Figure 2. Example of behaviors that contribute to teamwork failures in the closed case review.

In 54 cases where poor teamwork was judged to contribute to the clinical error, failure to: Assign roles and responsibilities to team members had a frequency of teamwork failure of 13 percent, of which 5 percent was the primary contributor to the failure and 7 percent a contributor to the failure; Hold team members accountable had a frequency of teamwork failure of 16 percent, of which 10 percent was the primary contributor to the failure and 6 percent a contributor to the failure; Identify established protocol to be used or develop a plan had a frequency of teamwork failure of 19 percent, of which 11 percent was the primary contributor to the failure and 8 percent a contributor to the failure; Advocate or assert a position or corrective action had a frequency of teamwork failure of 17 percent, of which 13 percent was the primary contributor to the failure and 4 percent a contributor to the failure; Use check back process to verify communication had a frequency of teamwork failure of 12 percent, of which 6 percent was the primary contributor to the failure and 6 percent a contributor to the failure; Communicate plan to team members had a frequency of teamwork failure of 12 percent, of which 5 percent was the primary contributor to the failure and 7 percent a contributor to the failure; Seek information for decision making had a frequency of teamwork failure of 15 percent, of which 0 percent was the primary contributor to the failure and 6 percent a contributor to the failure; Prioritize tasks for a patient had a frequency of teamwork failure of 17 percent, of which 12 percent was the primary contributor to the failure and 5 percent a contributor to the failure; Cross monitor actions of team members had a frequency of teamwork failure of 28 percent, of which 19 percent was the primary contributor to the failure and 9 percent a contributor to the failure

Return to Document