Promoting patient safety in interprofessional teams

Author(s): Georgia Reiner, BS

nursing teamwork

Across the United States and around the world, interprofessional healthcare teams with nurses at their center have stepped up and banded together to tackle one of the biggest crises modern society has ever faced—the novel coronavirus (COVID-19) global pandemic. If there is one lesson that can be gleaned from these uncertain, anxious, and challenging times, it’s the importance of working collaboratively as a team towards common goals. In contrast, when interprofessional teamwork is lacking, patients and providers can be placed at risk. Consider the following scenario, based on a published account of a real-life case.

A female patient in her early 70s was admitted to the hospital. Prior to her admission, she had been taking an anticonvulsant: 1,500 mg levetiracetam twice daily. Upon admission, an internal medicine physician believed that the patient may have experienced a stroke, which may have impaired her ability to swallow, and discontinued the medication. Later that day, a neurologist evaluated the patient and determined that she could continue taking the medication, reinstating the twice-daily dosage. However, neither the neurologist nor the patient’s nurse recorded these instructions in the patient’s electronic healthcare record, and the patient did not receive the medication.

The next day, a nurse noted that the patient had not been receiving her prescribed doses of the anticonvulsant. The nurse called the physician, who approved administration of levetiracetam. The patient was prescribed 1,500 mg levetiracetam twice daily, but the pharmacist dispensed 150 mg, which the nurse administered. The patient never received another dose of levetiracetam.

Two days later, 3 days after her admission to the hospital, the patient experienced serial seizures that caused respiratory arrest. For the next 3 months, the patient’s respiration was controlled by a medical ventilator. While the patient was eventually taken off the respirator, she lost much of her neurological function and was moved from her home to an assisted living facility. During the ensuing medical malpractice trial, the physician, neurologist, nurses, and pharmacist tried to shift blame away from themselves, blaming each other for failing to ensure the patient’s prescription was properly filled and administered. The jury ruled in favor of the patient, issuing a verdict in the low eight figures.

Unfortunately, this was likely not an isolated incident of ineffective collaboration among the patient care team. This case highlights a cultural deficiency—an environment of finger pointing rather than a shared accountability for managing the contributing factors that can lead to a negative patient outcome.

Organizational culture plays a critical role in preventing errors and promoting patient safety. Promoting a safety culture requires individuals at all organizational levels to fight the “culture of low expectations”, which is the assumption that systems will not work and communication will fail, so individuals ignore safety standards, employ workarounds, and fail to collaborate and perform safety checks. When individuals at all levels work to improve collaboration among interprofessional healthcare teams, it promotes a culture of safety, improve patient outcomes, and benefit healthcare workers. Nursing professionals are in a key position to support interprofessional collaboration among healthcare team members.

Promoting effective teamwork

Over the last couple of decades, healthcare has acknowledged the limitations of the traditional, hierarchical model of care delivery and the need to move towards a collaborative, team-based care model to improve outcomes for patients and providers alike. Individual human factors contribute to the potential for errors, but effective teams can employ several overlapping risk control strategies to address patient safety issues and block potential causes of errors.

Interprofessional team training, including strategies that help optimize communication, cooperation, and collaboration, is one method commonly employed to promote a culture of safety. The foundation of an effective interprofessional healthcare team is one that practices shared accountability among team members, effective communication, and patient advocacy. Here are some strategies nurses can use to facilitate effective interprofessional healthcare teamwork.

Understand the nurse’s role on the team. For nurses to effectively reach across disciplinary boundaries and collaborate with other members of the healthcare team, nurses must be able to clearly articulate their role and the significance of their unique perspective. Nurses inherently are in a key position to support collaboration between all members of the patient care team, including healthcare professionals, the patient, and their family. Nurses’ holistic perspective allows them to promote the patient’s and patient’s family members’ roles in the healthcare team, and to identify changes in the patient’s condition that may indicate potential complications.

Nurses are also keenly skilled in communicating effectively with individuals from various educational backgrounds, including physicians, technologists, administrators, patients, and family members. As such, they play an important role communicating with members of the patient care team, navigating differing goals and responsibilities, and facilitating care coordination. Nurses can work to boost their influence within the interprofessional team by being a good listener, empowering those around them, and earning their team member’s trust by being accountable and keeping promises.

Promote effective communication. Poor outcomes tend to stem from breakdowns in communication and poor collaboration among team members. Nurses can work to prevent such errors and promote positive patient outcomes and patient satisfaction by communicating concerns and proactively addressing problems.

Several communication techniques and strategies are available to facilitate patient safety and quality of care efforts by the interprofessional team. The Institute for Healthcare Improvement (IHI) and the Agency for Healthcare Research and Quality’s TeamSTEPPS® program present effective strategies to improve communication among members of the interprofessional team and promote situational awareness and patient safety (See Improving team communication.)

