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Patient safety

Learning from the aviation industry

Kosnik, Linda K. RN, APN, MSN; Brown, Jeff MEd; Maund, Tina RN, CPHQ, MS

Author Information
Nursing Management (Springhouse): January 2007 - Volume 38 - Issue 1 - p 25-30

History has repeatedly taught us that bad things can happen in complex systems…

At dusk on February 1, 1991, an airliner operated by Skywest Airlines was cleared by an air traffic controller to taxi onto a runway at Los Angeles International Airport (LAX) and hold position, awaiting further permission to take off. Within 2 minutes the same controller cleared a US Air Boeing 737 to land on the same runway. In the ensuing collision and fire, dozens aboard the 737 were killed or injured, and all 22 of the passengers and crew aboard the Skywest airliner were killed. Not surprisingly, in the aftermath of this tragedy, the controller was vilified by the press and public. Yet, as the National Transportation Safety Board investigation progressed, it became apparent that the conditions of work in the Los Angeles Air Traffic Control Tower at the time of the accident were ripe for provoking her catastrophic lapse of memory.1

At the time of the accident, the air traffic controller was managing the arrival and departure of multiple airplanes. Some of the key factors that combined to precipitate the catastrophic event included:

  • ♦ poor observability of the situation: The controller couldn't directly observe and visually distinguish the aircraft she was in communication with due to the glare of terminal lighting.
  • ♦ deviation from standard operating procedures related to tracking and handing off flights in progress.
  • ♦ degraded ability to detect a problem and mitigate related to excessive demands and reliance on short-term memory.1

These and other factors, discovered in hindsight, set the stage for human performance failure in a time-pressured and frequently interrupted work environment. The safeguards and countermeasures designed to support error avoidance and limitation had been eroded insidiously over time; this atmosphere wasn't a result of malicious or irresponsible behavior on the part of air traffic controllers or facility managers.

Changes in policy, procedure, and practice can produce latent conditions for failure that unexpectedly couple with dynamic conditions—such as a memory lapse—to provoke active failure.2 As the next case reveals, tragic accidents of this sort not only happen in aviation; similar opportunities for failure in other socially and technologically complex systems—such as healthcare organizations—abound.

At 1 p.m. on the third floor of General Hospital, a nursing assistant was asked to draw blood for a type and cross for patient Alma Jones in room 305. The assistant walked into room 305 and asked for Alma Jones. The patient in bed one, who happened to have a hearing deficit, answered him and he promptly drew, labeled, and sent the blood off to the lab for a type and cross for 1 unit of PRBCs, having failed to visually check the labels with the patient's ID band. On the next shift at 8 p.m., 1 unit of PRBCs arrived for Alma Jones. Two nurses conscientiously cross-checked the unit of blood with Alma Jones' name band at her bedside in room 305, bed two. Within minutes of the initiation of the blood transfusion, Jones developed shortness of breath and chest pain. The nurse stopped the transfusion immediately, but Jones died shortly thereafter from anaphylaxis due to a blood incompatibility.

The resulting root cause analysis identified the following contributing factors:

  • ♦ deviation from standard operating procedures
  • ♦ inadvertent removal of human performance redundancies (verification of two identifiers)
  • ♦ hearing impediments to patient identification process
  • ♦ multiple handoffs unsupported by structured communication.

Such human performance breakdowns are inevitable, with the individuals involved being the victims of system defects rather than the main instigators of an accident. At a bird's-eye level, accidents seem to be side effects of decisions made within and among organizations, often over extensive time frames. Adverse events are frequently linked to inadequate knowledge of frontline experiences of hazards and error-provoking conditions. The capability to detect and intervene in such conditions, before they induce tragedy, is of paramount concern.3

