Importance of high-performing teams in the cardiovascular intensive care unit
2021; Elsevier BV; Volume: 163; Issue: 3 Linguagem: Inglês
10.1016/j.jtcvs.2021.02.098
ISSN1097-685X
AutoresLauren R. Kennedy-Metz, Atílio Barbeito, Roger D. Dias, Marco A. Zenati,
Tópico(s)Surgical Simulation and Training
ResumoCentral MessageThe CVICU team is a complex action team providing care to high-acuity patients in a challenging environment. Evidence-based teamwork interventions are critical to deliver high-quality care in the CVICU.See Commentaries on pages 1105 and 1106. The importance of teamwork in health care delivery and patient safety is increasingly being recognized1Wahr J.A. Prager R.L. Abernathy III, J.H. Martinez E.A. Salas E. Seifert P.C. et al.Patient safety in the cardiac operating room: human factors and teamwork: a scientific statement from the American Heart Association.Circulation. 2013; 128: 1139-1169Crossref PubMed Scopus (190) Google Scholar and has benefitted substantially by adopting a human factors' perspective and approach. The scientific field of human factors can be defined in many ways, but the commonality across definitions and applications is the focus on those components within an interactive system related to human functionality and fallibility. By recognizing human-centric and human-driven strengths and flaws in a complex system, we may be able to better understand their root causes to maintain performance-enhancing behaviors and improve or support error-generating behaviors. As systems increase in complexity, consequences of suboptimal performance become more severe, demands become excessive and time-sensitive, and human lives are at stake, relying on teams represents a natural solution to enhance perspective, decision-making, and global knowledge beyond the individual level.2Salas E. Cooke N.J. Rosen M.A. On teams, teamwork, and team performance: discoveries and developments.Hum Factors J Hum Factors Ergon Soc. 2008; 50: 540-547Crossref PubMed Scopus (690) Google Scholar In a system as complex as health care, optimal teamwork requires collaboration within and across organizational, disciplinary, technical, and cultural boundaries. Although recent literature has indicated a substantial role of cognitive errors in the occurrence of adverse events in health care, teamwork and communication combined were identified as human performance deficiencies contributing to adverse events in more than 17% of cases.3Suliburk J.W. Buck Q.M. Pirko C.J. Massarweh N.N. Barshes N.R. Singh H. et al.Analysis of human performance deficiencies associated with surgical adverse events.JAMA Netw Open. 2019; 2: e198067Crossref PubMed Scopus (32) Google Scholar According to Salas and colleagues' teamwork model,4Salas E. Sims D. Burke C.S. Is there a “big five” in teamwork?.Small Gr Res. 2005; 36: 555-599Crossref Scopus (1164) Google Scholar effective teamwork is based on the quality of team leadership, mutual performance monitoring, back-up behavior, adaptability, and a team orientation at its core. In addition, mutual trust, closed-loop communication, and shared mental models underlie and coordinate the 5 core dimensions in this model. Of these features, the shared mental model serves as the cornerstone for effective teamwork in health care5Westli H.K. Johnsen B.H. Eid J. Rasten I. Brattebø G. Teamwork skills, shared mental models, and performance in simulated trauma teams: an independent group design.Scand J Trauma Resusc Emerg Med. 2010; 18: 1-8Crossref PubMed Scopus (110) Google Scholar and has been ranked as one of the most essential teamwork factors in cardiac surgery in particular.6Brown E.K.H. Harder K.A. Apostolidou I. Wahr J.A. Shoo D.C. Farivar R.S. et al.Identifying variability in mental models within and between disciplines caring for the cardiac surgical patient.Anesth Analg. 