near death of patient - CRM advice

[freshgasflow]

hello friends,
i am an anaesthesiologists (one who puts people to sleep for an surgery and wakes them up ! ) and recently we had a near death with one of our patients because of an instrument failiure. yet we managed to save the situation by working as a team.
in my profession , we work in a team environment and try to use aviation CRM techiques.
i am planing to write a report about the near misshap that we had with our patient and want to get a rough idea about CRM issues such as fixation error etc.
Can anyone suggest some good websites that i can visit ?
many thanks
prasanna

[Brian Abraham]

Is this the sort of stuff you're after?
http://www.highbeam.com/doc/1G1-134692358.html
http://www.mindef.gov.sg/rsaf/download/Focus_47.pdf
http://www.iitsec.org/documents/H_2260_001.pdf
http://asrs.arc.nasa.gov/report_sets/crm.pdf

[freshgasflow]

thankyou, and yes that is the type of thing i was looking for.
anymore ideas are welcome.

prasanna

[have another coffee]

Buy this book, read it and make sure you understand it:

The Field Guide to Human Error Investigations
Sidney Dekker
Ashgate Publishers
ISBN 0 7546 1924 9

Can be ordered via publishers website.

After reading you can ask me all the questions you can ask for help.

Good luck!!
:ok:

[main gear touchdown]

Hi freshgasflow

http://www.abdn.ac.uk/iprc/ants_papers.shtml

and then follow the "ANTS handbook" link -may be quite helpful in describing the different actions involved.

There is also a good review article in the British Journal of Anaesthesia:

Arnstein, F (1997) "Catalogue of human error", British Journal of Anaesthesia, 79, 645-654

[freshgasflow]

main gear ...that is EXACTLY what i need.

many thanks

prasanna

[Markhkg]

CRM is recognized as a potential way to reduce medical mistakes. The production "Charlie Victor Romeo" (which is CVR...Cockpit Voice Recorder) was produced for the Institute of Healthcare Improvement. It involves the cockpit re-enactments of the final moments aboard aircraft disasters to highlight CRM issues.

http://www.charlievictorromeo.com/

deleted for advertising

[Hawk]

"i am planing to write a report about the near misshap that we had with our patient and want to get a rough idea about CRM issues such as fixation error etc.
Can anyone suggest some good websites that i can visit "?

No problems freshgas..so long as you quote PPRuNe as a secondary source in your report.

[alf5071h]

freshgas See Reporting of medical errors. (http://qhc.bmjjournals.com/cgi/reprint/9/3/144?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&searchid=1&FIRSTINDEX=120&minscore=5000&resourcetype=HWCIT)

Try a search of that website under ‘J Reason’, this should provide some additional resources as you requested, e.g. Human Error, models and management. J Reason. (http://bmj.bmjjournals.com/cgi/reprint/320/7237/768)
Or the slightly more complex paper on The role of error in organizing behaviour. J Rasmussen. (http://qhc.bmjjournals.com/cgi/reprint/12/5/377?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&searchid=1&FIRSTINDEX=0&minscore=5000&resourcetype=HWCIT)

Also see The reinvention of Human Error ( www.lusa.lu.se/o.o.i.s/6131)and several other references by Dekker.

[DC-Mainliner]

Hi FreshGasFlow -

I flew for a number of airlines including major global ones (lots of CRM exposure over 12 years) and after the big slump the Staes suffered six years ago I found myself out of a job. So I ventured into the emergency medical transportation business where I flew and managed aircraft operations for international medical flight teams.

It was a very interesting experience to say the least but one area I was shocked at was the lack of CRM used consistently among doctors, nurses and medics. Please understand I am not throwing stones, I just noticed a very big cultural difference. It seemed to me that one of the most serious impediments to CRM was the long hours and downright exhaustion the typical medical professional is exposed to in the long, uninterrupted shift work that is present. I saw a lot of errors that were, frankly, obviously fatigue related.

Where I would be on a legal duty period, in some cases, the same nurse would have been working during my previous duty period not to mention my rest period. This is possibly mostly limited to emergency medicine, where other disciplines would be on more regular hours? I can not say.

I really do applaud your interest in CRM. I firmly believe, even from my limited medical exposure, that the medical profession can greatly benefit the general public by adopting a stronger acumen for human factors that lead to CRM-like tools being integrated into medical protocols.

There is a wealth of information available online. However, as someone who is in the safety and human factors discipline myself, I caution you to search for fresh information and valid sources. The latest CRM skillsets are more effective and different than some of the previous, first or second generation CRM that was common even just a few years ago. Look for current buzz terms like "error management" and "primary and secondary behavior" styles, and such. CRM can be a very interesting, introspective excercise when looked into thoroughly.

[safetypee]

An interesting viewpoint given in the commentary - For those condemned to live in the future. (http://qhc.bmjjournals.com/cgi/reprint/12/4/311?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&searchid=1&FIRSTINDEX=70&minscore=5000&resourcetype=HWCIT)

[mcdhu]

Interesting! A colleague of mine was at a cocktail party recently where he met a surgeon who was expounding the value of his profession's recent adoption of Crm as a tool. My pal asked him if the most junior person in the theatre during an operation can call a halt to proceedings on the basis that he/she thinks an error is about to be comitted. The surgeon was horrified at the thought.

While I realise that you cannot generalise about the whole surgical profession, until that situation exists, they are only paying lip service to it.

