JAMA Study Finds TeamSTEPPS® Associated With Reduction in Medical Errors

Electronic Newsletter, Issue 411

AHRQ's Electronic Newsletter summarizes Agency research and programmatic activities.

February 4, 2014


AHRQ Stats

Adults between the ages of 65 and 84 accounted for more than half of the 718,000 hospital stays for knee arthroplasty in 2011. (Source: Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project Statistical Brief #165: Most Frequent Procedures Performed in U.S. Hospitals, 2011.)

Today's Headlines

  1. JAMA Study Finds TeamSTEPPS® Associated With Reduction in Medical Errors.
  2. New AHRQ Research Finds Evidence Lacking on Value of Preoperative Testing.
  3. Study Finds That Adding Telemonitoring To Support Diabetes Management Did Not Change Patient Outcomes.
  4. Register Now for February 12 Webinar on Teamwork and Measuring Hospital Patient Safety Culture.
  5. AHRQ's Health Care Innovations Exchange Focuses on Using Actionable Data To Improve Quality and Reduce Costs.
  6. AHRQ in the professional literature.

1. JAMA Study Finds TeamSTEPPS® Associated With Reduction in Medical Errors

Implementation of AHRQ's TeamSTEPPS® team training program, along with other interventions, led to a significant reduction in medical errors and preventable adverse events among hospitalized children, according to an article published December 4 in The Journal of the American Medical Association (JAMA). The study, which examined an intervention involving 84 resident physicians and 1,255 patient admissions in 2009 and 2010 on two inpatient units at Boston Children's Hospital, found that errors decreased from 33.8 to 18.3 per 100 admissions. The abstract and article, titled "Rates of Medical Errors and Preventable Adverse Events Among Hospitalized Children Following Implementation of a Resident Handoff Bundle," credited a "handoff bundle" with improvements in verbal and written handoff processes that helped to prevent errors. TeamSTEPPS, developed jointly by AHRQ and the Department of Defense, was one of the programs used to create the Boston Children's handoff bundle.

2. New AHRQ Research Finds Evidence Lacking on Value of Preoperative Testing

A new research review from AHRQ found that, with the exception of cataract surgery, there is a lack of reliable evidence about benefits, harms, and resource utilization associated with routine or "per protocol" preoperative testing. Preoperative testing—including blood and urine tests, chest radiography, and electrocardiograms—has long been part of the preoperative care process to determine patients' fitness for anesthesia and to identify patients at high risk for perioperative complications. According to the review, "Benefits and Harms of Routine Preoperative Testing: A Comparative Effectiveness Review," there is a high strength of evidence that preoperative tests do not affect outcomes in patients scheduled for cataract surgery. However, no conclusions could be drawn about the value of routine preoperative testing for other procedures. Given the large number of patients undergoing elective surgery, better evidence is needed to indicate when routine testing improves patient outcomes and reduces potential harms, according to the review.

3. Study Finds That Adding Telemonitoring To Support Diabetes Management Did Not Change Patient Outcomes

Adding telemonitoring to routine diabetes care did not significantly change patient outcomes, according to a new AHRQ-funded study. The study, "Effect of Home Telemonitoring on Glycemic and Blood Pressure Control in Primary Care Clinic Patients with Diabetes," appeared online January 3 in Telemedicine and e-Health. Researchers compared 53 people who received routine care with 55 people who got routine care plus telemonitoring. After 12 weeks of care, hemoglobin A1c and blood pressure levels were not significantly different between the two groups. The study findings and abstract suggest that the addition of technology alone is unlikely to lead to improved outcomes, and that telemonitoring should be limited to patients whose care plans change significantly. The study said more research is needed to determine how primary care practices can effectively use telemonitoring to support patients' abilities to manage diabetes.

