high expectations of family and society, possible disciplinary action, the threat to job security, and expectations of others as reasons for their reluctance to report. Recommendations for improving safety in the ICU focused on increasing staffing, while recommendations for the operating room centered on improved communication patterns (Sexton et al., 2000).

Mentioned frequently in discussions of strategies for error reduction and error recovery by teams is the use of simulations to create real-world conditions of uncertainty and decision-making response. A benefit of this approach is the ability to challenge team members concerning how to react in high-likelihood error situations without jeopardy to individual job security or risk to patients. According to experts, simulation training needs to be ongoing because of the potential for attitudes and skills to decay over time. Simulation procedures also need to be designed in accordance with conditions and experiences of the training organization (Helmreich, 2000).

Simulation methods help in assessing both technical skills and crisis management behaviors, including those associated with decision-making processes and team interaction (Gaba et al., 1998). Gaba and colleagues have successfully used simulations of perioperative crises to assess the technical and behavioral performance of team members and the overall team under high error situations. Included in their assessment of team performance is attention to orientation to case, inquiry/assertion, communication, feedback, leadership, group climate, anticipation/ planning, workload distribution, vigilance, and reevaluation behaviors. A limitation of their simulation process is the deliberate avoidance of combining nonphysicians and physicians on one team. Because most intraoperative crises are likely to include a variety of health care personnel, this restriction limits the application of the simulation procedure to actual practice.

At the University of Texas, an aviation model of threat and error has been adapted to the health care environment. According to the model developers, this approach fits with health care’s input–process–outcomes concept of team performance. Included in the simulation model are individual, team, organizational, environmental, and patient characteristics that contribute to latent and immediate threats to safe care delivery. Immediate threats are those associated with the patient’s condition or care provider’s ability, while latent threats pertain to aspects of the system that predispose to threat or error, such as staffing mix and number of staff (Helmreich, 2000).

Because health care teams are often dissimilar in makeup from other groups that have used simulations successfully, some additional refinement and study are needed to ascertain the most effective use of this training technology. In keeping with the high levels of stress and uncertainty associated with decision making in health care, computer applications and other



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