Eliminating Critical Incident Tracking Network Patient Safety Events at a Veterans Affairs Institution Through Crew Resource Management Training

Am J Med Qual. 2017 Sep/Oct;32(5):480-484. doi: 10.1177/1062860616673904. Epub 2016 Oct 20.


The objective of this study was to determine whether rates of Critical Incident Tracking Network (CITN) patient safety adverse events change after implementation of crew resource management (CRM) training at a Veterans Affairs (VA) hospital. CRM training was conducted for all surgical staff at a VA hospital. Compliance with briefing and debriefing checklists was assessed for all operating room procedures. Tracking of adverse patient safety events utilizing the VA CITN events was performed. There was 100% adherence to performance of briefings and debriefings after initiation of CRM training. There were 3 CITN events in the year prior to implementation of CRM training; following CRM training, there have been zero CITN events. Following CRM training, CITN events were eliminated, and this has been sustained for 2.5 years. This is the first study to demonstrate the impact of CRM training on CITN events, specifically, in a VA medical center.

Keywords: crew resource management training; patient safety; quality improvement.

MeSH terms

  • Hospitals, Veterans / organization & administration*
  • Humans
  • Medical Errors / prevention & control*
  • Patient Safety
  • Personnel, Hospital / education*
  • United States
  • United States Department of Veterans Affairs / organization & administration*