Presented by:

RAGUnathan Kanagaretnam CEO

Quality Associates, Malaysia

RANJINI Ragunathan Perioperative Fellow, Process Excellence Hospital For Special Surgery New York

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19 Feb 2012

No matter how competent healthcare professionals are, errors will occur.

The question then is: What can we do?

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THE AVIATION CRASH OF THE CENTURY:

The beginning of CREW RESOURCE MANAGEMENT (CRM)

Tenerife (Canary

Islands) 03/27/1977

two fully loaded

Boeing 747 jumbo jets

collided

on a fog-blanketed

runway – visibility

700m

claiming the lives of

583 people.

http://www.youtube.com/watch?v=9Zfw3w3FRMA&feature=related

http://www.youtube.com/watch?v=9Zfw3w3FRMA&feature=related

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were totally SUBORDINATE in their interaction with the Captain

were not encouraged to QUESTION the Captain freely

A. The First Officer & Flight Engineer:

were clearly INTIMIDATED by the Captain’s

overbearing and authoritative style

Q. Why did the First Officer and the Flight Engineer not assert their concerns,

even in the face of impending disaster?

Q. Why did the Captain not seek input from the other professional crew members

(First Officer & Flight Engineer) when making decisions?

Simple answer is:

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A REGRETFUL INTROSPECTION – 1976 Pre CRM

Chief

Flight Engineer

Chief Pilot

Training

Chief Pilot

Development

Acceptance Flight Testing of MALAYSIA AIRLINES 1st DC-10-30

LONG BEACH, CALIFORNIA, 1976

TECHNICALLY COMPETENT but DEFICIENT in COCKPIT TEAMWORK SKILLS

Oh Yes! An Abhorrent Culture

A shameful Past

Post Tenerife: An Intense Examination on Causes of Aviation Accidents

60-80 % of aviation accidents (Shappell & Wiegmann,1996) were caused by:

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and not

TECHNICAL INCOMPETENCY

A STARTLING REVELATION THAT

Fallibility of Decision Makers

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Humans are imperfect organisms and will necessarily make errors,

particularly under conditions of overload, stress and fatigue. Thus:

That Lead to the Realization that:

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The Federal Aviation Administration Defines Crew Resource Management

(FAA, 2009) As:

The effective use of all the resources available to crew members,

including each other, to achieve a safe and efficient flight.

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1. recognizing the human factors that cause errors

2. recognizing that in complex, high-risk settings, teams rather than

individuals are the most effective operating units

3. instilling practices that use all available resources to reduce the adverse impacts of those

human factors

CRM trains crew team members from multiple disciplines to

work together in a coordinated, safety-conscious environment

by (Marshall, 2009):

The Result of Using CRM in Aviation

AVIATION ACCIDENT TRENDS

9 CRM has helped the aviation industry to be safer in all aspects of the industry.

According to the National Transportation Safety Board, the fatality risk fell to 68 per billion

fliers this decade, less than half the risk in the 1990s. Since 2002, the risk fell to 19 per

billion, an 86 percent drop since the 1990s. This improvement can be partially attributed to

CRM and the Federal Aviation Administration requires that all commercial airline and

military pilots undergo CRM training.

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A Confidence Wrecking 1999 Institute of Medicine (IOM) study

‘To Err is Human’ reported:

44,000—98,000 annual deaths occur as a result of medical errors.

Medical errors are the leading cause, followed by surgical

mistakes and complications.

More Americans die from medical errors than from breast cancer,

AIDS, or car accidents.

7% of hospital patients experience a serious medication error.

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Ref.: Annual Report on Quality & Safety, Joint Commission, 2007

Root Causes of Sentinel Events 1995 – 2005, By the Joint Commission

66% Communication Failures:

The leading causes of inadvertent

patient harm (Leonard et al, 2004)

Communication is essential to workplace efficiency and for the delivery of

high quality and safe work.