2017; 125: 29-37Crossref PubMed Scopus (12) Google Scholar A shared mental model refers to the shared cognition in a team as a collectivity7Rouse W.B. Cannon-Bowers J.A. Salas E. The role of mental models in team performance in complex systems.IEEE Trans Syst Man Cybern Syst. 1992; 22: 1296-1308Crossref Scopus (278) Google Scholar and may be described as the extent to which individuals possess a similar cognitive representation of some situation. Effective shared mental models produce mutual awareness, with which team members can reason about not only their own situation but also the status of team members in the pursuit of joint goals. Shared mental models are proposed to explain certain coordinated team behaviors. Common knowledge (beliefs) of the domain problem under concern, communication protocols to use, and assumptions to take (eg, sincerity, communication reliability) establishes a common basis for agents to understand and respond to each other's behaviors. A team structure may specify such information as team membership, subteam relations, predetermined leader, roles each member can play, capability requirements, and so forth. To have a shared team structure enables an individual to develop a higher-level abstraction about the capabilities, expertise, and responsibilities of other team members. Among high-performing medical teams, interdisciplinary teamwork has been associated with improved patient outcomes in emergency medicine,8Alsabri M. Boudi Z. Lauque D. Dias R.D. Whelan J. Östlundh L. et al.Impact of teamwork and communication training interventions on safety culture and patient safety in emergency departments.J Patient Saf. September 7, 2020; ([Epub ahead of print])Crossref Scopus (9) Google Scholar critical care medicine,9Donovan A.L. Aldrich J.M. Gross A.K. Barchas D.M. Thornton K.C. Schell-Chaple H.M. et al.Interprofessional care and teamwork in the ICU.Crit Care Med. 2018; 46: 980-990Crossref PubMed Scopus (108) Google Scholar and internal medicine10Havyer R.D.A. Wingo M.T. Comfere N.I. Nelson D.R. Halvorsen A.J. McDonald F.S. et al.Teamwork assessment in internal medicine: a systematic review of validity evidence and outcomes.J Gen Intern Med. 2014; 29: 894-910Crossref PubMed Scopus (70) Google Scholar through various settings. Effective teamwork skills have also been documented as significant predictors for patient outcomes, demonstrated through medical simulation involving participants across health professions.11Shrader S. Kern D. Zoller J. Blue A. Interprofessional teamwork skills as predictors of clinical outcomes in a simulated healthcare setting.J Allied Health. 2013; 42: 1E-6EPubMed Google Scholar,12Robertson J.M. Dias R.D. Yule S. Smink D.S. Operating room team training with simulation: a systematic review.J Laparoendosc Adv Surg Tech. 2017; 27: 475-480Crossref PubMed Scopus (40) Google Scholar In surgical departments, poor communication and information sharing, both critical teamwork behaviors, have been associated with higher occurrences of complications and death.13Mazzocco K. Petitti D.B. Fong K.T. Bonacum D. Brookey J. Grahma S. et al.Surgical team behaviors and patient outcomes.Am J Surg. 2009; 197: 678-685Abstract Full Text Full Text PDF PubMed Scopus (497) Google Scholar Meanwhile, discrepancies exist between perceived teamwork levels in operative settings,14Makary M.A. Sexton J.B. Freischlag J.A. Holzmueller C.G. Millman E.A. Rowen L. et al.Operating room teamwork among physicians and nurses: teamwork in the eye of the beholder.J Am Coll Surg. 2006; 202: 746-752Abstract Full Text Full Text PDF PubMed Scopus (460) Google Scholar complicating the ability to accurately measure and improve teamwork. Additional barriers to effective teamwork in the operating room (OR) environment exist on individual, environmental, institutional levels, and cultural levels.15Weller J. Boyd M. Cumin D. Teams, tribes and patient safety: overcoming barriers to effective teamwork in healthcare.Postgrad Med J. 2014; 90: 149-154Crossref PubMed Scopus (328) Google Scholar Examples range from how an individual copes with cognitive demands, to environmental barriers associated with uneven lighting and excessive noise, to institutional burdens associated with teaching requirements in academic hospital settings, to the cultural implications of a deeply rooted hierarchical system with an inherent imbalance among power dynamics. Highly functioning teams are tasked with overcoming these and additional barriers under oftentimes adverse and time-sensitive conditions during a patient's hospital stay. Additionally, patient care and interdisciplinary team interaction continue beyond the OR, where effective and dynamic teamwork is critical in both the handover process and the patient's intensive care stay. In surgery, recent initiatives have been adopted in the United States and worldwide,16Tsuburaya A. Soma T. Yoshikawa T. Cho H. Miki T. Uramatsu M. et al.Introduction of the non-technical skills for surgeons (NOTSS) system in a Japanese Cancer Center.Surg Today. 