A practical approach to observation of the emergency care setting.

T he most astute clinicians would have to admit to occasionally being caught unaware by looking without seeing. We are trained to collect and analyze data, but we often make clinical decisions based on past experiences and shared anecdotes from our colleagues, as well as learned scholars and teachers. We also know that to care for a sick patient, we must conduct an observational assessment of what is happening, as well as what is not happening, to that patient. The same applies when attempting to diagnose, treat and heal a “sick” healthcare system. Health care teamwork training, which contains modified elements of crew resource management (CRM) and the science of teamwork, is being suggested as a method for improving teamwork between disciplines that could lead to a reduction in medical error. Airline pilots are evaluated for teamwork competencies by trained observers during actual flight conditions as well as in simulation. In our experience, learned from both aviation and healthcare, survey self-reporting and didactic training with traditional methods of evaluation (ie, written testing) are limited in ability to identify threats to safety thoroughly, especially when services are delivered by teams rather than individuals. To detect changes in behavior, direct observation of the healthcare team in the “living laboratory” of the clinical setting has been confirmed as an additional methodology that helps to identify and analyze these threats and opportunities for improvement as well as the existing safety culture. Observations before structured teamwork training initiatives can identify specific teamwork opportunities to customize training content; observations after training measure team behavioral change. Observations do not consist of simply standing in a room and watching the clinical milieu. Observational methodology must be taught, nurtured, and encouraged, as well as held to the highest standards, as in any other scientific discipline.