The Washington Post

Training healthcare providers to reduce medical errors

Every year, tens of thousands of patients die or are harmed by preventable medical errors such as pharmaceutical prescription mistakes, hospital acquired infections and surgical missteps. Breakdowns in communication among doctors, nurses and other care providers are a leading cause of these tragic errors.

Heidi King of the Department of Defense (DOD) Patient Safety Program and colleagues at the Agency for Healthcare Research and Quality (AHRQ) set out to do something about this troubling crisis, developing a health-care provider training system known as TeamSTEPPS that has become the gold standard for eliminating preventable medical harm.

“We believe thousands of lives have been saved and countless more medical encounters have been vastly improved as a result of this effort,” said Dr. Joshi Maulik, senior vice president of the American Hospital Association.

King and James Battles at AHRQ began the effort some nine years ago, pulling together more than 100 independent experts to develop strategies, tools and a training system for professionals who work not only in high-stress situations — such as surgical suites, emergency departments and intensive care units — but also in ambulatory care settings, including physicians’ offices.

The principles are based on research from teams working in high-risk environments, such as aviation, nuclear power and the military, where the consequences of errors are great. The training teaches medical teams about human factors that contribute to errors, such as team members giving too much deference to someone with a higher-rank, even when they’re about to make a mistake.

Heidi King (Sam Kittner/

“It provides mechanisms for everyone to step up and say, ‘something’s not right,’” said Dr. Donald W. Robinson, director of the DOD Patient Safety Program. “It really is cultural development.”

Teams are taught four skill sets: leadership, mutual support, situation monitoring and communication. If, for example, a surgeon is about to amputate the wrong limb, “we make sure anyone who has information is comfortable saying something and will speak up, even if he or she is the lowest-paid person in the room, even if the doctor is the top surgeon in the world,” Battles said.

King helped establish a national training infrastructure, including 11 centers across the country, through which more than 6,200 health care professionals have become master trainers and instructors who return to their health-care systems to lead implementation of the program. The curriculum, available free online, includes assessment, planning, training, implementation and sustainment phases.

“We saw a real need for an immediate solution,” said King. “Patients were losing their lives due to medical errors, and the harm was preventable. The program has now taken off like wildfire.”

TeamSTEPPS or the Team Strategies and Tools to Enhance Performance and Patient Safety program is in use in all 50 states, reaching an estimated 25 percent of the more than 5,700 U.S. hospitals. It also has been employed in more than 80 percent of DOD healthcare facilities worldwide.

“For programs to work, we really need the buy-in of service leadership,” said Dr. Jack W. Smith from the Office of the Assistant Secretary of Defense for Health Affairs. “The fact that this is so widely accepted across services speaks to the value of the program.”

The reach of the program has been growing steadily. It has been adopted as a quality and safety improvement tool by the Centers for Medicare and Medicaid Services, included in the educational curriculum of the World Health Organization and made part of a public-private partnership launched by the Obama administration to improve the quality, safety and affordability of health care.

“We are seeing an increase in patient involvement in their care, effective communication among clinical teams, safe handoffs of patients between providers, and all staff speaking up when there is a concern or question,” said King.

This article was jointly prepared by the Partnership for Public Service, a group seeking to enhance the performance of the federal government, and Go to to nominate a federal employee for a Service to America Medal and to read about other federal workers who are making a difference.

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