2016; 46: 1451-1455Crossref PubMed Scopus (21) Google Scholar, 17Scott J. Revera Morales D. Mcritchie A. Riviello R. Smink D. Yule S. Non-technical skills and health care provision in low- and middle-income countries: a systematic review.Med Educ. 2016; 50: 441-455Crossref PubMed Scopus (32) Google Scholar, 18Pradarelli J.C. Gupta A. Lipsitz S. Smink D.S. Yule S. Evaluating the non-technical skills for surgeons assessment tool adapted to the US surgical context.J Am Coll Surg. 2019; 229: S242Abstract Full Text Full Text PDF Google Scholar aiming to train surgical providers, from novices to senior levels, on important nontechnical skills, such as situational awareness, leadership, decision-making, communication, and teamwork. In fact, in 2016, the American College of Surgeons adopted and recommended nontechnical skills training beginning during undergraduate medical education and continuing through surgical residency and postgraduate training as a requirement of ongoing Maintenance of Certification.19Scott D.J. Dunnington G.L. The new ACS/APDS skills curriculum: moving the learning curve out of the operating room.J Gastrointest Surg. 2008; 12: 213-221Crossref PubMed Scopus (250) Google Scholar Furthermore, the Non-Technical Skills for Surgeons framework has implemented and validated to the US surgical context as a team-training platform.18Pradarelli J.C. Gupta A. Lipsitz S. Smink D.S. Yule S. Evaluating the non-technical skills for surgeons assessment tool adapted to the US surgical context.J Am Coll Surg. 2019; 229: S242Abstract Full Text Full Text PDF Google Scholar The cardiovascular intensive care unit (CVICU), is a complex socio-technical system where critical care is delivered with the support of sophisticated technology to treat and prevent complications arising from advanced postsurgical care: The ultimate success of the delivery of care rests on the multidisciplinary team of clinical providers.20Kasaoka S. Evolved role of the cardiovascular intensive care unit (CICU).J Intensive Care. 2017; 5: 1-5Crossref PubMed Scopus (17) Google Scholar The CVICU team may be described as an action team. Action teams are “interdisciplinary teams that often work under complex, dynamic, and time-pressured conditions to accomplish critical patient care tasks.”21Janssens S. Simon R. Beckmann M. Marshall S. Shared leadership in healthcare action teams: a systematic review.J Patient Saf. June 4, 2018; ([Epub ahead of print])Crossref PubMed Scopus (9) Google Scholar Action teams differ from regular teams in that they are highly specialized, have a dynamic membership structure, incorporate different professional cultures, work together for short periods, and have to improvise and coordinate their actions in intense, unpredictable situations.22Edmondson A.C. Speaking up in the operating room: how team leaders promote learning in interdisciplinary action teams.J Manag Stud. 2003; 40: 1419-1452Crossref Scopus (1024) Google Scholar The typical CVICU team is led by a physician specialized in intensive care medicine and is composed of bedside nurses, several respiratory therapists and physical therapists, a clinical pharmacist, a nutritionist, and occasionally other team members such as a psychologist and a chaplain. Given that the cardiothoracic critical care patient population is increasingly older and sicker, and surgical procedures are also growing in complexity, CVICU intensivists leading the team require a unique combination of skills that include basic critical care training plus additional skills and familiarity with cardiothoracic surgery and perioperative care principles. Recognizing this need, other surgical and medical societies