Communication and Patient Safety

and difficulties of transmitting information within and between large

organisations (e.g. safety alerts).

status effects inhibiting junior staff from speaking up;

Communication failures relate

to the following:

shift or patient handovers;

the quality of information

recorded in patient files,

case notes and incident reports;

CRM Programs for Healthcare is recommended

by these and other healthcare agencies

Australian Institute

of Health Innovation

Accreditation Council for

Graduate Medical Education

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“As a conclusion it is clear that this process [CRM] would reduce errors, cut the

costs of litigation, reduce wasted capacity and reduce the patients stay in

hospital” (East Cheshire Hospitals NHS Trust, 2002).

CRM success evidences found in peer-reviewed healthcare publications.

A 50% reduction in surgical counts errors (Rivers, Diane & Nixon, 2003)

Clinical error rate reduction from 30% to 4.4% (Morey, et al., 2002)

Teamwork and communication skills, more than previous surgical experience,

determine how quickly medical personnel develop expertise with new technology,

e.g. robotics for minimally invasive cardiac surgery, (Pisano, 2001).

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Aviation and Health Care Have Much in Common

5. Both are entrusted with the safety of others

6. In both human factors are cause of the majority of errors and accidents

1. Both are extremely complex industries

2. Both require highly skilled and trained crew members

4. Both need to function ably under stressful conditions

3. Both should work effectively as a team to reduce errors

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1. Checklists

2. Briefings & debriefing 2. Pre-procedure briefings, shift change

start-of-the-day clinic briefing,

debriefing checklist, etc.

3. Flight standing orders

4. Standard operating

procedures

5. Structured

communications techniques

3. Read files

4. Patient hand-off formats, etc.

5. SBAR

1. Time-out requirements, pre-procedure

briefings, equipment setup, etc.

Given the Similarities between Health Care and Aviation. Aviation CRM error-reducing tools could adapt well to Health Care

The Fundamentals of Health Care CRM Philosophy

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1. checklist,

2. structured communication techniques, SBAR

3. briefing - WHO surgery checklist

4. debrief,

5. handoff, cross-monitoring, feedback, etc.

1. leadership,

2. mutual support,

3. situation monitoring, and

4. communication.

These CRM tools to be

discussed next.

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Example of a ‘Normal Landing’ ‘Do & Read’ Checklist in Aviation

The UBIQUITIOUS CHECKLIST How things get done in Aviation

The ‘Do & Read’ Checklist

Captain: “Before Landing Checklist”

Captain: “Checked” (Double checking that all flaps are in the full landing configuration)

Flight Engineer: “ Roger, Flaps 30, 30, Green light” (This statement confirms he has the command to execute the Before Landing Checklist)

Co-Pilot: “Flaps, 30, 30 Green light” (Confirms the flap handle is at the 300 detent, the flap indicator gauge shows 300 on

both the inboard and outboard flaps, and the cockpit light indicating that all the flaps are

down is illuminated)

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The consequences of missing a single item can be tragic

Example of an Emergency Checklist

Engine Fire or Severe Damage

‘Read and Do’ Checklist

The UBIQUITIOUS CHECKLIST How things get done in Aviation

The ‘Read & Do’ Checklist

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In 2001 a critical-care specialist at Johns Hopkins Hospital named Peter Pronovost decided to give “Checklist” a try. He designed a checklist to tackle just one problem: LINE INFECTIONS

Over a 27 month period only two line infections occurred.

In 2001 a critical-care specialist at Johns Hopkins Hospital named Peter Pronovost decided to give “Checklist” a try. He designed a checklist to tackle just one problem: LINE INFECTIONS

Central Line Insertion

Checklist in Healthcare

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The Tenerife crash in 1977 changed aviation communication

As a result of this accident an increased emphasis was

placed on using standardized phraseology in ATC

communication.

KLM Copilot: “We are now at take-off”

(he meant on the take run)

Air Traffic Control understood it to mean that KLM

was static at take-off position and so replied: “OK”.

For example:

“Take-off” was changed to “Taxi into position and hold”

“Take-off” is only used when actual take-off clearance is given.

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Flying Tigers Boeing B747 crash at Kuala Lumpur, Malaysia in 1989

Four crew, were killed when the freighter crashed 8 miles from the runway.

Air Traffic Control: "Descend two four zero zero" (he meant two thousand four hundred ft.)

Visibility was only two miles in fog as the aircraft was issued this clearance.

