Learn From the Pilots to Minimize Errors in Anesthesia Management: Recognition and Prevention
Stephen J. Gleich BS (MSIII)
Juraj Sprung MD, PhD
Crew resource management (CRM), also known as crisis resource management, emphasizes a team approach to managing a situation in which the role of human factors is considered. Included in the CRM model are the effects of fatigue, predictable perceptual errors (e.g., misreading monitors or mishearing instructions), and the effects of various management and organizational styles in high-stress, high-risk environments. Originally developed in the aviation industry, CRM training fosters a unified environment with effective communication in which junior personnel are unconstrained about alerting others when something is amiss. If an error occurs, the goal of the team is to capture the error before it progresses and causes an adverse event.1
APPLICATION OF AVIATION-ADOPTED CREW RESOURCE MANAGEMENT TO ANESTHESIA PRACTICE
The practice of anesthesiology and the operation of commercial aircraft share some key characteristics: interaction with team members, continuous monitoring, and standard operating procedures (SOPs). The aviation industry has taken great strides in enhancing safety by adopting and implementing CRM in the 1980s. Likewise, these safety procedures captured interest in the anesthesia community as a method for decreasing risk to patients.
In 1978, a commercial airliner experienced a minor landing gear indicator malfunction, which required the crew to troubleshoot the problem before landing. The aircraft was low on fuel, and even with the installation of new digital fuel gauges and warnings, the three-person crew did not realize the low fuel situation until the engines began to flame out. The flight circled the airport until the plane ran out of fuel and crashed. The experienced crew was focused on resolving the landing gear problem, did not coordinate their actions, and did not identify another developing adverse event, even in the presence of modern technology.
The widespread adoption of CRM principles can decrease adverse events in aviation and in the perioperative setting. Adverse events are rarely
caused by a single factor and typically occur when a number of conditions are met. According to Rampersad and Rampersad, adverse events often occur along the following trajectory of adversity:
caused by a single factor and typically occur when a number of conditions are met. According to Rampersad and Rampersad, adverse events often occur along the following trajectory of adversity:
A catalyst event (e.g., landing gear malfunction vs. patient oxyhemoglobin desaturation).
A system fault (e.g., failure of the new digital fuel gauges to alert the crew to a low fuel situation vs. failure of the pulse oximeter alarm to alert the anesthesiologist of the desaturation).
Loss of situational awareness (e.g., cockpit crew was focused on the landing gear problem vs. anesthesiologist preoccupied with charting and does not recognize the desaturation).Related posts:
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