MAS 2011 Proceeding

Improving Patient Safety: A Model of Drift in Health Care Teams

Authors:   R. Severinghaus, C. Donald Combs


Rasmussen & Cook (2005) provide a framework for developing a model of risk management to improve patient safety by applying systems dynamics modeling to understand team performance and how it drifts from best practices. Drifting into failure is not so much about individual deficits as it is about organizations not adapting effectively to the complexity of their structure and environment (Dekker 2005). Expanding the conceptual model using the taxonomy of the medical domain to more fully define the interconnections of individual and team performance, risk assessment, management of resources, and recognition of the limits of team workload and maintenance of high performance is an essential next step. Lamb, et. al. (2010) indicates the usefulness of modeling drift in the naval domain. This paper summarizes research underway to develop a health care team specific model of drift. This model characterizes the sets of factors that influence team performance boundaries, identifies and describes team performance and decision making behaviors that determine the size and positioning of the team operating space, a concept developed within the model. A dynamic system will then be described in a manner that can serve as the basis for the development of a variety of simulations intended to improve team performance, maintain high performance over time, and thus improve patient safety.

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