ATC should not have dropped the ‘to’

(to)

Pilot: "OK, four zero zero" (four hundred feet)

ATC should have detected the incorrect readback of omission

(to two)

Communication Misinterpretation with the homonyms;

'to, too and two'.

CRM Based Approach: Communication Model

for Inter-Professional Communication Among Clinicians

Must understand

the motivation

of the Receiver.

Nurses – descriptive

Doctors - factual

Message Information sender wants

to convey

Feedback Sender should confirm

message has been received

Receiver interprets

the message

and responds

For CRM based

approach

repetition

& reinforcement

is essential.

Repeat The Medium

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Hierarchy

Sex

Knowledge Skills

Past experiences

Paradigms, etc.

Assumptions

Not sharing information

Poor documentation

Confusion

Work overload

Too busy

Fatigue

Stress

Conflict

Example of aviation communication based on the CRM

Communication Model: Clear, concise and standardized

Station calling Vegas Ground

say again your callsign

Vegas Ground, BIGJET 347,

radio check 118.3

BIGJET 347, Vegas Ground,

readability 5

Ground, BIGJET 347, stand 24,

information bravo, QNH 1011,

request start up

BIGJET 347, start up approved

Flight Start Up Approval

Vegas Ground, BIGJET 347,

radio check 118.3

Reference: CAP 413, Radiotelephony Manual, Edition 20

1. PRECISE COMMUNICATION

(Communication skill)

2. STANDARD TERMINOLOGY

(Safety tool)

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What do you see?

1. A young woman

2. An old woman

Mental Models

People act according to their “mental models” ,i.e.

different conclusions of the same subject.

“Mental models are deeply ingrained assumptions, generalizations, or … images that influence how we

understand the world and how we take action.” Peter Senge – The Fifth Discipline

“Mental models are deeply ingrained assumptions, generalizations, or … images that influence how we

understand the world and how we take action.” Peter Senge – The Fifth Discipline

What are Mental Models? C

an a

lso b

e b

etw

een

Docto

r to

Docto

r O

r N

urs

e t

o N

urs

e

“Two people with different mental models

can observe the same event and describe it

differently.” Ragunathan K. Externalizing Tacit Knowledge For Training

Effectiveness: A Cognitive Model Of Knowledge Conversion.

PhD Thesis, Kuala Lumpur, July 2002.

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Nurse

Vision of

The

World

Doctor

Vision of

The

World

Joint Commission 2007

Humans tend to

consider that their

vision of the world is

correct whenever

events happen in

accordance with their

expectations.

The Joint Commission notes that in 66% of

sentinel events, communication is a

contributing factor in medical errors.

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SBAR is a tool to share clinicians MENTAL

MODELS of a patient’s clinical condition.

State what you think is the problem. Provide patient

A - Assessment

State your name and briefly the patient related issue you

are concerned about

Describe the

S – Situation

State what you like to do to correct the problem. Make or ask for

R - Recommendation

Describe the clinical background or context. Provide the

B – Background

SBAR enhances the effectiveness of communication through an established structure that;

improves safety, clarity, efficiency, and respect for the message sender and receiver.

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Nurses like the SBAR tool, as it gives them the

“authority” to make a recommendation & their

contribution is valued.

Doctors are delighted to get straight to the point

facts rather than the usual descriptive version

said to be typical of nurses.

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In aviation, BRIEFING facilitates teamwork building, opens up lines of communication, prepares team

members for the task at hand and provides opportunities to discuss potential contingency plans.

Enables Mental Model Convergence

1. Preflight dispatch briefing

by Flight Despatcher

2. Preflight technical aircraft

status briefing by Engineer

3. Takeoff & Departure

briefing by Pilot Flying

4. Descent & Arrival

briefing by Pilot Flying

To invite crew participation a the

Captain’s briefing may end like this:

“I am human so I am prone to

miss something or make

mistakes. If you notice anything

that deviates from standard

operating procedures please

shout out. OK”

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0

10

20

30

40

50

60

70

80

1 2 3 4 5

%

Characterizing Teamwork in the OR

26%

73%

39%

28%

10%

Anesthesiologists Surgical

Nurses

Anesthesia

Nurses

Anesthesia

Residents

Attending

Surgeons

Survey Question: “Rate the quality of teamwork and communication or

cooperation with consultant surgeons”

Communication & Teamwork in Medicine: A Research Findings

(Sexton, Thomas & Helmreich, 2000)

Although attending surgeons perceive that teamwork in their operating rooms

is quite good, the rest of the team members disagree, proving that one should

never ask the leader about the quality of teamwork!