CRM 1979 to 2006

Crew resource management (CRM) was developed by the aviation industry to reduce the incidence of human errors and related air transportation accidents. The tools and applications of CRM create enhanced communication focused on team-centered decision-making systems. CRM doesn't only depend on communication techniques, but also embraces other complementary components such as the strategic use of technology and the development of efficient processes. CRM has been able to change the “work” of aviation from being dependent on individual attitudes, personalities, and social skills—which fluctuate based on events, environment, and team mix—to work that's collaborative with joint accountability of all team members, and is strongly and consistently supported by structured, focused communication. The CRM methodologies and associated training require specific, routine communication behaviors under all circumstances that are observable and measurable. These key building blocks comprise the CRM tool kit:

  • reduced hierarchy
  • backup systems
  • team communication and coordination
  • monitoring and cross-checking
  • briefings and debriefings
  • resource management
  • system knowledge
  • personal readiness planning
  • correction of known problems and issues
  • management support.

CRM and healthcare

With today's critical concerns related to patient safety, the importance of collaboration and a team approach to patient care has become paramount. The CRM methodologies are easily transferable to healthcare. Research has demonstrated that healthcare can achieve a 53% reduction in adverse outcomes through the application of CRM tools and processes.4 An aircrew engaged in complex flight operations resembles the staff functioning in such complex healthcare environments as emergency departments, operating rooms, and intensive care units.5 In fact, much of the work done to apply CRM to healthcare environments has been driven by anesthesiologists to support safe practices in operating suites.6

Accidents, errors, and adverse events

Adverse events are frequently linked to frontline staff having inadequate experience and training in error-prone conditions. Common human factors identified during adverse event or root cause analyses include extraordinary complexity of the work, deviations from usual workflow—often due to distractions or high workload demands—poor coordination across and between roles and job functions, poor dynamic task reallocation, lack of adequate handoff briefings, missed side effects of change, and compromised observability of situations, which limits the ability to detect and mitigate problems.7

Healthcare providers have tremendous tolerance for unsafe conditions because we've become inured to the hazards these conditions hold for our patients and ourselves, and/or we're confident in our ability to continue to work around unsafe conditions without failure.8 Moreover, it's part of clinical culture to believe that it's a professional responsibility to compensate for the error-provoking or otherwise unsafe conditions and practices that may have arisen as unintended consequences of organization processes.9,10

There are environmental conditions that precipitate errors, yet staff is often forced to work with poorly designed or awkward technology that complicates the work. This often includes meeting an organizational need that's far removed from and undermines the safety of the work at the bedside. An example would be the hospital with limited nursing unit staff due to budget constraints, which requires that routine morning blood samples be drawn by an assigned nursing assistant. The procedure requires that labels and tubes are brought to the bedside, visually cross-checked with the patient's ID band, and that tubes are labeled before leaving the bedside—one patient at a time. Given that the assistant is also responding to call lights, helping patients to the bathroom, and completing vital signs, the resources are inadequate to perform the procedure as required.

The assistant is left with the option of taking ”shortcuts”—such as bringing in labels to draw both patients in a room at the same time, saying the patient's name instead of visually comparing two identifiers using the labels and ID band, or batching tubes and label after drawing multiple patients' blood—or not completing her assignment and failing to meet patients' and co-workers' needs and expectations. The resource constraints and process requirements of the organization are a setup for failure by this staff.

In essence, human error opportunities are everywhere, and every healthcare error has at least two victims, the patient and the healthcare provider. Healthcare must strive to protect itself by creating more highly reliable systems.10 But how do we create reliable systems? Essentially, we build better teams supported by effective communication strategies. Healthcare teams are particularly challenged in that providers often don't have a history of working with each other and, therefore, don't understand or know each others' strengths and weaknesses.

In addition, the very patients that providers have been brought together to serve are, in themselves, unique. The challenges to providing safe and effective patient care aren't only a function of the social and technological complexity of the healthcare delivery system, but the unique physiological needs and condition of each patient.

Applying CRM methodologies

Crew resource management is, by design, organized to develop highly functional teams. Team members are encouraged to create work processes that offer overlapping knowledge of roles and tasks.11 This enhances the ability to cross-check, monitor, and back up team members across disciplines.12 All members of a team have equal accountability for the success of each event or process without consideration for status or job description.