Improving team communication

Effective communication is complete, clear, brief and timely. It includes using verbal strategies to improve communication between team members, such as those suggested by IHI and the TeamSTEPPS® program:

  • SBAR: A standard framework for communication9
    • Situation—What is going on with the patient?
    • Background—What is the clinical background or context?
    • Assessment—What do I think the problem is?
    • Recommendation and Request—What would I do to correct it?
  • Call out
    • Used to communicate important information to all team members simultaneously during a critical event.
    • Typically followed by a check back.
  • Check back
    • Closed-loop communication to ensure that information conveyed by the sender is understood by the receiver as intended by repeating back information.
    • This tool is used to verify and validate information exchanged between team members.
  • Hand over
    • Accurate and timely transfer of information from one caregiver to another.
    • Discussion includes the patient’s current condition, treatment, and any recent or anticipated changes.
  • Two Challenge Rule
    • The team member being challenged must acknowledge the other team member’s concern.
    • If a team member assertively voices their concern at least two times and the outcome is still not acceptable, they should:
      • Take a stronger course of action.
      • Utilize the chain of command.

Be an advocate. Nurses are the patient’s advocate, ensuring he or she receives safe and appropriate care when needed. The connection that nurses foster with the patient and their family members allows them to understand the patient’s goals and values.

Advocacy includes the duty to invoke both the nursing and medical staff chains of command to ensure timely attention to the needs of every patient and persisting to the point of satisfactory resolution. Nurses must be comfortable with using the medical chain of command whenever a practitioner does not respond to calls for assistance, fails to appreciate the seriousness of a situation or neglects to initiate an appropriate intervention.

The following strategies can help nurses advocate for their patients:

  • Proactively address communication issues between nursing and medical staffs, and identify instances of intimidation, bullying, retaliation or other deterrents to invoking the chain of command.
  • When advocating, assert your viewpoint in a firm and respectful manner. You should also be persistent and persuasive, providing evidence or data for your concerns.
  • If attempts to voice the concern are still disregarded, but you believe patient or staff safety is or may be severely compromised, then take a stronger course of action by notifying a supervisor or invoking the chain of command.
  • Notify leadership of individuals or areas that prevent nursing staff from invoking the chain of command or impose punitive actions for doing so.
  • If the organization’s current culture does not support invoking the chain of command, explain the risks posed to patients, staff, practitioners and the organization, and initiate discussions regarding the need for a shift in organizational culture.

Opportunities for nurses

Nurses are key to effective interprofessional teamwork, helping to facilitate collaboration between the healthcare providers involved in the patient’s care and the patient and their family. By defining and articulating their value to the interprofessional patient care team and practicing good communication skills, nurses can advocate for a culture of safety and prevent patient injury

Georgia Reiner is senior risk specialist for Nurses Service Organization (NSO) in Fort Washington, Pennsylvania. This article is provided for general informational purposes only and is not intended to provide individualized business, insurance, or legal advice. You should discuss your individual circumstances thoroughly with your legal and other advisors before taking any action with regard to the subject matter of this article.

References

Agency for Healthcare Research and Quality. TeamSTEPPS® 2.0 fundamentals. 2019. ahrq.gov/teamstepps/instructor/fundamentals/index.html

Altmiller, G. Interprofessional teamwork and collaboration. In: Kelly P, Vottero BA, Christie-McAuliffe CA, eds. Introduction to quality and safety education for nurses: Core competencies. New York: Springer Publishing; 2014:131-160.

Bosch B, Mansell H. Interprofessional collaboration in health care. Can Pharm J. 2015;148(4):176–79.

​​Institute for Healthcare Improvement. SBAR Tool: Situation-Background-Assessment-Recommendation. 2017. ihi.org/resources/Pages/Tools/SBARToolkit.aspx

Laska L. Failure to see that anticonvulsant medication was continued during hospitalization. Medical Malpractice Verdicts, Settlements & Experts. 2019;35(1):11-12.

Moss E, Seifert CP, O’Sullivan A. Registered nurses as interprofessional collaborative partners: Creating value-based outcomes. Online J Issues in Nurs. 2016;21(3):4.

Sherman RO, Cohn TM. Boosting your influence. Amer Nurse Today. 2015:10(12). myamericannurse.com/boosting-influence/

Wachter RM, Gupta, K. Understanding patient safety. 3rd ed. New York, N.Y: McGraw-Hill Education LLC; 2018.

Weaver SJ, Lubomksi LH, Wilson RF, et al. Promoting a culture of safety as a patient safety strategy: A systematic review. Ann Intern Med. 2013;158(5 Pt 2):369-74.

Wright D, Brajtman S. Relational and embodied knowing: Nursing ethics within the interprofessional team. Nursing Ethics. 2011;18(1):20-30.

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