Team of Teams

Last year the BMJ reported medical error as the third greatest cause of death in healthcare.

Does the design of error reporting systems render them powerless to change this?

Current systems are designed using a command structure:


Command structures have been present for hundreds of years and were used with great effect to improve efficiency during the industrial era. However they only work when those in charge actually understand how everything will interact.

Healthcare work environments have become so complex that it’s impossible for those at the top to truly understand the nuances of front line work.


Perhaps the ability to predict the outcome to an intervention is what separates an issue which is merely complicated from one which is complex.

For example if staff continue to pour antiseptic solutions into unlabelled gallipots despite a policy dictating otherwise this is a complex problem.

With so many interactions at play, one cannot reasonably forecast the output based on the input (the policy). In this case interactions include staff turnover, limited access to the policy, historical practices, lack of access to sterile labels, poor awareness of adverse events, time pressure…..

You cannot force the complex to merely conform to rules meant for the complicated.

Further, the command structure of current error reporting systems secludes vital information.

An error which occurs at hospital or department ‘X’ cannot be learnt from by those in hospital ‘Y’. It can only be shown to other parties if released by those at the top on a ‘need to know’ basis. The problem with this logic depends on the assumption someone actually knows who does and who doesn’t need to know what.

Competition between departments and hospitals has been used in the past to help drive improvement – in effect generating a ‘command of teams’. However competition stifles cooperation and inhibits the valuable sharing of information.


If we remove a hazard at one institution are we not morally obliged to remove it elsewhere?

How we organise structure says a lot about how we think people behave, but how people behave is often a by product of how we set up structure.

Error reporting systems, through their command design send out a message that error information is to be secluded.

We become more concerned with how best to control information than how best to share it. This culture permeates throughout healthcare. As a result dispersed information about adverse events becomes even more scarce and much less impactive.

That there are no systems for reporting hazards conveys a message front line staff should just put up with their work environments.

As healthcare stands few will be criticised if we maintain the status quo, keep quiet about the hazards yet present the adverse events which occur because of their presence into inneffective opaque reporting systems. As a result the same adverse events repeat again and again and again.

Healthcare safety would benefit from a transparent de-identified medical error and hazard reporting system which generates networked teams to conceive effective solutions. Progress made on generating these solutions should be available for everyone to see.

Greater transparency about what is being done to achieve a goal is a massive boost to morale.

Solutions should be developed by those most likely to understand what will be effective – front line workers and human factors engineers working in teams with others from numerous backgrounds.

The role of those currently at the top of command structures needs to change. They need to develop an ‘eyes on hands off’ approach, where they can view everything that is happening, provide support where it is needed, request more information to help guide decisions and supervise processes. Their role should no longer be one of controlling puppet master but rather that of an empathetic crafter of culture.

We all want the best for patients. Let’s provide frameworks to deliver this, frameworks where anyone is able to drive improvement kept in check by others.

In empowering those on the front line, solutions will come more quickly, their quality will be greater and they will be much more effective.

For patient safety to improve we’ll need to become a ‘Team of Teams’.



Much of the text of this post has been adapted from ‘Team of Teams’ by General Stanley McChrystal et al – we highly recommend you read it.


Below we discuss several ‘command’ solutions (click on links in red) in response to error reports. They’ve been developed by those at the top of command structure error reporting systems.

Within the command structure everyone is doing the right thing – front line staff are reporting an adverse event, the adverse event is being entered into a secure error database, the information is reviewed by the custodians of the error report information who work diligently to develop a solution. This solution is then passed back down to the front line. Everyone has done right thing within the command structure however nothing has been done right – the solutions have minimal if any effect on the front line.

We provide alternative effective solution which we hope to deliver.

Command Solution – Reminder for staff to clamp off central lines to avoid air emboli
Effective Solution – Only use central lines which don’t open to air

Command Solution – Policy to inhibit re-spiking of IV fluid bags to prevent air emboli
Effective Solution – Use only IV fluid bags which don’t entrain air when disconnected

Command Solution – Safety notice
Effective Solution – Ban Indistinct Pourable Chlorhexidine

Command Solution – Proposals to Gas Pipeline Mix Up
Effective Solution – Use of gas analysers in resuscitation areas

Command Solution – Alert about hazardous Draeger APL valves
Effective Solution – Recall Draeger APL valves

Command Solution – Admonish hospital staff for not maintaining dental drills
Effective Solution – Use only dental drills which cut out if they heat up

We’ve chosen these examples to help illustrate the problems with patient safety. All of these unnecessary hazards (and thousands more like them) still exist within hospitals throughout the world. While we have command structures of error reporting they will persist. We’re working to remove them and creating great networks for future progress.

The patient safety machine is broken – perhaps it’s design and the increasing complexity of our work environments meant it could never work.

We’re excited with the prospect of developing a network to drive effective patient safety improvements.

You can help and we would very much appreciate your input. Please get in touch.

11 thoughts on “Team of Teams

  1. If you want to improve patient safety, please make it simple, focus on values, culture, good leadership, good governance and excellent staff and patient engagement and mostly use IT so that staff do not spend time filling same details again and again and medicine errors can be totally eliminated.

    We have reduced harm by 90% simply by keeping it simple and making it as human stories. Healthcare is about kindness, caring and compassion and we need leaders who are kind, caring, compassionate but with courage to do the right thing and create culture of staff happiness. Happy staff- Happy patients. Happy patients – Happy staff!