Crew resource management tools are organized to optimize information processes and decision making among all frontline personnel, and must be supported by continuous monitoring and process improvement. Leadership must be uniquely positioned to provide essential, reliable support in the midst of complex systems.

The work of CRM has identified five key behavioral safeguards that support team-based safety and create outcome reliability.

  1. Identify and facilitate consistent activities and actions. Some opportunities to do this are through checklists, work process forcing functions, and standard operating policies and procedures.
  2. Use pattern monitoring and statistical process control to offer information to measure compliance and support process improvement toward decreased variation and increased use of best practices.
  3. Support safe practices with technological safeguards and countermeasures that signal potential defects and error risk—such as those found in alerts, alarms, and hard stops in subsystem automation; documentation systems; and other information systems.
  4. Implement behavior safeguards and countermeasures to support the building of strong teams.
  5. Drive frontline team functionality with communication and knowledge processes, cognitive reliability, and adaptive activities and actions.13

The core of CRM methodology is structured communication. In healthcare, personnel with interdependent professional roles need to communicate in consistent ways that optimize situation assessment, strategy development, and coordinated action.13 In CRM, communication and interaction have ground rules focused on structured interactions that desensitize rank, facilitate team building, promote objectivity in decision making, create synergy, and drive optimal patient outcomes.

The Naval Aviation Schools Command training program promotes that CRM is based on seven skills: situational awareness, adaptability and flexibility, leadership, communication, decision making, assertiveness, and mission analysis.14

It's senior leadership's responsibility to support CRM implementation, which starts with facilitating a reduced hierarchical culture that supports decision making on the front line.15 Although as leaders we enjoy the psychological rush that occurs from “coming to the rescue” and “saving the day,” this approach to leadership is a barrier to frontline staff empowerment and accountability for safe practice. The best leaders build team spirit and empowerment through trust and organizational commitment. Leaders are responsible for team performance and, although they may direct actions based on experience and best practices, they must always ask and rely on assistance to avoid errors and accidents. The best decisions during critical events are made through teamwork in which informed decision making is based on information gleaned from excellent communication, strategies, and experience.

Successful CRM implementation into the healthcare workplace hinges on clinical champions who are knowledgeable and passionate about the application of CRM behaviors, and a culture in which all team members speak freely. This culture should value frontline staff members' opinions and ideas, giving them equal and nonjudgmental acceptance as opportunities for additional information and resources. Conflict resolution should be an objective process in which decisions regarding workload assignments and contingency planning for technology, and process failures or emergency intervention, are made with input from any and all team members.16

The fact is that we are never “out of the woods.” The safety of socially and technically complex systems is shaped dynamically, by people and technology within and among organizations, across varied environments, and over time. The ability to reliably manage complex, high-consequence work—and keep patients safe—is a property of highly effective, adaptive frontline teams.17