Cheers,
mcdhu

[Brian Abraham]

freshgasflow - a fellow by the name of Dick Karl writes aviation articles for the US "Flying" magazine. He owns and operates his own twin turboprop and is a full time surgeon in Tampa specialising in cancer if memory serves correct. Could be he could be a source of info for you? Contact the magazine at flyedit#hfmus.com (replace the # with @) in the first instance and they will put you in contact within a couple of days if my experience is anything to go by.

[Max Angle]

Freshgasflow, check your private messages please.

[john_tullamarine]

DoogieD,

In this forum we maintain a reasonable degree of respect for other posters (whether mod or not). Those are the rules here. I have no hesitation in removing posts which I consider to be inappropriate in this forum ..

regards,

JT

[gingernut]

Freshgasflow- have you had a look at the "Significant Event/Clinical Governance" stuff from the DofH.

I'm pretty sure a white paper was written a few years ago.

I attended a talk given by the former head of Clinical Governance for the D of H, he spoke some pretty inspirational stuff, and I believe he spent a fair bit of time in the airline industry, examining how the industry learns from its mistakes.

He recently left, and I'm a little wary of putting his name on the web, but pm me if you want.

[Hawk]

Interesting! A colleague of mine was at a cocktail party recently where he met a surgeon who was expounding the value of his profession's recent adoption of Crm as a tool. My pal asked him if the most junior person in the theatre during an operation can call a halt to proceedings on the basis that he/she thinks an error is about to be comitted. The surgeon was horrified at the thought.
Mcdhu

You raise a very good question IMHO. Whilst the principals of "crew resource management" were not invented by the aviation industry. It would be useful to see the extent other professions adopt similar communication and its success or otherwise. I suspect the concept is part of many areas of employment. Perhaps those airmen who are professionally qualified across other industries might be able to make a contribution to this thread.

[Bad medicine]

There has been a lot of work on the implementation of CRM into the medical (and especially operating theatre) environments. A lot of the links already posted point to valuable information on this.

Unfortunately, there are a number of complicating factors when trying to adapt the aviation model to the medical environment. One already mentioned is the total lack of "duty limits" when it comes to the medical staff in a lot of jurisdictions. Back in my early days as a resident, it was not uncommon to work the "weekend shift", which at my hospital started at 0800 on Friday Morning and finished at 1600 on Monday afternoon. Hardly conducive to peak performance. I know of one large medical regulatory body which has recently limited doctors to working a 90 hour week.

Another is the drive to practice "defensive" medicine, brought about by the booming medical litigation industry. One cannot admit, and therefore learn from errors without being exposed to litigation.

I'm not sure that "the most junior person in the operating theatre" should be able to call a halt to procedings. Give input...yes; offer opinion...yes, have everyone down tools and have a round-table discussion at a critical point in procedings...definitely not. As with any team, there has to be a leader who welcomes input, takes into account the available information, and then makes a decision and acts upon it. The leader also takes responsibility for the outcome. "The most junior person in the operating theatre" will not be held responsible for an adverse outcome, and will not be the one having damages awarded against them.

It is exactly the same for an aircraft Captain. When I'm aircraft Captain, I welcome and encourage input from all of the crew, often ask them what they believe is the best course of action, but ultimately, the decision and the responsibility reside with me. When I'm co-pilot, I offer information, solutions and assistance, but the Captain makes the decisions, and once made I support him to the best of my ability. Sometimes the decisions need to be made quickly, and without much in the way of consultation. Sometimes I believe the decisions to be flawed, but I don't argue in the cockpit - leave that for the debrief.

CRM doesn't mean that everyone has an equal role in the decision making process.

Anyway, that's my $0.02

Cheers,

BM

[DC-Mainliner]

I'm not sure that "the most junior person in the operating theatre" should be able to call a halt to procedings. Give input...yes; offer opinion...yes, have everyone down tools and have a round-table discussion at a critical point in procedings...definitely not....
It is exactly the same for an aircraft Captain. When I'm aircraft Captain, I welcome and encourage input from all of the crew, often ask them what they believe is the best course of action, but ultimately, the decision and the responsibility reside with me. When I'm co-pilot, I offer information, solutions and assistance, but the Captain makes the decisions, and once made I support him to the best of my ability. Sometimes the decisions need to be made quickly, and without much in the way of consultation. Sometimes I believe the decisions to be flawed, but I don't argue in the cockpit - leave that for the debrief.
CRM doesn't mean that everyone has an equal role in the decision making process.
Anyway, that's my $0.02
Cheers,
BM

VERY true in my humble opinion.

In the late 80's and into the 1990's, the role of the Captain in aviation CRM had been found to be somewhat marginalized and the need to re-emphsize command leadership came about. One global carrier calls their CRM "CLR" meaning, "Command, Leadership, Resource-management" in place of the simple crew resource management badge.

Round table discussions work to great effect on the ground, or out of the Operating Room, during strategic planning. When tactical operations are in effect - in the OR or in the air, a whole different dynamic must be in place for good reason.

The point of CRM not being an easily substitutable program between industries is valid. I'm certain the timing of decisions and the variables of each process - medicine and aviation - lead to completely different CRM models. The one constant is that one specific model will work only in the context of the behavioral environment it operates in. Over time the aviation CRM model has evolved to adapt to the evolving culture of aviation. The same will be true for medical CRM. Where it starts today as a reflection of the environment will not be where it stands ten yerars from now, but it will be where it has to be, to suit the doctors and nurses above all else. CRM is a tool. Tools work for us, we should not work for the tool.