murphyCharles E. Murphy, MD, is board certified in general surgery, surgical critical care and thoracic and cardiac surgery. He is a former fellow of the American Hospital Association and National Patient Safety Foundation’s Patient Safety Leadership Fellowship program and is active nationally in patient safety initiatives. He currently serves as chief patient safety officer at the Inova Heart and Vascular Institute. Read Dr. Murphy’s profile.

“First, do no harm.” It’s one of the fundamental principles of medicine, and one that healthcare providers take seriously.

Unfortunately, mistakes happen. According to a study published this spring in the British Medical Journal, medical errors are the third leading cause of death in the United States, behind heart disease and cancer. We need to prevent errors from harming our patients.

 Many healthcare organizations say patient safety is a priority. Yet their procedures and administrative structures don’t always back that up. At Inova, we’re taking concrete steps to practice what we preach when it comes to keeping our patients safe.

shutterstock_277159526Teaming Up For Patient Safety

Before joining Inova, I was the associate chief patient safety officer for the Duke University Health System. During that time, Duke was one of six national training centers for a program called TeamSTEPPS. The program improves communication and teamwork skills among healthcare professionals to improve patient safety.

An increasing number of studies are showing that TeamSTEPPS training improves teamwork and outcomes for patients. As a result, hospitals nationwide are beginning to implement the program. This year, we’ve started rolling out TeamSTEPPS throughout Inova Fairfax Hospital.

Improving Communication, Improving Care

Outstanding communication is critical to ensuring patient safety. We’re introducing several important strategies to improve the way our healthcare providers communicate. Those include:

  1. Briefings. At the beginning of every shift, team members come together to get up to speed on what’s happening, such as how many beds are filled, how many patients are scheduled to be moved or discharged and any special information that needs to be shared. This creates a shared “mental model” – or shared thought process – for our team.
  1. Huddles. Just like the Redskins huddle up before a play, we want our healthcare providers to come together to make a plan when shifting gears or making important decisions. If several seriously ill patients show up to the ER at once, for example, the team can huddle to figure out how best to deploy resources.
  1. Closed-loop communication. Have you ever sent an email that went unanswered and wondered if your recipient even saw it? We close the communication loop by repeating instructions back to confirm that the message was received correctly.
  1. Debriefings. At the end of a shift or an event, our teams talk about what went well – and just as importantly, what didn’t. For instance, a team in the intensive care unit recently needed equipment to open a patient’s airway. One of the pieces of the equipment wasn’t in place, causing a delay. At the debriefing, the team identified the problem and implemented steps to make sure all the necessary pieces were ready to go at all times.

Making Safety a Priority

We’re excited to be teaching the TeamSTEPPS program to healthcare teams in all departments across Inova Fairfax Hospital. Already more than a thousand staff members have started attending the trainings. Great teamwork and communication support our journey to preventing errors and improving care for our patients.

I’m proud that Inova Fairfax is emerging as a leader in patient safety. Learn more about the Inova Fairfax Medical Campus.



  1. Gary on November 7, 2016 at 10:32 am

    Teaching Teams often fail the patient and the patient’s family experience in an area that no longer seems important to us-who is the patient’s physician. The doctor-patient relationship has been gutted by TEAM work, especially the weekly turnover in most medical specialties. There is only memory of the patients course in the EMR (with its daily cut and paste notes). The Attending Physician cannot be a fly by week team member but needs consistency, dedication, and ACCOUNTABILITY to the patient.

  2. Charles Murphy, MD on November 9, 2016 at 3:01 pm

    Gary, Thank you for your comment. I fully agree about the importance of the doctor-patient relationship as well as accountability. Our focus on teamwork (which includes the patient and their family) improves the ability of the many members of the healthcare team (doctors, specialists, nurses, techs, pharmacists, respiratory therapists, physical therapists) to function at a very high level with a shared mental model of what is occurring that day and during the hospitalization, as well as providing a solid transition to care after leaving the hospital. The physician is a leader of the care team and is dedicated to the best outcome for his/her patient. Better teamwork and communication help ensure that we do not fail our patients and their families.

  3. Daniel on November 30, 2016 at 9:10 pm

    Dr. Murphy,

    Thank you for the informative commentary. It is great to hear that Inova is implementing the TeamSTEPPS program in the hopes of achieving a shared mental model amongst providers. Great communication (ie. patient-provider, provider-provider, computer-provider, computer-computer) is absolutely key for improving outcomes and ultimately to strive towards value based care. I am curious, have you or your team discussed possible ways to incentivize providers to perform the actions that you’ve listed above?

    • Charles E Murphy on December 1, 2016 at 11:54 am

      Thanks for your comment. I agree with you about great communication.
      You have asked an important question. We have mostly focused on implementing and sustaining the use of these tools to enhance communication and teamwork. We are using unit-based action teams to give real time positive feedback about the use of the tools. In addition, telling stories based on the successful use of these tools also helps. Importantly, these tools work and that is also key to their adoption. We have not directly incentivized use of the tools; many of our incentives are based on optimal patient outcomes, which is the critical goal. We also have the teams report out to a quality group at intervals to monitor the program. Would love to discuss further if you have specific ideas.

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