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Do No Harm: A Case Study of Interprofessional Healthcare Team Adaptation in Response to Adverse Events Open Access

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This qualitative, explanatory case study addressed one primary research question: How do interprofessional healthcare teams adapt in response to an adverse event? There were two subquestions: How does employing the components of change enable interprofessional healthcare teams to adapt? and How does employing the components of team enable interprofessional healthcare teams to adapt? Despite knowledge of the benefits of interprofessional teams, flawed teamwork is often to blame for adverse events (Manser, 2009). Unfortunately, most studies have not identified what aspects of teamwork need to be improved to prevent adverse events. In addition, Bowie, Skinner, and de Wet (2013) concluded from a study of healthcare root cause analysis (RCA) conducted after adverse events that only 82% of changes suggested by the RCA were implemented fully or partially. Literature that addresses how teams adapt after an adverse event is limited. This study examined three interprofessional healthcare teams within a large academic medical center. Data gathered from document review, supervisor interviews, focus groups, and team member interviews were used to explain how teams adapted in response to an adverse event by examining factors related to change and teams. The contributions of factors of change and teams to team adaptation were also revealed. The study offered the following broad conclusions. First, it is important to capture ongoing learnings from teams beyond the RCA. Second, the type and pace of change contribute to how ambiguity manifests. Third, a common mental model focused on the patient enables teams to make changes to reduce harm. Fourth, strong communication and leadership can help reduce ambiguity resulting from change. Fifth, team learning is robust when relationship conflict is minimal and psychological safety is strong. Lastly, team adaptation is composed of cognitive and behavioral adaptations, which are enabled by change and team factors, respectively. The study concludes with implications for theory and practice, as well as recommendations for further research.

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