United States Department of Veterans Affairs

National Center for Patient Safety

Medical Team Training

Medical Team Training

Where the Idea Originated

The idea for Medical Team Training (MTT) came from the realization that many safety issues in health care are related to a failure in communication.

The aviation industry recognized this problem 25 years ago and developed Crew Resource Management (CRM) to address communication failure. CRM is defined as using all available sources (information, equipment, and people) to achieve safe and efficient operations.

The focus of CRM is the safety, efficiency, and morale of humans working together.

Since health care has many features in common with aviation (high profile, complex technology, well educated professionals, and significant risk), NCPS hypothesized that CRM principles would have applications in health care — and they do!

Why it is Important
Studies continue to show that a majority of adverse medical events involve communication failure.

NCPS has developed an internal, confidential, non-punitive system — the Patient Safety Information System (nicknamed “SPOT”). More than 14,700 root cause analysis (RCA) reports and 427,900 safety reports have been recorded in SPOT since NCPS was established.

Upon review of 5,511 of these RCA case reports from VA Medical Centers throughout the United States, 78 percent of the cases identified communication failure as at least one root cause contributing factor in the reported adverse event or close call.

Specifics About the Program

The MTT program was developed in 2003-2004 to improve outcomes of patient care through more effective communication and teamwork among health care providers.

NCPS has conducted 109 MTT Learning Sessions, involving 83 facilities, and targeting more than 7,500 caregivers. The following clinical units were involved:

  • 84 Operating Rooms
  • 65 Intensive Care Units
  • 22 Medical-Surgical Units
  • 51 Ambulatory Clinics
  •   1 Long-Term Care Unit
  • 10 Emergency Departments

The program will also be available to ambulatory care clinics, medical-surgical units, emergency departments, and other clinical units upon request from facility directors of VA Medical Centers.

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Medical Team Training

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