TeamSTEPPS Fundamentals Course: Module 7

Summary Skills Practice Exercise Sheet

TeamSTEPPS is a teamwork system developed jointly by the Department of Defense (DoD)and the Agency for Healthcare Research and Quality (AHRQ) to improve institutional collaboration and communication relating to patient safety.


  1. Break into four small groups. Each group will receive one of four teamwork skill handouts.
  2. Read the scenario below.
  3. Identify the instances where a breakdown in teamwork has occurred as it relates to the specific teamwork skill assigned to your team.
  4. Identify 2 or 3 tools or strategies related to the specific teamwork skill assigned to your team that can be applied to remedy the teamwork breakdowns. Refer to your course materials if needed.
  5. Assign roles among your team members and create a script that demonstrates the use of the tools and strategies that your team has decided on.
  6. Present your scenario.

 A facilitated debrief will wrap up the exercise.


It is flu season in the Pediatric Inpatient Ward, and the number of admissions is high because of the influenza epidemic. Dr. Powers, who is notoriously difficult to work with and does not work well under stress, is attending to a new patient who has been oversedated. Dr. Powers gives a verbal order for 1 Amp Narcan to Nurse Shelley. Nurse Shelley repeats the verbal order as "1 Amp Narcan."

In a rush, Nurse Shelley writes the verbal order on the chart. The written order is then sent to the pharmacist. He is a float pharmacist who does not usually work on the pediatric floor, and he is fatigued from approaching the 10th hour of his 7th day of working. He is also overloaded and overburdened by the large number of admissions in the ward. The pharmacist misreads the poorly written transcription as "1 Amp Norcuron."

At the end of Nurse Shelley's shift, she hands off to Nurse Givens. During the handoff, the Code Team is activated, and Nurse Shelley has to respond. Nurse Givens then returns to the pharmacist, who dispenses Norcuron. Nurse Givens suspects something is wrong with the order but decides Norcuron must be a generic name for Narcan. (Norcuron is actually a neuromuscular blocker.) Nurse Givens administers Norcuron to the patient, who immediately experiences respiratory arrest and requires intubation.

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Page last reviewed March 2014
Page originally created September 2012
Internet Citation: TeamSTEPPS Fundamentals Course: Module 7. Content last reviewed March 2014. Agency for Healthcare Research and Quality, Rockville, MD.