have advocated for a specific training in cardiothoracic critical care and some critical care programs are offering combined critical care fellowship pathways with an emphasis in cardiothoracic care.23Dual training in adult cardiothoracic anesthesia|Society of Cardiovascular Anesthesiologists.https://www.scahq.org/dual-training-in-adult-cardiothoracic-anesthesia/Date accessed: February 5, 2021Google Scholar, 24Stamou S.C. Camp S.L. Stiegel R.M. Reames M.K. Skipper E. Watts L.T. et al.Quality improvement program decreases mortality after cardiac surgery.J Thorac Cardiovasc Surg. 2008; 136: 6-11Abstract Full Text Full Text PDF Scopus (43) Google Scholar, 25Katz J.N. Minder M. Olenchock B. Price S. Goldfarb M. Washam J.B. et al.The genesis, maturation, and future of critical care cardiology.J Am Coll Cardiol. 2016; 68: 67-79Crossref PubMed Scopus (60) Google Scholar Family members are also considered part of the team in most modern CVICUs.26Au S.S. Roze des Ordons A.L. Parsons Leigh J. Soo A. Guienguere S. Bagshaw S.M. et al.A multicenter observational study of family participation in ICU rounds.Crit Care Med. 2018; 46: 1255-1262Crossref PubMed Scopus (19) Google Scholar Each of these disciplines brings a unique set of perspectives, vocabulary, and skills, which typically add value to the care provided by the CVICU team. Unfortunately, these differences also may lead to conflict and ineffective interactions among the team members. Unresolved conflict may further hinder communication and may perpetuate or accentuate poor team performance.27Azoulay É. Timsit J.F. Sprung C.L. Soares M. Rusinová K. Lafbrie A. et al.Prevalence and factors of intensive care unit conflicts: the conflicus study.Am J Respir Crit Care Med. 2009; 180: 853-860Crossref PubMed Scopus (363) Google Scholar Another characteristic of the CVICU team is the existence of hierarchies and power differences among the team members, which may inhibit information exchange, especially during rounds where most of the members are present and have the opportunity to speak up, and where shared goals are established or maintained.28Ervin J.N. Kahn J.M. Cohen T.R. Weingart L.R. Teamwork in the intensive care unit.Am Psychol. 2018; 73: 468-477Crossref PubMed Scopus (67) Google Scholar In addition to high patient acuity and complex team dynamics, CVICU teams perform under uniquely challenging physical and emotional constraints that may affect team performance.28Ervin J.N. Kahn J.M. Cohen T.R. Weingart L.R. Teamwork in the intensive care unit.Am Psychol. 2018; 73: 468-477Crossref PubMed Scopus (67) Google Scholar The challenging environment of constant alarms, uneven lighting, space limitations and improperly placed equipment typical of the CVICU all affect the performance of the team.29Bartley J. Streifel A.J. Design of the environment of care for safety of patients and personnel: does form follow function or vice versa in the intensive care unit?.Crit Care Med. 2010; 38: S388-S398Crossref PubMed Scopus (35) Google Scholar Furthermore, the emotional distress brought on by stressors such as high workload, high-stakes situations, and frequent experiences of death and grieving can reduce team performance.30Piquette D. Reeves S. LeBlanc V.R. Stressful intensive care unit medical crises: how individual responses impact on team performance.Crit Care Med. 2009; 37: 1251-1255Crossref PubMed Scopus (43) Google Scholar At the interface of perioperative and postoperative care, the patient is transitioned from the OR to the intensive care unit (ICU) teams during the “handover.”31Segall N. Bonifacio A.S. Schroeder R.A. Barbeito A. Rogers D. Thornlow D.K. et al.Can we make postoperative patient handovers safer? A systematic review of the literature.Anesth Analg. 2012; 115: 102-115Crossref PubMed Scopus (172) Google Scholar Patient handover is fraught with potential risk for preventable technical and communication errors32Catchpole K.R. De Leval M.R. Mcewan A. Pigott N. Elliot M.J. McQuillan A. et al.Patient handover from surgery to intensive care: using formula 1 pit-stop and aviation models to improve safety and quality.Paediatr Anaesth. 