Can you imagine this happening in

a flight cockpit.

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Surgical Checklist by the World Health Organization (WHO) Promotes effective teamwork and prevents wrong site, wrong procedure

and wrong person surgery from occurring.

A 2007-2008 WHO study on the use of the Surgical Safety Checklist worldwide

confirms that at least half a million deaths per year could be prevented.

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.

Before skin incision, the checklist coordinator should ask the surgeon if

imaging is needed for the case. If so, the coordinator should verbally confirm

that the essential imaging is in the room and prominently displayed for use

during the operation.

The checklist coordinator should ask each person in the room to introduce

him or herself by name and role.

The checklist co-ordinator will ask everyone in the operating room to confirm

the name of the patient, the surgery to be performed and the site of surgery

The checklist co-ordinator will ask out loud whether prophylactic antibiotics

were given during the previous 60 minutes.

Effective team communication is a critical component of safe surgery,

efficient teamwork and the prevention of major complications. To ensure

communication of critical patient issues, the checklist coordinator leads a

swift discussion among the surgeon, anaesthesia staff and nursing staff of

critical dangers and operative plans.

A Pre - Surgery Briefing: A ‘Page’ from Aviation CRM (WHO, 2009)

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Loss of authority – concern of physicians.

(Goal of CRM is to make better decisions … enhances the physicians authority)

What if I speak up and get yelled at?

(The organization must not accept hostility and if it happens it should deal with it.)

I do not buy CRM and I am not going to do it.

(Patient safety is not optional.)

CRM, not in an emergency.

(Errors are more likely to occur in emergencies when departing from well-trained standard procedures)

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Marshall, David. Crew Resource Management: From Patient Safety to High Reliability.

Colorado: Safer Healthcare Partners, 2009. p. 19

Federal Aviation Administration, Department of Transportation, Part 121, Subpart Y, Section 121-907. 2009

Rivers R.M., Diane S. & Nixon B. Using aviation safety measures to enhance patient outcomes. Association of

PeriOperative Registered Nurses (AORN) 2003; 77:158.

Morey J.C., et al. Error reduction and performance improvement in the emergency department through

formal teamwork training: Evaluation results of the MedTeams project. Health Service Results 2002; 37:1553.

Pisano G.P. et al. Organizational differences in rates of learning: Evidence from the adoption of minimally invasive

cardiac surgery. Management Science 47, No.6 (June 2001):752.

East Cheshire Hospitals NHS Trust. Error Prevention Programme Conclusion & Recommendations Report, 22/10/02.

Gaffney F.A., Harden S.W., Seddon R. Crew Resource Management: The Flight Plan for Lasting Change in Patient Safety.

HCPro, Inc.: Marblehead. 2005.

Sexton, Thomas & Helmreich . Error, Stress and Teamwork in Medicine and Aviation: Cross Sectional Surveys.

BMJ Volume 320. 2000.

References

World Health Organisation. Implementation Manual WHO Surgical Safety Checklist 2009: Safe Surgery Saves Lives.

Geneva: WHO, 2009. Print.

Leonard, M., Graham, S. & Bonacum, D. (2004) The human factor: the critical importance of effective teamwork and

communication in providing safe care. Quality and Safety in Health Care, 13, 85-90.

Shappell, S. & Wiegmann, D. (1996). U.S. naval aviation mishaps 1977-92: Differences between single- and dual-

piloted aircraft. Aviation, Space, and Environmental Medicine, 67(1), 65-9.

Ragunathan Kanagaretnam, PhD

Ranjini Ragunathan, BS (ISyE)

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Conclusion:

If humans are involved, error is inevitable.

Health Care! It Is Time To File Your Aviation

CRM Flight Plan For Patient Safety