TeamSTEPPS® Instructor Guide: Specialty Scenarios
A 44-year-old female is admitted to the Medical ICU in acute respiratory distress
with upper and lower GI bleeding. Her past medical history is significant for
end-stage liver disease due to alcohol abuse. The patient is intubated in response
to worsening respiratory distress, aggressively resuscitated, and given blood
transfusion and vasopressor drugs. Multiple consultation services are involved
in the patient’s care. All recommend that the patient’s DNR status
be addressed. Eight hours into her stay, a member of the GI consultation team
places a call to the patient’s mother, who lives out of state. Her mother
is aware that her daughter has end-stage liver disease and states that her
daughter would “not want all these things done and they should be stopped.” Over
the next 6 hours, however, despite this information, the patient continues
to be aggressively resuscitated. At 16 hours into her stay, the patient’s
blood pressure begins to drop. The MICU physician comes to the patient’s
bedside and pronounces her dead.
Approximately 20 hours after the patient’s arrival, the patient’s
mother calls to ask about her condition. She is very upset at failing to be
notified of her daughter’s death 4 hours earlier.
In this scenario, a shared mental model and advocate is lacking. When new
information is obtained by a team member, it should be called-out to the team
by a formal handoff. No leader or team actions are taken to identify and determine
whether the patient is DNR status. Upon that determination, the team briefs
or huddles regarding the appropriate plan of care, and everyone has a shared
Team structure, Mutual support, Shared mental model.
Brief, Huddle, Handoff, Collaboration
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At 1800, near the conclusion of a busy 12-hour shift in the Neonatal ICU,
Karen, a new staff nurse, is preparing to start an IV on a premature infant
who was admitted earlier in the day. She is expecting a new admission to be
arriving momentarily from Labor and Delivery and has medications to administer
to her other patients. Karen wants to complete her assignment by the end of
the shift because a co-worker has criticized her for this previously. The infant
receiving the IV is experiencing poor blood flow to her right hand. Karen inserts
the IV into the right arm and applies a dressing. At the change of shift, the
oncoming nurse, Alice, notes that the infant’s fingers are cool and cyanotic.
She applies warm soaks to the hand to alleviate the condition, but the condition
does not improve. Some 4 hours after the IV is placed, the physician is informed
of the problem and orders the application of nitroglycerin paste to the infant’s
hand. The order is not carried out until 3 hours later because Alice is busy
with other patients. No other treatment is used. Gangrene develops, and the
fingers of the infant’s right hand are amputated.
In this scenario, time, nurses, and information handoffs are scarce. Neither
nurse seeks assistance from her teammates. This may be because of criticism
received from a co-worker or patient volume and acuity. Information regarding
poor blood flow to the hand and the state of the IV is not discussed in the
handoff. The physician should have been summoned to view and assess the hand.
Discuss how an unmanaged workload may lead to adverse outcomes for a patient.
Point out other teamwork issues, such as failure to communicate essential information
on the patient’s condition to the physician or charge nurse.
Team structure. Situation awareness. Situation monitoring. Mutual support.
Brief, Handoff, Collaboration, Advocacy/Assertion, Cross monitoring
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A patient in the ICU has coded and CPR is in progress. The resuscitation team
is busy working on the patient, ensuring IVs are patent and the ET tube is
properly positioned. Dr. Matthews, the team leader, is calling out orders for
drugs, X-rays, and labs. Judy, a nurse, is at the bedside inserting an IV.
Nancy is the nurse at the cart drawing up the meds. Judy can tell by Nancy’s
expression that she did not get the last order that Dr. Matthews gave. “Nancy,
he wants the high-dose Epinephrine from the vial in the top drawer,” Judy
calls out as she continues with her IV.
Using situation awareness and call-out, the ability to be aware of what was
happening with the team and to provide effective communication techniques helped
this team to function more effectively.
Situation Monitoring: Assess status of patient and team and the progress toward
the goal. Mutual support: Provide task-related support and verbal support.
Communication: Offer information.
Call-out, Task assistance, Cross monitoring, Collaboration
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John Peter, a premature infant with a history of hyaline membrane disease
and bronchopulmonary displasia, has been a patient in the neonatal intensive
care unit (NICU) for several months requiring long-term artificial ventilation.