2007; 17: 470-478Crossref PubMed Scopus (372) Google Scholar; human-derived flow disruptions33Kowitlawakul Y. Leong B.S.H. Lua A. Aroos R. Wong J.J. Koh N. et al.Observation of handover process in an intensive care unit (ICU): barriers and quality improvement strategy.Int J Qual Health Care. 2015; 27: 99-104PubMed Google Scholar are also common. Patients transitioning to the CVICU from cardiac surgery are particularly vulnerable to the negative outcomes associated with poor handovers.1Wahr J.A. Prager R.L. Abernathy III, J.H. Martinez E.A. Salas E. Seifert P.C. et al.Patient safety in the cardiac operating room: human factors and teamwork: a scientific statement from the American Heart Association.Circulation. 2013; 128: 1139-1169Crossref PubMed Scopus (190) Google Scholar Previous work has suggested that up to 28% of surgical adverse events were documented during transitions of care, including the handover process.34Gawande A.A. Zinner M.J. Studdert D.M. Brennan T.A. Analysis of errors reported by surgeons at three teaching hospitals.Surgery. 2003; 133: 614-621Abstract Full Text Full Text PDF PubMed Scopus (739) Google Scholar Further, during the postoperative handover in particular, adverse events are associated with poorly executed handovers.31Segall N. Bonifacio A.S. Schroeder R.A. Barbeito A. Rogers D. Thornlow D.K. et al.Can we make postoperative patient handovers safer? A systematic review of the literature.Anesth Analg. 2012; 115: 102-115Crossref PubMed Scopus (172) Google Scholar To adequately address and mitigate preventable errors during the handover, clinicians and patient safety experts have advocated for a human-centric approach.35Segall N. Bonifacio A.S. Barbeito A. Schroder R.A. Perfect S.R. Wright M.C. et al.Operating room-to-ICU patient handovers: a multidisciplinary human-centered design approach.Jt Comm J Qual Patient Saf. 2016; 42 (AP1-AP5): 400-409Abstract Full Text Full Text PDF PubMed Google Scholar With appropriately designed interventions targeting teamwork and communication, it is possible to improve efficiency and effectiveness of the handover process.31Segall N. Bonifacio A.S. Schroeder R.A. Barbeito A. Rogers D. Thornlow D.K. et al.Can we make postoperative patient handovers safer? A systematic review of the literature.Anesth Analg. 2012; 115: 102-115Crossref PubMed Scopus (172) Google Scholar In summary, the CVICU team is an action team that provides care to a high-acuity patient population, exhibits complex team composition and dynamics, and operates in an emotionally and physically adverse environment. Activities targeted at improving teamwork are paramount to delivering high-quality care in the CVICU. Despite the known necessity for effective teamwork, the health care domain has surprisingly underinvested in structured and evidence-based practices for managing teams and coordinating care.36Institute of MedicineTo Err Is Human: Building a Safer Health System. 71. The National Academies Press, Washington, DC2000Google Scholar But given the strength of observed improvements in ICU teamwork and their association with improved patient outcomes,37Baggs J.G. Schmitt M.H. Mushlin A.I. Mitchell P.H. Eldredge D.H. 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Improving teamwork in healthcare: current approaches and the path forward.Postgrad Med J. 2012; 88: 245-248Crossref PubMed Scopus (8) Google Scholar To improve teamwork dynamics, the first step is to measure teamwork components and identify barriers to effective teamwork. Tools used to measure teamwork in health care have largely relied on self-report or observational approaches.42Rosen M.A. Schiebel N. Salas E. Wu T.S. Silvestri S. King H.B. Improving patient safety through teamwork and team training.in: Salas E. Frush K. How can team performance be measured, assessed, and diagnosed? Oxford University Press, Oxford, UK2012: 59-79Google Scholar A more objective approach is required to compensate for the shortcomings associated with these approaches.43Jeffcott S.A. Mackenzie C.F. Measuring team performance in healthcare: review of research and implications for patient safety.J Crit Care. 2008; 23: 188-196Crossref PubMed Scopus (56) Google Scholar In addition to being more cost-effective and less biased, objective approaches incorporating sensor technology (eg, radio frequency identification tags, infrared sensors, audio/video recording devices, computer vision, and accelerometers) are capable of objectively capturing and evaluating teamwork behaviors (eg, behavior, speech analysis, team centrality, device, workplace locations) in an automated way.44Rosen M.A. Dietz A.S. Yang T. Priebe C.E. Pronovost P.J. An integrative framework for sensor-based measurement of teamwork in healthcare.J Am Med Inform Assoc. 