Do You See What I See A Robust Overview of Human Factors and Crew Resource Management for Healthcare Simulation Educators Welcome Aboard US Airline Passenger Sta tistics 2009 ID: 531850
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Slide1
The View from the Cockpit:Do You See What I See? A Robust Overview of Human Factors and Crew Resource Managementfor Healthcare Simulation Educators Slide2
Welcome Aboard!Slide3
U.S. Airline Passenger Statistics2009US Census 2009 = 306,771,529 Total Passengers =
631,939,829
1.73 million per day = 2.05 / year
1 crash
52 total fatalitiesSlide4
Iatrogenic Deaths 2009James, J. T. (2013). A New, Evidence-based Estimate of Patient Harms Associated with Hospital Care. Journal of Patient Safety, 9(3), 122-128Jewell, K., & McGiffert, L. (2009). To err is human, to delay is deadly: ten years later, a million lives lost, billions of dollars wasted. Yonkers, N.Y.: Consumers Union.
140,000+Slide5
Human Factors &Crew Resource ManagementThe psychology behind the successes & failures of Team Dynamics.Slide6Slide7
How does this apply to Simulation Training & Curriculum Design??Slide8
Why airplanes?What’s your story?
What is CRM?
Is it “really” important?Slide9
Airlines were REALLY dangerous!! Eastern 401 – CFIT (1972) Delta 723 – CFIT (1973) TWA 514 – CFIT (1974) Tenerife – culture/rush (1977) United 173 – fuel starve (1978) Air Florida 90 – ice/rush (1982) NWA 255 – flaps/checklist (1987)
Delta 1141 – flaps/checklist (1988)
Avianca
52 – fuel starve (1990)
NWA Detroit – runway/rush (1990)Slide10
Eastern Airlines #401 (1972) Slide11
The Detail Chain:Slide12
Everyone knows WHAT went wrong, but….WHY did this happen?Slide13
Similarities inMedicine and Aviation“Zero-Fail” industriesHighly technical.Takes a long time to get good.High achievers, with ATTITUDE.Instant life-threats are decided IN SECONDS by whomever is there.
Critical Decisions Fast:
Mistakes can be fatal!Slide14
#1 Similarity:Blind trust with your life!Slide15
Differences inMedicine and AviationBiologic VariabilityHeavy regulation: training/instructor standardsMedia coverageIncident report vs. NTSBIn healthcare, we bury our mistakes
The Pilot dies.
(Motivation to Buy-In and learn!)Slide16
Our Common HistoryAviation, 1960’s - 1989Medicine, 900 BC - present
MASSIVE RESISTANCE to change!Slide17
MASSIVE resistance??Blake & Mouton – 1964FAA 121: “Pilots vs. crews”NASA workshop – 1979United Airlines CLRUNITED 232 - 1989FAA AQP – 1990, 1993Slide18Slide19
Everyone knows WHAT went wrong, but….WHY did this happen?Slide20
Airplanes & Healthcare?
Experienced; Routine Procedure
Visual/Aural Alarm
Established Protocol
Unusual Events
Danger Implied!
Authority Not Questioned
Who’s in control?Slide21
Easy Fix! “Make technology better!” (fix the planes, not the crews)But the evidence proved…Slide22
Recognizing AND Trapping any event breaks the accident chain!
Errors Are A Chain of Events.Slide23
ECCLESIASTICAL CANON of CRM DOGMA:MISADVENTURES WILL HAPPEN(Upon this hangs all the law.)Slide24
Human FactorsWe ALL have this! Macho – “We would really../never..” – “Can’t happen to me.” Ego – “I’m experienced.” Superiority – “I’m the surgeon.” Inferiority – “I’m just a new nurse.”
Convinced – “That HAS to be it.”
Denial – “This can’t be happening!”
Fear of being wrong
Fear of punishment
Unfamiliar, Untrained
Fatigue / Boredom
Sensory/Perception Limitations
Task Saturation & Task Shedding
Tunnel Vision & Monitor Fixation
Family & Life’s Pressures!!!Slide25
So how do we apply this to medicine?Slide26
COMBATING HUMAN FACTORS:CREW RESOURCE MANAGEMENT (CRM)Slide27
The belief in your heart:Slide28
“I expect you to check me on everything I say and do, and speak up when there is a potential for any error that will kill someone.”Slide29
What is CRM, really?Slide30
CRM’s “NoTech” ComponentsHumans WILL make mistakesReduce authority gradientSituational Awareness & Shared Mental ModelsPerformance Monitoring and the Two-Challenge RuleAssertiveness: “What is your Intention
?”
Team Roles
Task Prioritization
Contingencies, Aborts & Decisions…under pressure
Checklists
Briefings
Clear messages,
Read-Backs, Closed-LoopsSlide31
Situational AwarenessKnowing (not just believing)what’s really going on,and dividing attentioneffectively.Slide32
Situational AwarenessSlide33
NOT Situational AwarenessSlide34
Situational AwarenessSlide35
Situational AwarenessSlide36
Clearly defined responsibilities.Making sure stuff happens at the right time.Team Roles & Task Prioritization:Slide37
Clear Messages & “Hangers”:DIRECTOPENCOMMUNICATIONis the most effectivetrap of errors.Slide38
Read-Backs & Closed Loops:"LIMITED: Command/Confirm”PriorityExpectedPolling1 – Order / Concise Information2 – Read-back (VORB)
3 –
Deconflict
4 – Action happens
5 – Confirm when done
6 – AcknowledgeSlide39
ChecklistsApplied fully, in every case, at every critical phase.Emergency/drill: Only FIVE “Memory Items”, MAX!!Event change = new checklistMust be EASY to find & read, Under stress!One person: Read/Do vs. Flow Check
Two person: Challenge & ResponseSlide40
Checklist DesignNormalQuick-ReferenceEmergencySlide41
WHY the Checklist works!!Human Factors (the stage is set..)Not stressed? Complacency & Routine…The Unexpected..Brain does funny things under stress!Team does funny things under stress!More Dominoes line up…More Human Factors continue the clouding…Slide42
CrosschecksTwo-person verificationCritical / risky itemsCrisis = higher riskSlide43
Technical CompetenceSimulation & HF/CRMInitial trainingExperienceRecurrent trainingLow-frequency, High Stakes eventsSource of certificationSafe (not minimum) standardsSlide44
When was the last fatal crash of a major (United States flagged) airliner?(this stuff really does work.)
STILL
Not a believer yet?Slide45
NOT A MIRACLE ON THE HUDSON!!Play the hand you’re dealt; you may not have an option.High-Fidelity Simulation (Intensity)Recency & Exercise (every 6 months)Knowledge + Practice = DecisivenessCRM, always.Slide46
How Many Pilots….….does it take to crash an airliner?Slide47
How Many Medical Practitioners….…does it take to kill a patient?“…And we will all go down, together.” --Billy Joel in Good Night Saigon, 1982Slide48
Happy Landings!Slide49
Photo Credits
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, J. T. (2013). A New, Evidence-based Estimate of Patient Harms Associated with Hospital Care. Journal of Patient Safety, 9(3), 122-128
.
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Photo Credits
Karppinen
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Farrington, C./US Navy (2011). US Navy officer aboard New Zealand ship [digital image].
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Photo Credits
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