In this series, Steve Kreiser describes a model for applying aviation’s crew resource management to healthcare. This model incorporates different elements inherent in most CRM programs but has an additional benefit of including simple error prevention tools and techniques that help reduce human error. These seven tools, essentially a “people bundle” to make humans more reliable, can help individuals experience fewer errors while encouraging teams to catch and trap those errors that do still occur in complex systems. The series will continue on Tues. and Thurs. through Jan. 19.
Element #2 – Resource Management
In December 1972, Eastern Air Lines Flight 401 was on its final approach to the Miami International Airport late at night when the crew noticed a green “landing gear down” indicator light was not illuminated. The captain made the decision to abort the landing attempt and circle the airport to troubleshoot the problem over the vast darkness of the Florida Everglades. While the cockpit crew removed the light assembly and the flight engineer went down below to visually confirm the landing gear was down, the captain accidentally bumped the control stick, unaware that he had put the autopilot into a mode that had commanded a slight nose-down attitude and gradual descent. By the time the pilots realized what had happened, the aircraft had lost 2,000 feet of altitude. It impacted the ground at 227 miles per hour. In all, 101 of the 163 passengers and crew were killed simply because somebody forgot to fly the airplane.1
Managing resources is the responsibility of everyone on a team, but the ultimate authority for delegating tasks and providing oversight rests with the team leader. An effective team leader maintains a big-picture view of the situation – looking at things through a “big lens” – while delegating and assigning tasks to appropriate team members. These team members can then look through the “little lens” of individual task details without compromising the overall mission. There are a lot of things to take into account when delegating tasks to team members, including individual knowledge and skill, workload, fatigue, and distractions. In one healthcare case study, a 32-year-old woman undergoing a laparoscopic cholecystectomy died when, at the surgeon’s request, a plane film x-ray was shot during a cholangiogram. The anesthesiologist stopped the ventilator for the film to prevent movement of the diaphragm and blurring of the image. The x-ray technician was unable to remove the film because of its position beneath the table. The anesthesiologist attempted to help her, but found it difficult because the gears on the table had jammed. Finally, the x-ray was removed, and the surgical procedure recommenced. At some point, the anesthesiologist glanced at the EKG and noticed severe bradycardia, suddenly realizing he had never restarted the ventilator. Just as in the case of Eastern Flight 401, distractions, poor task management, and a failure to maintain a “big lens” by the team leader led to a tragic event of preventable harm.
Discussing threats to patient safety and outlining contingencies during pre-job briefs, looking for threats – “red flags” – during procedures or the plan of care, and communicating these threats to fellow team members while delegating tasks and responsibilities are all part of a high-functioning team’s ability to effectively manage its resources.
High Reliability Tip #2 – Leaders keep sight of the big picture by maintaining a “big lens” view of the situation, monitoring for threats and delegating tasks to team members for “little lens” focus.
Watch for the next post in this series, Element #3 – Communication, on Thurs., Jan. 5.
Steve Kreiser is a consultant with Healthcare Performance Improvement (HPI). previously, Kreiser was an FA-18 pilot with more than 21 years of experience in the U.S. Navy, and a first officer for a major airline, where he worked extensively in the area of crew resource management. Mr. Kreiser can be contacted at firstname.lastname@example.org.
- NTSB Aircraft Accident Report, File # 1-0016, Eastern Airlines Inc. L-1011, N310EA, Miami, FL. June 14, 1973.