2014; 22: 11-18Crossref PubMed Scopus (47) Google Scholar Barriers to interdisciplinary teamwork must then be identified and measured, preferably using multiple modalities, to target appropriate changes to introduce. Common obstacles facing ICU teamwork that have been identified previously include educational, psychological, and organizational/cultural barriers.15Weller J. Boyd M. Cumin D. Teams, tribes and patient safety: overcoming barriers to effective teamwork in healthcare.Postgrad Med J. 2014; 90: 149-154Crossref PubMed Scopus (328) Google Scholar In particular, factors such as the number of providers involved in the handover process, frequent trainee rotation schedules, and high staff turnover contribute to these barriers on many levels. Tangible and accessible approaches to overcoming these barriers and promoting an environment of diligence may incorporate cognitive engineering approaches previously identified in cardiothoracic surgery,45Zenati M.A. Kennedy-Metz L. Dias R.D. Cognitive engineering to improve patient safety and outcomes in cardiothoracic surgery.Semin Thorac Cardiovasc Surg. 2019; 32: 1-7Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar which are readily adaptable to the CVICU setting. In this context, the use of cognitive aids and emphasis on the “sterile cockpit”46Wadhera R.K. Parker S.H. Burkhart H.M. Greason K.L. Neal J.R. Levenick K.M. et al.Is the “sterile cockpit” concept applicable to cardiovascular surgery critical intervals or critical events? The impact of protocol-driven communication during cardiopulmonary bypass.J Thorac Cardiovasc Surg. 2010; 139: 312-319Abstract Full Text Full Text PDF PubMed Scopus (108) Google Scholar have a high potential to influence behaviors and outcomes. Introducing a straightforward but standardized handover form prepared by the anesthesiologist to document the details of the procedure, patient requirements (eg, mechanical ventilation), team members involved, any complexities associated with the patient's course, and current lines and infusions functions to update the ICU nurse and has been shown to increase overall satisfaction with the handover process.35Segall N. Bonifacio A.S. Barbeito A. Schroder R.A. Perfect S.R. Wright M.C. et al.Operating room-to-ICU patient handovers: a multidisciplinary human-centered design approach.Jt Comm J Qual Patient Saf. 2016; 42 (AP1-AP5): 400-409Abstract Full Text Full Text PDF PubMed Google Scholar A systematic review of handover characteristics concluded that the introduction of a standardized handover document was associated with significant improvements in the majority of studies.47Foster S. Manser T. The effects of patient handoff characteristics on subsequent care: a systematic review and areas for future research.Acad Med. 2012; 87: 1105-1124Crossref PubMed Scopus (71) Google Scholar This finding has since been corroborated, in addition to the observed increase in confidence and reduction in perceived near-miss events, in a controlled trial evaluating the effectiveness of a structured handover tool in comparison with traditional methods of conducting the OR-ICU handover.48Payne C.E. Stein J.M. Leong T. Dressler D.D. Avoiding handover fumbles: a controlled trial of a structured handover tool versus traditional handover methods.BMJ Qual Saf. 2012; 21: 925-932Crossref PubMed Scopus (37) Google Scholar In cardiac surgery in particular, the introduction of a standardized OR-CVICU handover protocol involving a multidisciplinary team demonstrated a significant reduction in technical errors and omissions of verbal handover information.49Joy B.F. Elliott E. Hardy C. Sullivan C. Backer C.L. Kane