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.
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