Crew Resource Management in the Operating Room

CREW RESOURCE MANAGEMENT: CREATING A CULTURE OF SAFETY IN THE OPERATING ROOM

Crew resource management (CRM) was developed in the aviation industry to allow personnel to inter-vene or call for investigation of any situation thought to be unsafe. Comprising seven principles, its goal is to avoid errors caused by human actions. In the air-line model CRM gives any crew member the author-ity to question situations that fall outside the range of normal practice. Before the implementation of CRM, crew members other that the captain had little or no input on aircraft operations. After CRM was instituted, anyone identifying a safety issue could take steps to ensure adequate resolution of the situation. The ben-efit of this method in the operating room is clear, given the potential for a deadly mistake to be made.

The seven principles of CRM are (1) adaptabil-ity/flexibility, (2) assertiveness, (3) communication, (4) decision making, (5) leadership, (6) analysis, and situational awareness. Adaptability/flexibility refers to the ability to alter a course of action when new information becomes available. For example, if a major blood vessel is unintentionally cut in a routine procedure, the anesthesiologist must recog-nize that the anesthetic plan has changed and vol-ume resuscitation must be made even in presence of medical conditions that typically contraindicate large-volume fluid administration.

Assertiveness is the willingness and readiness toactively participate, state, and maintain a position until convinced by the facts that other options are better; this requires the initiative and the courage to act. For instance, if a senior and well-respected sur-geon tells the anesthesiologist that the patient’s aor-tic stenosis is not a problem because it is a chronic condition and the procedure will be relatively quick, the anesthesiologist should respond by voicing con-cerns about the management of the patient and should not proceed until a safe anesthetic and surgi-cal plan have been agreed upon.Communication is defined simply as the clearand accurate sending and receiving of information, instructions, or commands, and providing useful feedback. Communication is a two-way process and should continue in a loop fashion.

Decision making is the ability to use logical andsound judgment to make decisions based on avail-able information. Decision-making processes are involved when a less experienced clinician seeks out the advice of a more experienced clinician or when a person defers important clinical decisions because of fatigue. Good decision making is based on real-ization of personal limitations.

Leadership is the ability to direct and coordinatethe activities of other crew members and to encour-age the crew to work together as a team. Analysis refers to the ability to develop short-term, long-term, and contingency plans, as well as to coordi-nate, allocate, and monitor crew and operating room resources.

The last and most important principle is situ-ational awareness; that is, the accuracy with which aperson’s perception of the current environment mir-rors reality. In the operating room, lack of situational awareness can cost precious minutes, as when read-ings from a monitor (eg, capnograph or arterial line) suddenly change and the operator focuses on the monitor rather than on the patient, who may have had an embolism. One must decide whether the monitor is correct and the patient is critically ill or the monitor is incorrect and the patient is fine. The problem-solving method utilized should consider both possibilities but quickly eliminate one. In this scenario, tunnel vision can result in catastrophic mistakes. Furthermore, if the sampling line has come loose and the capnograph indicates low end-tidal CO₂, this finding does not exclude the possibility that at the same time or even a bit later, the patient could have a pulmonary embolus resulting in decreased end-tidal CO₂.

If all members of the operating room team apply these seven principles, problems arising from human factors can almost entirely be eliminated. A culture of safety must also exist if the operating room is to be made a safer place. These seven prin-ciples serve no purpose when applied in a suppres-sive surgical environment.