Notes on crisis resource management

1. CRISIS RESOURCE MANAGEMENT
DR. RAVIKIRAN H M
INTRODUCTION:
Excellent clinical performance is not achieved by the use of sound medical knowledge alone, as
clinicians have to face multifaceted challenges not just medical issues.
There is an increased awareness that human factors—both on the individual and the team level—
as well as organizational factors in the health care system play major roles in providing excellent
medical care.
Therefore, for anesthesia professionals
(1) The study of human performance is fundamental,
(2) The knowledge and successful application of efficient safety strategies are highly
relevant, and
(3) Understanding of the pertinent organizational matters is very important.
Organizations and individuals need to fully recognize that the performance of individual anes-
thesia professionals can—as for all human beings—be adversely influenced by performance-
shaping factors, including noise, illness, aging, boredom, distraction, sleep deprivation, and
fatigue, as well as by social dynamics within and between crews and teams.
It is necessary to have a clear understanding of known human performance pitfalls such as
fixation errors, ineffective team communication, misunderstandings, medication errors, unclear
task management, and erroneous assumptions.
While anesthesia professionals’ knowledge and skill are key strengths needed for safe patient
care, addressing the limitations will help them to actively avoid or mitigate the risk of adverse
events.
One approach to understanding and intervening in human performance issues for anesthesia care,
especially focused on challenging situations, is that of crisis resource management (CRM).

2. CRM (as in “cockpit [then crew] resource management”) was developed in aviation first but then
adapted to health care, initially for anesthesia care, in the early 1990s.
There are many formulations of CRM but they typically highlight :
1. Situation awareness,
2. Dynamic decision making,
3. Task management,
4. Communication, and
5. Teamwork.
The introduction of CRM in anesthesiology and its spread into many other health care disciplines
and domains have typically been associated with the use of realistic simulation-based training of
anesthesia professionals in single-discipline or combined team training.
It also has helped focus attention on systems’ issues that relate to key aspects of human
performance highlighted in CRM-oriented training.
DEFINITION:
Crisis resource management (CRM) in medicine, sometimes also referred to as crew resource
management, is an effective safety strategy concept and tool adapted from the domain of aviation
and modified to the needs of health care.
Gaba traditionally defines CRM: “CRM is the ability to translate the knowledge of what needs to
be done into effective team activity in the complex and ill-structured real world of medical
treatment.”
CRM means to coordinate, use, and apply all available resources to optimally protect the
patient—at an individual as well as at a team level.
Resources include all the personnel involved, along with all their skills, abilities, and attitudes—
albeit also with their human limitations. Machines, devices, and information sources, including
cognitive aids, are also critical resources.
FIFTEEN KEY POINTS

3. 1. Know the environment.
2. Anticipate and plan.
3. Call for help early.
4. Establish leadership and followership with appropriate assertiveness.
5. Distribute the workload. Use 10 s for 10 min concept.
6. Mobilize all available resources.
7. Communicate effectively—speak up.
8. Use all available information.
9. Prevent and manage fixation errors.
10. Cross and double check. Never assume anything.
11. Use cognitive aids.
12. Reevaluate repeatedly. Apply 10 s for 10 min concept.
13. Use good teamwork. Coordinate with and support others.
14. Allocate attention wisely.
15. Set priorities dynamically.
10- SECONDS-FOR-10-MINUTES PRINCIPLE:
Meaning, metaphorically spending 10 seconds in order to achieve a better coordinated team for
the next 10 minutes.
When making a diagnosis or feeling stuck, perform the 10- seconds-for-10-minutes team timeout
and check to see “what the biggest problem is right now” (Problem). Clarify this with all
available team members (Opinions). Gather the information available (Facts). Plan the treatment,
including the desired sequence of actions. Distribute the workload by assigning tasks and
responsibilities. Check actively with all team members about any further concerns of
suggestions. Then act as an organized team.

4. FIXATION ERRORS :
Human decisions and actions are based on an instantaneous mental model of the current
situation.
If the model is erroneous, the decisions and hence the actions will probably be wrong.
Faulty reevaluation, inadequate plan adaptation, and loss of situation awareness each can result
in the type of human error termed fixation error.
A fixation error describes a mental model of a situation that is persistently faulty despite
sufficient evidence to correct it.
A fixation error therefore leads to a persistent failure to revise a diagnosis or plan, even though
readily available evidence suggests that a revision is necessary.
Three main types of fixation errors:
Fixation Error # 1: “This and only this” or “cognitive tunnel vision.”

5. In this type of error, attention is focused on only one possibility. Other
alternatives (possibly or actually correct) are not taken into account (i.e., There is
profound hypotension and tachycardia; the patient must be hypovolemic, there
must be bleeding [disregarding anaphylaxis, cardiogenic shock, excessive vasodi-
lator administration, etc.]). The available evidence is interpreted to fit the initial
diagnosis or attention is allocated to a minor aspect of a major problem.
Fixation Error # 2: “Everything but this.”
In this type of error, attention is persistently focused on the search for further (ir-
relevant) information or diagnosis resulting in the failure to treat a probable cause
and commit to the definitive treatment of a major problem. (i.e., Hmm… there is
tachycardia, maybe it’s light anesthesia, maybe it’s hypovolemia, maybe it’s…
and there’s hypercapnia maybe it’s the CO2 absorber, maybe it’s… and there’s
fever, maybe the patient is septic, and… without ever committing to either
definitively rule out, or else treat for—“actually all these signs point to malignant
hyperthermia so I’m going to treat it as such”).
Fixation Error # 3: “Everything is OK.”
This is the persistent belief that no problem is occurring in spite of plentiful
evidence that it is. In this type of error, all abnormalities may be attributed to
artifact or transients. Possible (pre-) signs of a catastrophic situation are
dismissed. (i.e., “The blood pressure cannot be so low. Probably the blood
pressure cuff does not measure right. That is alright.”). Another form of this type
of fixation error is the failure to actively transition from routine mode into
emergency mode when the situation demands it. A failure to declare an
emergency or to accept help when facing a major crisis may stem from denial that
a serious situation is actually occurring.
Evidence for the Benefit of Crisis Resource Management and Other Human-Factor-
Related Team Training Curricula:
1. Increased provider satisfaction

6. 2. Improved safety culture and a heightened culture of teamwork
3. Increased clinical team performance
4. Decreased room turnover time
5. Increased percentage of on-time first case starts
6. Decreased preoperative delays, handoff issues, and equipment issues
7. Improved patient willingness to recommend
8. A decrease in medication and transfusion errors
9. Increased antibiotic prophylaxis compliance
10. An increase of efficiency for clinical processes for multidisciplinary trauma teams
11. Decreased mortality and morbidity
REFERENCE:
Miller 9th
ed