4. Register Now for February 12 Webinar on Teamwork and Measuring Hospital Patient Safety Culture

AHRQ will host a 1-hour Web conference February 12 from 1:00 p.m. to 2:00 p.m. ET on the use of the Agency's teamwork training program, TeamSTEPPS, and how to use AHRQ's "Hospital Survey on Patient Safety Culture" to evaluate the impact of teamwork training on changes in patient safety. Katherine Jones, P.T., Ph.D., associate professor in physical therapy education at the University of Nebraska Medical Center, will discuss the following:

  • How to use a training-evaluation model called Kirkpatrick's four levels of learning—student reaction, learning, behavior, and results—to measure changes in knowledge and adoption of team behaviors due to TeamSTEPPS training.
  • How to use the "Hospital Survey on Patient Safety Culture" to measure the results of TeamSTEPPS training.
  • Which characteristics of the work environment support adoption of team tools and strategies.
  • Why adopting team behaviors can improve all four components of safety culture—reporting culture, just culture, flexible culture, and learning culture.

Select to register.

5. AHRQ's Health Care Innovations Exchange Focuses on Using Actionable Data To Improve Quality and Reduce Costs

The latest issue of AHRQ's Health Care Innovations Exchange features three profiles about organizations that provided specific, actionable data to health plans and providers to support quality improvement efforts, leading to better care and lower costs. One featured profile describes how the Indiana Health Information Exchange provides health plans and Medicare-chartered accountable care organizations with daily alerts on members of their attributed populations who have visited an emergency department (ED) or were admitted to the hospital in the past 24 hours. Based on near real-time data, these notices (known as admission, discharge, and transfer alerts) allow the receiving organization to act on the information in a timely manner. In a pilot test, the program helped a managed health plan improve quality and lower costs by significantly reducing non-urgent ED visits, replacing them with lower cost primary care visits. The shift from ED to primary care visits that occurred during the pilot test saved the health plan an estimated $2 million to $4 million over the 6-month period. Other innovation profiles related to this topic are located on the Innovations Exchange Web site, which contains more than 825 searchable innovations and 1,550 quality tools.

6. AHRQ in the Professional Literature

Baker DW, Brown T, Buchanan DR, et al. Design of a randomized controlled trial to assess the comparative effectiveness of a multifaceted intervention to improve adherence to colorectal cancer screening among patients cared for in a community health center. BMC Health Serv Res 2013 Apr 29;13(1):153. Select to access the abstract on PubMed®.

Stock R, Mahoney E, Carney PA. Measuring team development in clinical care settings. Fam Med 2013 Nov-Dec;45(10):691-700. Select to access the abstract on PubMed®.

Dharmar M, Romano PS, Kuppermann N, et al. Impact of critical care telemedicine consultations on children in rural emergency departments. Crit Care Med 2013 Oct;41(10):2388-95. Select to access the abstract on PubMed®.

Wu AW, Kharrazi H, Boulware LE, et al. Measure once, cut twice—adding patient-reported outcome measures to the electronic health record for comparative effectiveness research. J Clin Epidemiol 2013 Aug;66(8 Suppl):S12-20. Select to access the abstract on PubMed®.

Devine EB, Alfonso-Cristancho R, Devlin A, et al. A model for incorporating patient and stakeholder voices in a learning health care network: Washington State's Comparative Effectiveness Research Translation Network. J Clin Epidemiol 2013 Aug;66(8 Suppl):S122-29. Select to access the abstract on PubMed®.

Holve E, Calonge N. Lessons from the Electronic Data Methods Forum: collaboration at the frontier of comparative effectiveness research, patient-centered outcomes research, and quality improvement. Med Care 2013 Aug; 51(8 Suppl 3):S1-3. Select to access the abstract on PubMed®.

Goff SL, Pekow PS, White KO, et al. IDEAS for a healthy baby—reducing disparities in use of publicly reported quality data: study protocol for a randomized controlled trial. Trials 2013 Aug 7;14:244. Select to access the abstract on PubMed®.

Branas CC, Wolff CS, Williams J, et al. Simulating changes to emergency care resources to compare system effectiveness. J Clin Epidemiol. 2013 Aug;66(8 Suppl):S57-64. Select to access the abstract on PubMed®.


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Page last reviewed February 2014
Internet Citation: JAMA Study Finds TeamSTEPPS® Associated With Reduction in Medical Errors: Electronic Newsletter, Issue 411. February 2014. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/newsletters/e-newsletter/411.html