**3. Effective team communication and coordination: "Together Everyone Achieves More"**

**2. Patient safety and teamwork**

4 Vignettes in Patient Safety - Volume 3

within the modern healthcare construct.

Patient safety can be defined as a discipline or characteristic of a healthcare system that focuses on the application of safety science methodologies to minimize the incidence and impact of adverse events, with the ultimate goal of creating a trustworthy and highly reliable healthcare delivery environment [9]. The critical importance of patient safety has been well established across the full spectrum of modern healthcare settings, including the more recent introduction of patient-centered care and quality-based reimbursement paradigms [3, 27, 28]. As the care delivery paradigm continues to evolve, we must strive to learn, grow, and make sustained improvements across all domains of practice, from the most mundane to the most complex ones. Because the focus on patient safety has its genesis in the combined desire and duty to "do the right thing" in conjunction with the realization that there is an unacceptably high prevalence of avoidable adverse events, we must all join forces and make the effort to

meaningfully contribute at the personal, team, and institutional levels [3, 29, 30].

For any meaningful change in practice (and thus organizational culture) to occur, a shift in mindset must be embraced at both individual and institutional levels [31]. In the past, there was a widely held belief that "well-trained and conscientious" providers generally do not commit errors and that most errors occurred because of "carelessness and incompetence" [9, 32]. Consequently, punitive approaches to error identification and correction prevailed, creating an environment of "fear, secrecy, and nondisclosure" [4, 9]. The resultant "culture of blame" gradually gave way to a more in-depth understanding of medical errors, with increasing realization that only a minority of errors are clearly attributable to a single individual or factor [3–5].

Research into human factors provides evidence that in great majority of cases it is not "the individual" who is to be blamed, but rather the error results from imperfections within the organization's systems, training, equipment, and/or management [9, 33, 34]. This sparked a transition toward system-based thinking and adoption of error management, an effective method used in aviation, into health care as a way of introducing a more sustainable paradigm change [3, 4, 35]. Subsequent identification and improved understanding of various "failure modes" such as "latent failures" that may be "hidden" within an otherwise highly efficient and safe environment [35] gave us further insight into phenomena "we did not know that we did not know." Among various areas of scrutiny, it became apparent that the largest number of opportunities for improvement resided

within the general domains of "team communication" and "team coordination" [36, 37].

For the purposes of our discussion, a team is described as one or more individuals working together toward a specific, shared aim [21]. This highlights the importance of any verbal or written communication between providers and caretakers where at least two individuals are involved, regardless of how trivial such communication may seem at the time. Also, integral to the team context, each individual has a special role to play within their own area of knowledge and expertise [21]. Inherent to effective teamwork, individuals should be willing to share their resources, communicate and coordinate closely in order to provide the very best care and experience for the patient from every conceivable standpoint, including clinical outcomes, quality, and safety [21]. Of note, the above statements describe nearly every team-based microsystem When people work together toward a common goal, remarkable achievements are possible. There are, however, important team-specific considerations. With the growth of team size and complexity, so does the potential for errors. Essential to reducing the number of errors is the presence of robust, often redundant feedback mechanisms [4, 41, 42]. In addition to improving safety and effectiveness of teams, properly structured teamwork may also help improve staff well-being and morale [21]. Consequently, targeted restructuring of microsystems and processes toward a more team-based approach can bring about important benefits and synergies [21]. Finally, thoughtful implementation of interventions that foster shared decision-making, planning, and problemsolving can also be effective in improving both clinical outcomes and patient safety [32].

Although healthcare professionals tend to be aware of the importance of teamwork, communication, and coordination, this awareness does not universally translate into appropriate or optimal behavioral manifestations [21]. As a result, breakdowns in teamwork—rather than lack of knowledge or clinical skills—continue to contribute to a significant proportion of adverse healthcare events [21]. Thus, the importance of working effectively within a complex team-based environment cannot be overstated, with evidence from one observational study conducted in the pediatric surgical setting demonstrating that "…effective teamwork was associated with fewer minor problems per operation, higher intraoperative performance and shorter operating times" [21]. If coordinated teamwork and communication are so important to ensuring patient safety, what are some of the more common failure modes and more importantly the associated barriers?
