# Analysis of patient safety event report categories at one large academic hospital

## TL;DR

This paper analyzes patient safety event reports at a large hospital to identify common causes like poor communication and task prioritization.

## Contribution

The study introduces a methodology using TeamSTEPPS and TENTS to categorize and prioritize patient safety events.

## Key findings

- Most safety events were linked to poor communication and teamwork.
- Lack of situation monitoring and inappropriate task execution were frequent issues.
- The proposed method helps prioritize safety improvement efforts.

## Abstract

Given the persistent safety incidents in operating rooms (ORs) nationwide (approx. 4,000 preventable harmful surgical errors per year), there is a need to better analyze and understand reported patient safety events. This study describes the results of applying the Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) supported by the Teamwork Evaluation of Non-Technical Skills (TENTS) instrument to analyze patient safety event reports at one large academic medical center. Results suggest that suboptimal behaviors stemming from poor communication, lack of situation monitoring, and inappropriate task prioritization and execution were implicated in most reported events. Our proposed methodology offers an effective way of programmatically sorting and prioritizing patient safety improvement efforts.