Patient Safety Focus: To Err is Human

 


To Err is Human
Using Crew Resource Management to Reduce Errors in the Lab


James Hernandez, MD, MS

Assistant Professor, Medical Director of Laboratories, and Chair of the Division of Clinical Pathology
Department of Laboratory Medicine and Pathology, Mayo Clinic Arizona
Scottsdale and Phoenix, Ariz.

When an airline flight from San Diego to Minneapolis recently went astray by 150 miles, the story made front-page headlines for days. No injuries resulted from the pilots’ error, which was attributed to a loss of situation awareness, but the incident triggered heightened scrutiny of airline safety procedures. Overall, the airline industry has a very good track record for safety, thanks in part to a tool known as crew resource management (CRM). Now CRM is being adapted in healthcare to methodically optimize communication among team members and to reduce human errors.

In this interview, James Hernandez, a member of the Patient Safety Focus Editorial Board, describes how laboratories can benefit from this approach to human error management.

Nancy Sasavage, PhD, conducted this interview.

What is crew resource management?
CRM was developed by the airline industry, National Aeronautics and Space Administration, and the Department of Defense and is based on scientific analysis of human behavior in airline accidents. Its framework comes from the Human Factors Analysis and Classification System, a system used in the military and general aviation sectors to examine underlying human casual factors in accident investigations, and from James Reason’s “Swiss cheese” model of accident causation. Prior to Reason’s work, most accidents, including those in healthcare, were believed to be caused by careless individuals, or the “sharp end.” Reason stated that since humans are fallible, error rates should be diminished by focusing on systems, or the “blunt end,” rather than blaming individuals.

What are some of its basic elements?
CRM is part of a broader strategy of building stronger teams, clarifying roles, and empowering both leaders and team members to raise safety concerns. The goal is to prevent work overload situations that compromise situation awareness and can lead to errors. CRM includes clear guidelines for how to delegate, how to build strong and cohesive teams, and how to conduct a formal debriefing. Tactics include: forming teams and assigning roles in so-called “briefs”; using short problem-solving huddles to discuss critical issues, anticipate outcomes, and express concerns; and employing formal process improvement “debriefs” that occur after an event to provide an honest assessment of how the team can improve its future performance.

How has CRM been used in healthcare settings?
CRM is already being used in anesthesiology settings. Studies have shown that 65%–70% of safety problems in anesthesiology can be attributed at least partially to human error. At Mayo Clinic, the department of anesthesiology developed an evidence-based CRM curriculum called Strategies and Tools to Enhance Performance and Patient Safety that is now the Mayo Clinic standard. In addition, several anesthesiologists from the Veteran’s Administration Palo Alto Health Care System and Stanford University and funded by the Anesthesia Patient Safety Foundation developed Anesthesia Crisis Resource Management, which is also modeled on CRM. They even have a full-day course on neonatal resuscitation training for neonatologists and pediatricians using the model.

What other healthcare settings could benefit from CRM?
CRM is particularly helpful in healthcare settings such as operating rooms, labor and delivery, emergency departments, military medicine settings, and laboratories. These settings share several features. They are highly complex, tightly coupled systems, meaning there is not much time to recover from errors, and the outcomes involve high risk to patients.

What conditions lead to lack of situation awareness?
Conditions that undermine Situation Awareness (SA) include failure to: share information with team members; request information from others; and direct information to specific team members.

How did you start using CRM in your lab?
Teams in laboratories share many of the same characteristics as teams in airline cockpits, so CRM is particularly appealing to and intuitive for laboratorians. We first had our human resource staff provide instruction on formal team-building skills, as well as barriers to team-building, assertion skills, and conflict resolution skills.

Are there any particular tips you can provide?
One technique we use is called “CUS” words, which stands for I am concerned, I am uncomfortable, and this is a safety issue. This helps lab staff communicate succinctly. For example, a team member may want to signal others on the team to pause. By saying, “May I have some clarity?” others on the team know that an individual wants to raise a safety concern.

Hand-Off Communication for Critical Situations

From: ________________________
To: __________________________

From: ________________________
To: __________________________

From: ________________________
To: __________________________

Date/Time____________________
(or include below when appropriate)

Pathologist on Call notified? ____________________

 

S

Situation

SITUATION

  • Patient name, location, Accession number
    Issue/problem/history on the patient/specimen/test

 

B

Background

BACKGROUND

  • What actions have you taken so far, test results to date

A

Assessment

ASSESSMENT

  • What information or actions are you waiting for

 

R


Recommendations

RECOMMENDATIONS

  • What needs to happen in what time frame
By standardizing communication on an SBAR form, lab team members get a clear understanding of the situation, thereby reducing human errors.

What are some applications of CRM in your lab?
In addition to implementing the strategies described above, the lab manager at the Mayo Clinic Hospital in Phoenix modifi-ed the Situation-Background-Assessment-Recommendation (SBAR) tool for use in our laboratories (See box, above). We use SBAR to communicate critical information, especially during hand-offs and changes in shifts. Our lab research coordinator also uses it to avoid critical miscommunications when handing off complicated research protocols between shifts. In addition, we discourage distractions, such as noisy non-work related conversations and interruptions by other laboratorians, especially when a bench technologist is performing a critical task.

ADDITIONAL READING

  • Wiegmann DA and Shappell SA. A Human Error Approach to Aviation Accident Analysis, The Human Factors Analysis and Classification System. Ashgate Publishing Co. Burlington, Vermont, 1988.
  • Reason J. Human Error: Models and Management. Website accessed October 22, 2009.
  • Pizzi L, Goldfarb NI, and Nash DB. Crew Resource Management and its Applications in Medicine. Website accessed October 22, 2009.
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Patient Safety Focus Editorial Board

Chair
Michael Astion, MD, PhD
Department of Laboratory Medicine
University of Washington, Seattle

Members
Peggy A. Ahlin, BS, MT(ASCP)
ARUP Laboratories
Salt Lake City, Utah 
James S. Hernandez, MD, MS 
  Mayo Clinic Arizona
Scottsdale and Phoenix

Devery Howerton, PhD

Centers for Disease Control and Prevention
Atlanta, Ga.

Sponsored by ARUP Laboratories, Inc.
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