From the Cockpit to the Hospital – CRM for Docs
Have you ever been part of Code Blue (patient in full arrest) that went horribly wrong? Almost all docs have a horror story from either a real-world or (preferably) sim lab scenario where a resuscitation fell apart and ultimately led to catastrophe. What happened? If I’m wagering a bet on the question, I’d put my money on a breakdown in communication. And many studies would support the claim that miscommunication is a leading cause of medical errors.1
In the world of aviation, mistakes also have catastrophic consequences. In the late 1970’s a series of commercial airline crashes culminating in the United 173 Crash outside Portland, Oregon led mishap investigators to conclude that interactions between crew in the cockpit played a significant causal role. In this particular plane crash, the crew became so preoccupied with a perceived mechanical malfunction that they flew in a holding pattern until they unexpectedly ran out of fuel. From this mishap, the National Transportation Safety Bureau (NTSB) recommended a revolutionary new type of training for all aircrew. Although the name went through several iterations in the early days, Crew Resource Management (CRM) was born. Throughout the 1980’s and 90’s the aviation industry enjoyed huge improvements in safety as fatal crashes dropped in number and one of the primary causes is thought to be the introduction of this radical new training on interpersonal communication during flight.
Certainly, even subtle miscommunications in the complex world of medicine can have disastrous consequences on patient morbidity and mortality. How can the tenets of CRM be effectively translated into a medical lexicon for the benefit of patients?
A quick look on what Crew Resource Management teaches pilots and other aircrew:
- Recognizing Conditions Leading to Error – This is the bedrock of CRM. I.D. the threat early and error is avoided. Isolate the threat after the error to control it before catastrophe. This process is employed in all subsequent areas.
- Effective Mission Planning – Plan as a team. Create a constructive environment to do so.
- Common Communication Deficiencies & Skills to Overcome – Know the various psychologic, cultural, and environmental filters that degrade communication. Use specific skills to avoid them.
- Skill Set for Appropriate Crew Coordination – Build a team cross-check. Develop techniques to resolve conflict.
- Task Management – The importance of knowledge, prioritization, & managing task loads effectively.
- Situational Awareness – How to identify loss of S.A. in oneself and other crew members. How is this state avoided and how is this critical awareness regained.
- Risk Management & Decision Making – What is the current risk to operations? How to mitigate risk and what level of risk is considered intolerable.
- The Debrief – Learning, avoiding future mistakes, and process improvement occur here. What are effective techniques for debriefing?
In many ways CRM has been incorporated into medicine already. Many similar examples of the above skills are specifically taught to medical students, residents, attending physicians and the rest of the hospital staff. Most hospitals and large healthcare systems have patient safety offices that know the importance of these tenets. Unfortunately, medicine still seems to have a lot to learn from aviation as medical errors continue to persist at unacceptably high rates. The degree of acceptance for CRM principles varies by institution and there must be genuine buy-in from the administrative and clinical leaders within healthcare organizations. This means the executives, but also the doctors. Of course, there are also notable differences between medicine and aviation, which cannot be understated enough. A detailed discussion on other human factors and their intimate relationship with errors has been covered in a previous post.
The demand for this type of training has lead a variety of private companies to develop curricula that they sell to hospitals and healthcare organizations. A search engine inquiry will lead you to the web sites for a number of these companies. I don’t have a personal opinion on which of these are superior to one another, but many of these organizations have very high quality and entertaining content to provide instruction on Medical ‘Crew Resource Management’, though it is often advertised to medical providers under other names.
There is evidence to support that improvements in communication through standardization and process implementation does translate into better outcomes for patients. A paper published in the New England Journal of Medicine in Nov 2014, for example, found that in 10,740 patient admissions, the medical-error rate decreased by 23% from the pre-intervention period to the post-intervention period after standardized patient handoffs were incorporated into shift changes.2 This is just one example that the power of CRM principles could have in medicine if it were more fully embraced and incorporated into healthcare processes.
Why are there still so many medical errors and why do huge pockets of resistance to CRM reforms seem to still exist? Are we too busy? Too overworked? Are the principles not directly transferrable? Is medicine simply inherently distinct from aviation?
Or maybe it is because there is something in our human nature that allows us to not take safety quite as seriously when it is not our life on the line, but only our patients.