Eventually the patient requires a tracheostomy. After his surgery, John Peter
receives 100-percent supplemental oxygen; but in the NICU, his oxygen saturation
and carbon dioxide levels fluctuate wildly. Dr. Wilson, the second-year pediatric
resident, orders NICU Nurse Smith to increase the settings on John Peter’s
ventilator. Later, John Peter appears slightly “puffy.” The team
discusses weighing him to determine whether he has a fluid overload and agrees
this procedure requires caution because his tracheostomy is so recent. John
Peter is moved to the scale with the assistance of a co-worker. As Nurse Smith
begins moving the patient, still attached to the ventilator, Pat, a respiratory
therapist, intervenes, correctly pointing out that weighing the baby would
require the assistance of a therapist as well as the nurses, and that the patient
should be manually ventilated during weighing to prevent decannulation. In
this case, a shared mental model and team structure prevent any conflict that
might result from Pat’s advocacy for the patient.
- Discuss how cross monitoring by the respiratory therapist promotes safe
patient care by adhering to a protocol designed to prevent decannulation
and possible respiratory failure.
- Discuss the threatening nature of cross monitoring unless the goal is clear:
mutual respect and team accountability for patient outcomes. Emphasize that
this strategy is meant to assist the team in meeting its collective goal
of safe and effective patient care.
Communication. Situation monitoring: Assess status of patient. Situation awareness.
Shared mental model. Mutual support.
Cross monitoring, Collaboration, Advocacy/Assertion, Conflict resolution
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At 1300, a 5-year-old boy is admitted to the Intensive Care Unit after having
electrodes implanted in his skull for long-term electroencephalographic monitoring
for epilepsy. At 1936, the patient is not yet hooked up to monitoring equipment
when he has a seizure. An intensive care fellow is called to the bedside immediately.
A resident from Neurosurgery is paged and sees the patient within minutes.
Over the telephone, the physicians and two nurses also consult a neurology
fellow who has been involved with the case earlier. The neurosurgery fellow
gives a telephone order for Ativan up to 4 milligrams IV. The patient receives
only 1 milligram, a quarter of a milligram at a time, over 27 minutes. The
child continues to seize during this time. After 39 minutes, the patient is
given two doses of a stronger drug, fosphynytoin, but the seizures continue.
An hour and 18 minutes into the seizure, the attending physician arrives and
notices that the patient is not breathing. The patient is quickly intubated
and anesthetized but goes into cardiac arrest at 2055 followed by unsuccessful
resuscitation efforts. In an event review conducted the next day, the nurses
express confusion regarding who was in charge of the case and cannot say why
the seizure protocol was not followed. The fellow who was consulted by telephone
later says she was surprised to hear that others thought she was managing the
case, and assumed that people at the bedside would take charge. Several of
the doctors and nurses say they were surprised at the time that the seizure
was not being managed more aggressively but thought that was because using
higher drug dosages would prevent seizures for several days, which would delay
gathering data and keep the electrodes in the skull longer, increasing risk.
The failures in this case include no handoff from the Neurosurgery to ICU
team coupled with poor ICU team formation. The clear lack of leadership and
role definition may have contributed to the patient’s death because of
confusion regarding which physician had primary accountability for the patient.
Lack of knowledge about the plan of care contributed to the team failure. Situation
awareness was not maintained, nor was communication enhanced with essential
check-backs or call-outs. The patient’s deteriorating respiratory status
was not treated until the attending physician arrived on the unit. If the ICU
team, on behalf of the patient, had advocated and asserted a position to the
neurosurgery fellow, clearly stating that the seizure continued; and if the
ICU team had used SBAR to clearly state the condition of the patient and the
need for the fellow to come to the unit, would the outcome for this patient
be different? We cannot always change outcomes, but we can ensure we meet teamwork
Team structure. Communication. Situation monitoring. Situation awareness.
Shared mental model. Mutual support, Leadership.
Brief, Call-out, Check-back, Handoff, Conflict resolution, Task assistance,
Advocacy/Assertion, Collaboration, Two-Challenge rule
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