• Edward J Dunn, Peter D Mills, Julia Neily, Michael D Crittenden, Amy L Carmack, and James P Bagian.
• Department of Veterans Affairs National Center for Patient Safety, Ann Arbor, MI, USA. Edward.Dunn@va.gov
• Jt Comm J Qual Patient Saf. 2007 Jun 1;33(6):317-25.

BackgroundCommunication failure, a leading source of adverse events in health care, was involved in approximately 75% of more than 7,000 root cause analysis reports to the Department of Veterans Affairs (VA) National Center for Patient Safety (NCPS).MethodsThe VA NCPS Medical Team Training (MTT) program, which is based on aviation principles of crew resource management (CRM), is intended to improve outcomes of patient care by enhancing communication between health care professionals. Unique features of MTT include a full-day interactive learning session (facilitated entirely by clinical peers in a health care context), administration of pre-and postintervention safety attitudes questionnaires, and follow-up semistructured interviews with reports of program activities and lessons learned.ResultsExamples of projects in these facilities include intensive care unit (ICU) teams' patient-centered multidisciplinary rounds, surgical teams' preoperative briefings and debriefings, an entire operating room (OR) unit's adoption of "Rules of Conduct" for expected staff behavior, and an ICU team's use of the model for daily administrative briefings.DiscussionAn MTT program based on applied CRM principles was successfully developed and implemented in 43 VA medical centers from September 2003 to May 2007.

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