J.M. Standardized multidisciplinary protocol improves handover of cardiac surgery patients to the intensive care unit.Pediatr Crit Care Med. 2011; 12: 304-308Crossref PubMed Scopus (150) Google Scholar A more recent interventional study analyzing the transition from OR to CVICU additionally introduced a sterile cockpit time-out and observed fewer handover interruptions and more frequent postoperative patient care planning, without a substantial increase in handover duration. Participants also reported improvements in self-perceived teamwork, content received, and patient care planning.50Gleicher Y. Mosko J.D. McGhee I. Improving cardiac operating room to intensive care unit handover using a standardised handover process.BMJ Open Qual. 2017; 6: e000076Crossref PubMed Google Scholar Additional cognitive aids, such as wall-mounted posters, may facilitate the handover process further by reminding providers of critical elements and providing additional structure (eg, Figure 1). Encouraging nursing staff to play an active role in listening, asking questions, and taking notes while the entire team is present for the duration of the handover ensures that team members are actively updating their mental models to drive optimal teamwork. Given the vulnerability of communication processes at transition points such as the handover, a focus on enhancing the quality and frequency of communication is strongly recommended as a method of improving the optimal teamwork required to produce an effective patient transition to the CVICU. To effectively integrate cultural changes in an environment such as the health care system, psychological safety must be established and fostered. Psychological safety in health care environments refers to willingness to take interpersonal risks at work, whether to admit an error, ask a question, seek help, or simply say “I don't know.” Although it seems intuitive that a behavioral style of health care teams that encourages criticism-free team communication should result in better clinical outcomes, Edmondson51Edmondson A.C. Learning from mistakes is easier said than done: group and organizational influences on the detection and correction of human error.J Appl Behav Sci. 2004; 40: 66-90Crossref Scopus (129) Google Scholar found that hospital units characterized by high-quality relationships, supportive and available leadership, and expectations of excellence somewhat surprisingly had higher error rates. The hypothesis to explain this paradox is that high-functioning teams were not committing more errors; they were just more able to disclose, discuss, and learn from them. It is important to realize that only a small fraction of errors lead to patient harm (eg, those errors that lead to an “error cycle”), and most of them are related to being an intrinsically fallible human being. To consider errors as “treasures” means to take full advantage of the learning opportunity provided by disclosure of errors or near misses in environments that are psychologically safe. Notably, recent work has demonstrated the modifiable nature of psychological safety through a systematic team training framework, providing evidence of trends toward improvements in teamwork, communication, psychological safety, and patient outcomes.52Ridley C.H. Al-Hammadi N. Maniar H.S. Abdallah A.B. Steinberg A. Bollini M.L. et al.Building a collaborative culture: focus on psychological safety and error reporting.Ann Thorac Surg. 2021; 111: 683-689Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar Simulation-based training is an effective method to improve not only technical skills but also teamwork in a variety of health care settings,53Eppich W. Howard V. Vozenilek J. Curran I. Simulation-based team training in healthcare.Simul Healthc J Soc Simul Healthc. 2011; 6: S14-S19Crossref PubMed Scopus (93) Google Scholar including the CVICU.54Nunink L. Welsh A.M. Abbey M. Buschel C. In situ simulation-based team training for post-cardiac surgical emergency chest reopen in the intensive care unit.Anaesth Intensive Care. 2009; 37: 74-78Crossref PubMed Google Scholar, 55Figueroa M. Sepanski R. Goldb
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