Crisis Resource Management Skills

What are Human Factors and Why are they important?

Many modern Simulation Training courses are based around looking at Human Factors and how they can be addressed to improve patient safety and improve clinical outcomes.   Patient safety is a key issue in the clinical governance of healthcare institutions and it is known that there is significant overlap between Human Factors and Safety.

Mistakes of course will always happen – sometimes these mistakes are unavoidable but on many occasions human errors can be attributed NOT to a lack of skill or knowledge but lack of application, attention or communication of information.   There are various cognitive pitfalls that we can fall into (an will fall into) unless we are aware of them and try to avoid them by being conscious of problems that can arise.   Usually falling into one of these biases or pitfalls is harmless for the patient but occasionally mistakes in healthcare cause can cause harm to patients.   The reason most mistakes do not cause harm most of the time is that the ‘holes don’t line up’.  This is known as Swiss Cheese Theory in the Aviation world:

Taking into account the Swiss Cheese Theory (shown above) we know that to cause an accident multiple problems have to occur at once.  In other words multiple mistakes have to happen all at the same time to cause an ultimately bad outcome.

In all industries (including both aviation and health care) ‘systems’ are generally designed to prevent common and anticipated problems.  As healthcare professionals we work in a complex system.  As individuals working in this unpredictable environment we may not see harm as a result of our actions on a daily basis but we know from the history of medicine that errors do occur on a regular basis.  Therefore, we believe it is important to be realistic and acknowledge that we are ALL susceptible to various human errors and cognitive biases and increase our awareness of these issues.

The study of Human Factors teaches us that we are prone to making errors regardless of how junior or senior we are in terms of our experience.

While some accidents are not preventable, up to 75% of critical incidents in aviation can be attributed to human error.

Root cause analysis of error in healthcare has shown that poor communication contributes to a large number of adverse events and the numbers are thought to be similar to those seen in the airline industry.

These issues are really well summarised in the video featured below.  In this short video documentary an airline pilot (and expert in the study of Human Factors), Martin Bromiley describes the events leading up to his wife’s untimely death.  She died as the result of a ‘routine operation’ that went wrong as a result of an unexpected anaesthetic complication.  His wife had an unanticipated ‘Can’t intubate’ & ‘Can’t oxygenate’ (CICO) situation.  As a result of prolonged low oxygen levels she suffered a severe Hypoxic brain injury and died a few days later in intensive care.  These events occurred despite the presence of several very experienced expert anaesthetists and an Ear Nose and Throat (ENT) specialist:

Truncated Video on Human Factors

Full Video on Human Factors

In thinking about the issues surrounding the Trauma Team Training course I was asked to discuss some of the issues around Human Factors, Errors, Negotiation and Graded Assertiveness.

Human Qualities and Persuasion Skills are important in order to prevent chaos in Major Trauma scenarios – the default position is chaos in my experience of crisis situations run without effective leadership and management skills.

Errors are more common in increasingly complex and stressful cases.

We suggest you think about management of the TEAM, YOURSELF and the ENVIRONMENT in order to remain in control:

• YOU – Are you H.A.L.T? (Hungry, Angry, Late or Tired)
• ENVIRONMENT – Are you familiar? Noise Levels (patient, team)? Distractions?

The highly functioning TEAM requires good leadership and followership to move forward effectively and efficiently towards shared common goals.  As the team leader it is important to continuously allow for feedback, share your thought processes and summarise at regular intervals.

Teamwork and a functioning team dynamics are important int the chaotic environment of Severe Trauma and most Medical Emergencies.  After the case has been treated try to reflect on how the team went in regards to Human Factors.  This debriefing process is important after each Emergency case you attend.

Why is Self Control and Control of the Team Important?

Things may descend into Chaos even when members of the team ‘know what they are doing’ and ‘want to do their best’.  One way to consider the ‘diagnosis’ of what is going wrong in a crisis is to consider Yourself (how are you feeling and acting?), Others (how is the team working together and how are others feeling/acting?) and the Environment (how can you optimise noise levels, patient comfort, clinical distractions, equipment issues etc. to make life easier for managing the emergency)

Cliff Reid follows this idea in his diagram outlining factors to focus to avoid a ‘Loss of Control’ in Healthcare Emergencies:

Video starring the now famous Sam Worthington:

Graded Assertiveness

C.U.S.S.

• C – CONCERN – I am concerned that we haven’t checked for allergies
• U – UNSURE – I am uncertain that this Augmentin duo forte medicine can be given to someone with a possible penicillin allergy
• S – SAFETY – I am really worried it is UNSAFE to give this patient a penicillin like drug given his known allergy
• S – STOP – Please stop – we need to take a timeout and discuss this further…
  • For More on Graded Assertiveness look at our article on this topic – CLICK HERE

Essential C.R.M. Skills for Acute Medicine

Medical Negotiation Skills

Disagreements are inevitable in managing Trauma Cases

“Credibility, authority, and being LIKED are powerful persuasion tools” Cliff Reid (2013)

Suggested Strategies for Negotiation

6 Laws of Influence (Ciadini)

• Authority
  • Individuals are more likely to comply with experts/authority
• Reciprocity (“Do us a favour”)
  • If you give something to people, they feel compelled to return the favour.
• Scarcity
  • This is less applicable to medicine – i.e. rare items are more valuabl
• Liking
  • We are more inclined to follow the lead of someone who is similar to us rather than someone who is dissimilar
• Commitment
• Consistency
• Social Proof
  • We view a behaviour as more likely to be correct if others are performing in a similar manner.
  • Video Link:

In conclusion, Human Factors and Team Training will have an increasing role in the future of healthcare education and training.  Challenges will include participant and senior buy in as well as maintenance and long term retention of skills.

Essential Viewing on Human Factors (Cliff Reid)

Harvard Crisis Resource Management Review – CLICK HERE

If you have an IPAD we recommend the Massive Open Online Course (MOOC) from Stanford ‘ Crisis Code’ – CLICK HERE