This paper explores the contribution of teamwork skills in serious adverse events, using the TeamSTEPPS<sup>®</sup> framework. Adverse events are the undesirable events that are not due to the natu...This paper explores the contribution of teamwork skills in serious adverse events, using the TeamSTEPPS<sup>®</sup> framework. Adverse events are the undesirable events that are not due to the natural course of a disease;they are considered serious when they prolong a hospital stay, lead to a physical disability or to death. Failures in teamwork, particularly with interprofessional teams, can lead to potential risks to patient safety. Using a dataset of de-identified reports of serious adverse events in 2016 in a tertiary teaching hospital, we explored the contribution of teamwork skills according to the TeamSTEPPS<sup>®</sup> framework to these adverse events. We found that 61% of the 41 analyzed events involved failures in teamwork skills, with 80% of these involving communication, 52% in situation monitoring and team structure, 44% in mutual support and 40% in leadership. Sixty-four percent of the events involved more than one teamwork component. Our findings emphasize the need to improve teamwork training in healthcare, focusing not only on communication, but also on other teamwork skills as they often contribute together in adverse events. Future analyses of serious adverse events should include a focus on teamwork competencies, to guide the development of future quality and safety training programs.展开更多
In the cold regions of northern China, incidents of municipal underground gas pipeline rupture and leakage occur quite fi-equently, aaost often in winter. To prevent harm to citizen safety and property, analysis of th...In the cold regions of northern China, incidents of municipal underground gas pipeline rupture and leakage occur quite fi-equently, aaost often in winter. To prevent harm to citizen safety and property, analysis of the causes of such cracking and leakage is therefore valuable. Two incident analyses are discussed here and the reasons why most of these types of cases occur dttring winter are clarified. Fhe effects of vehicle loadings above buried pipelines are calculated and compared with the effects and calculations of frost heaving forces. We demonstrate thtit when the soil layer above a pipeline freezes rapidly, the soil generates repeated frost heaving, which exerts heaving forces on the pipeline that can result in fatigue crack propagation and ultimate pipeline failure. Therefore, the incident induced 9y frost heaving is one of the primary reasons of gas pipeline failure. Based on these analyses, we present some recommendations pertaining to the proper design, construction, and management of gas pipelines.展开更多
文摘This paper explores the contribution of teamwork skills in serious adverse events, using the TeamSTEPPS<sup>®</sup> framework. Adverse events are the undesirable events that are not due to the natural course of a disease;they are considered serious when they prolong a hospital stay, lead to a physical disability or to death. Failures in teamwork, particularly with interprofessional teams, can lead to potential risks to patient safety. Using a dataset of de-identified reports of serious adverse events in 2016 in a tertiary teaching hospital, we explored the contribution of teamwork skills according to the TeamSTEPPS<sup>®</sup> framework to these adverse events. We found that 61% of the 41 analyzed events involved failures in teamwork skills, with 80% of these involving communication, 52% in situation monitoring and team structure, 44% in mutual support and 40% in leadership. Sixty-four percent of the events involved more than one teamwork component. Our findings emphasize the need to improve teamwork training in healthcare, focusing not only on communication, but also on other teamwork skills as they often contribute together in adverse events. Future analyses of serious adverse events should include a focus on teamwork competencies, to guide the development of future quality and safety training programs.
基金supported by the National Natural Science Foundation of China (NNSF) (No. 10472020)the Special Foundation of Dalian University of Technology (DUT) (DUTTX2009-103)
文摘In the cold regions of northern China, incidents of municipal underground gas pipeline rupture and leakage occur quite fi-equently, aaost often in winter. To prevent harm to citizen safety and property, analysis of the causes of such cracking and leakage is therefore valuable. Two incident analyses are discussed here and the reasons why most of these types of cases occur dttring winter are clarified. Fhe effects of vehicle loadings above buried pipelines are calculated and compared with the effects and calculations of frost heaving forces. We demonstrate thtit when the soil layer above a pipeline freezes rapidly, the soil generates repeated frost heaving, which exerts heaving forces on the pipeline that can result in fatigue crack propagation and ultimate pipeline failure. Therefore, the incident induced 9y frost heaving is one of the primary reasons of gas pipeline failure. Based on these analyses, we present some recommendations pertaining to the proper design, construction, and management of gas pipelines.
