SchemaI. BackgroundII. Literature review III. Nursing implicationsIV. Strategies for dealing with the problemV. ConclusionContextA culture of safety requires leadership commitment to positively impact outcomes. The recent emphasis on new CMS guidelines and third-party reimbursement initiatives associated with patient outcomes has caught the attention of leadership across healthcare organizations. Additionally, our organization's system-wide employee safety culture survey demonstrated that communication and teamwork are areas where improvements are needed. Years of research on communication and teamwork in highly trustworthy organizations support a correlation with safety. (XX) One of the most important and highly publicized joint commissions, the National Patient Safety Goals, is to improve communication across the healthcare continuum. (JC .com) Additionally, the organization's patient cases have been examined through root cause analysis, and the source is often linked to an inability to communicate effectively and role confusion. Well-defined roles within the team model can help improve communication, including mitigating variables such as distractions, individual emphasis on the wrong information, and communication breakdowns. (XXX) Implementing a formal teamwork program is one way to systematically address risk reduction within an organization. (Botwinick, L., Lavorano, M., & Harden, C., 2006) (Leonard, M., Frankel, A., Federico, F., Frush, K., & Haraden, C., 2013)IntroductionThe healthcare is focused on safety and quality outcomes, with a new emphasis on financial penalties if positive outcomes are not achieved. Consumers are armed with information about results and satisfaction. This motivated...... half of paper ...... Kohn LT, Corrigan & JM, Donaldson MS. To err is human: building a safer healthcare system. Washington, DC: National Academy Press, 1999. Leonard, M., Frankel, A., Federico, F., Frush, K., and Haraden, C., (2013) The Essential Guide for Patient Safety Officer (2 ed.) Oakdale Terrace, Illinois: The Joint Commission Recourses Inc.Manser, T. (2008), Teamwork and Patient Safety in Dynamic Domains of Healthcare: a review of the literature, Acta Anaesthesiologica Scandinavica, February, 53(2), 143-151. National patient safety goals. TheJointCommission.http://www.jointcommission.org/standards_information/npsgs.aspx. Accessed 6 December 2013.Mazzocco, K, Petitti, D, Fong, KT, Bonacum, D. Brookery, J., Graham, S., Laskey, RE, Sexton, JB, &Thomas, E., (2009) Surgical team behaviors and patient outcomes, The American Journal of Surgery197(5),678-685.