institute of Medicine . In:  Kohn LT ,  Corrigan JM ,  Donaldson MS editor. To Err is Human: Building a Safer Health System . Washington DC: National Academy Press; 2000;
  2. Leonard MS , Frankel A . Focusing on high reliability . In:  Leonard MS ,  Frankel A ,  Simmonds T ,  Vega KB editor. Achieving Safe and Reliable Health Care: Strategies and Solutions . Chicago, IL: Health Administration Press; 2004;p. 15
  3. Wachter RM . The end of the beginning: patient safety five years after “To Err is Human” . Health Affairs (Millwood) . 2004;July-December:W4-534–W4-545 (suppl web exclusives)
  4. Sentinel event statistics: as of June 30, 2007. The Joint Commission . http://www.jointcommission.org/NR/rdonlyres/D7836542-A372-4F93-8BD7-DDD11D43E484/0/se_stats_063007.pdf Accessed November 7, 2007.
  5. Joint Commission International Center for Patient Safety. Preventing infant death and injury during delivery . Sentinel Event Alert . July 21, 2004;30: http://www.jcipatientsafety.org/14734/ Accessed November 7, 2007.
  6. Chassin MR . Is health care ready for Six Sigma quality? . The Millbank Quarterly . 1998;76(4):565–591
  7. Beyea SC . High reliability theory and highly reliable organizations . AORN J . 2005;81(6):1319–1322
  8. Macleod N . Building Safe Systems in Aviation: A CRM Developer's Handbook . Aldershot, Hants, England; Burlington, VT: Ashgate; 2005;
  9. Reithmaier L , Miller JC , Frazier DA . Controlling Pilot Error: Culture, Environment & CRM . New York, NY: McGraw-Hill Professional; 2001;
  10. National Aeronautics and Space Administration. Resource Management on the Flight Deck. Proceedings of a NASA/Industry Workshop; June 26-28, 1979; San Francisco, CA.
  11. Helmreich RL , Merritt AC , Wilhelm JA . The Evolution of Crew Resource Management Training in Commercial Aviation . Austin, TX: The University of Texas at Austin; 2005;
  12. US Department of Transportation  , Federal Aviation Administration  . Advisory Circular: Crew Resource Management Training . Washington, DC: US Department of Transportation; January 22, 2004; [AC No. 120-51E]
  13. Pizzi L , Goldfarb NI , Nash DB . Crew Resource Management and its applications in medicine . Making Health Care Safer: A Critical Analysis of Patient Safety Practices . Rockville, MD: Agency for Healthcare Research and Quality; 2001; (Evidence Report/Technology Assessment: Number 43. AHRQ Publication No. 01-E058) http://www.ahrq.gov/clinic/ptsafety/ Accessed October 31, 2007.
  14. 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
  15. Hospital Survey on Patient Safety Culture  . Agency for Healthcare Research and Quality . http://www.ahrq.gov/qual/hospculture April 2007; Accessed November 5, 2007.
  16. Powell S , Hill RK . My copilot is a nurse—using Crew Resource Management in the OR . AORN J . 2006;83(1):179–198

PII: S0001-2092(07)00730-2

doi: 10.1016/j.aorn.2007.11.026

AORN Journal
Volume 86, Issue 6 , Pages 994-1011 , December 2007