    1. Rob this is wonderful! Yes its across the board of health…we are letting people down in our present system, we ve created a revolving door…my daughters standing at deaths door again homeless and lost…as mother i m being relegated to the sidelines whilst the control you mentioned and lack of true transperency takes over….i realise staff in the medical professionals intentions are well meaning however, it s an old framework as you ve mentioned.
      You have my support!
      Sandra Ladd


  2. There is another set of problems when the command structure approves medical and dental devices without sufficient regard for risk to patients’ immune reaction to device materials, which vary according to patient genetics and prior exposures. Especially when conflicts of interest allow for approval of devices such as Essure and Mesh that harm thousands of patients, or use of mercury in dental fillings without notice, written informed consent, or prescreening of patients in advance for tolerance vs. toxicity due to methylation challenges.

    A team of teams solution would involve rebooting FDA medical device regulations for the 21st century recognizing patient diversity and the need for “Precision Device” framework, analyzing dental records along with health records, integrating dental into comprehensive health assessment, and ending the siloing of the human body, diagnostics, care, insurance and treatment with protocols and walls that work for the players in the system, but against patient health.


    1. Hi Laura, Thank you for your comment. You are one of several people who have brought up this issue. It is definitely worth persuing further. Perhaps we could start a project on it – see the PatientSafe Network:

      Let me know your thouguhts and if you would be interested in taking a leadership role to drive such a project.

      Thanks again


  3. How about making everyone sign a legal informed consent form and know that they will be held legally accountable and that their failures – harm they cause to the lives of other human beings will have direct and immediate consequences to them personally- and their team. Pretend you care about the health, safety and lives of the people. We don’t care if your nice o happy, as long as your not miserable and cruel. We just care that you actually know what your doing and won’t kill us in the sick care death trap disease making industry.


    1. Hi Judy, Thank you for your comment. Perhaps I can direct you towards reading a book called Just Culture – by Sidney Dekker. Unfortunately there is no getting away from the fact that we are all human – doctors, nurses, everyone – and as humans we all make mistakes. Unfortunately when these inevitable mistakes occur in healthcare, with current systems not protecting against them, patients suffer unecessarily. Imagine having to go to jail every time you lost your keys – would it stop you from losing your keys again. If the threat of losing your keys meant that you would go to jail how likely would you be to tell us that you just lost your keys again?

      Yes healthcare staff have extremely important jobs and we must ensure they do everything as well as can be expected, however when you realise the increasing complexity of work environments you will begin to understand why medical error persists as the third greatest cause of death.

      See Bad Apple Theory:


  4. Very interesting (I shall certainly read Team of Teams). If you extend the idea a little further and stir in some behavioural insight, it quickly becomes apparent that the word Team, is an umbrella term for many different types of social groups with very different characteristics. Healthcare, being a mostly biological industry with only the odd machine; seems to have evolved a whole ecosystem of relationships and some are better than others at certain types of work.

    From small enduring Families, through highly reliable Crews and emotionally bonded Troupes, up to novel Communities and even large energised Swarms; we need to make sure that the methods match the situations. I can’t find the link to – When is a Team not a Team – but I’ll post it when I do.

    The cult of improvementology gets all fixated by old fashioned problem solving, so I love the examples you’ve given. Instead of focussing down on solving the problem, think about the wider systemic opportunities to make the problem irrelevant. A good example of matching actions with context in a complex system.

    PS Umesh, I disagree with you. In many situations those issues are significant, but they are certainly not simple.


  5. @patientsafe3 do patients as witnesses,advocates,alerters,experts in individual patient needs have a role too? Where spelt out?modelled? Evidenced? Respected? Facilitated ? Who is nurturing this source of energy,knowledge,focus? Systems need to be open. 3 year Journey to get naloxone patient safety alert in England November 2014 and 2015, obstructed by hospital,coroner,ombudsman,so called experts, Finally first time successfully (although experts knew,guidance spelt out) requiring independent paid for report touted around until Royal college of anaesthetists took it seriously shows whole system failing,covering up, ignoring informed patient advocates…in fact worse,like clinical whistleblowers I was treated as vexatious ,and most people treat me as obsessed.but about patient safety,learning lessons so others do not suffer surely makes it valid? Worth listening to? a story needs to be written,but who by and analysed for lessons..yet no one interested,so far…your readers?


    1. Thank you for your comment. You are not obsessed by this at all. You are presenting the issue into a culture which lacks transparency and real frameworks for improvement.

      We hope to help deliver frameworks which will create a cultural change. Your voice is important. Perhaps true leadership allows people to stand in everyone’s shoes.

      Welcome to the PatientSafe Network:


      1. I am a relative of an elderly patient who was subject to the ‘extrapyramidal effects’ and ‘fall’ based safety issues surrounding haloperidol administration for delirium which are known to NICE and cited in NICE guidance as being of concern- indeed NICE state that this drug is not even licensed for this purpose but NICE still recommend it and clinicians still prescribe it and cannot be criticised for this due to it being recommended in NICE guidance. Similarly my relative was also suybject to naloxone issues which, despite the Patient safety alert and a clinician was not critisised for acting against the alert due to the fact that they were a physician and not a palliative care consultant. Not having the money to commision an expensive report I have been forced to take this up within the NHS complaints system to no avail. Would resources, financial considerations, drug company’s, relationships, reputations, politics, lawyers, in house cronyism be as influential as systems models in the search for effective approach to safety?


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