1. National Transportation Safety Board. Aircraft Accident Report 91–08. Washington, DC: October 22, 1991.
2. Reason J. Managing the Risk of Organizational Accidents. Burlington, Vt: Ashgate Publishing Company; 1997:252.
3. Merry M, Brown J. From a culture of safety to a culture of excellence: quality science, human factors, and the future of healthcare quality. J Innovative Management. 2001;7(2):29–46.
4. Gaffney FA, Seddon R, Stephen W, Harding SW. Crew Resource Management: The Flight for Lasting Change in Patient Safety. Marblehead, Mass: HcPro; 2005.
5. Uhlig PN. Improving patient care in hospitals. J Innovative Management. 2001;7(1): 23–45.
6. Kosnik LK, Brown J. In press. The case for crew resource management. OR Nurse. 2007.
7. Patterson E, Render M, Ebright P. Repeating human performance themes in five health care adverse events. Proceedings of the Human Factors and Ergonomics Society 46th Annual Meeting. Santa Monica, Calif.; 2002.
8. Carthey J, de Leval MR, Reason JT. The human factor in cardiac surgery: errors and near misses in a high technology medical domain. Ann Thorac Surg. 2001;72(1):300–305.
9. Tucker A, Edmondson A. Why hospitals don't learn from failure: organizational and psychological dynamics that inhibit system change. California Management Review. 2003;45(2).
10. Patankar M, Brown J, Treadwell M. Safety Ethics: Cases from Aviation, Healthcare, and Occupational and Environmental Health. Aldershot, UK: Ashgate Publishing; 2005:85–103.
11. Lave J, Wenger E. Situated Learning: Legitimate Peripheral Participation. Cambridge, UK: Cambridge University Press; 1991.
12. Patterson E, Woods D, Cook R, Render M. Collaborative cross-checking to enhance resilience. Proceedings of the Human Factors and Ergonomics Society 49th Annual Meeting. Orlando, Fla.; 2005.
13. Brown J. Structuring communication for team-based error management. J Healthc Risk Manag. 2004;24(4):13–19.
14. U.S. Navy. Naval Aviation Schools Command. CRM seven skills. Available at: Accessed November 30, 2006.
15. Leonard M, Graham S, Taggart WB. The human factor: effective teamwork and communication in patient strategy. In: Leonard MS, Frandel A, Simmonds T, Vega KB, eds. Achieving Safe and Reliable Healthcare: Strategies and Solutions. Chicago, Ill: Health Administration Press; 2004.
16. Mudge GW. Airline safety: Can we break the old CRM paradigm? Transportation Law J. 1998;25(2):231–243.
17. Lawrence D. From Chaos to Care: The Promise of Team-Based Medicine. New York, NY: Perseus Books Group; 2002.

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Patient safety: Learning from the aviation industry


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The language of change

Crew resource management (CRM) communication tools strive to create a structured approach that marries perception and reality, and fosters situational awareness among personnel engaged in interrelated work.


SBAR has received much attention over the last few years, especially as the JCAHO has embraced it as an effective communication tool for critical handoffs. SBAR is a pneumonic that's designed to trigger a specifically structured communication that's particularly effective in handoff situations – especially when there's a significant or concerning change in patient status (i.e. the patient is immediately post-op or new symptoms are noted).

Situation (what's the event that I'm concerned about)

Background (history of the event)

Assessment (description of findings)

Recommendation (what actions or behaviors are needed to resolve the event)

Mission analysis (MA)/event analysis

Briefings and debriefings are the work of event analysis. In healthcare we have focused primarily on debriefings, which take the form of root cause analysis and are usually reserved for what the JCAHO defines as sentinel events. Fortunately, in recent years, leaders in healthcare safety have identified the “near miss” as being worthy of our analysis. Event analysis has tremendous value for developing short-term, long-term, and contingency planning. It also offers a forum for coordinating, allocating, and monitoring resources that are defined by staff, such as access to supplies, processes, and personnel that support the ability to get work done.1 Failure modes and effects analyses are a form of briefing in that they are done prior to events and offer an excellent opportunity to identify the resources and sequence of tasks that will make a process, implementation, or event more likely to be safe, successful, and effective. Event analyses can be done at any point before, during, and after an event, whenever situational awareness needs to be increased.

Briefings and time-outs

Briefings are focused on creating a shared situational awareness that supports common contingency plans and tolerances, monitoring and backup, and adaptive actions unique to the particular patient. Briefings have become increasingly commonplace with profound effectiveness in operating rooms (ORs). In such an environment, briefings are often coupled with “time-outs,” which require that all team members stop what they are doing to allow for uninterrupted, focused communication. Such preoperative discussions can be successfully completed in less than 2 minutes but are critical to information access and to setting the stage for open communication throughout the procedure. The information essential to each event is designed to support safe practice. For the OR, these briefings would include introduction of team members and roles; discussion of critical information regarding the patient such as name, procedure, site, and medication given; followed by surgeon, anesthesia, and nursing input.2 Briefings should be professional, focused, interactive, and complete and assign responsibility for all tasks identified.3 If situational awareness appears to be reduced during the event, a briefing should be used for short-term planning; to discuss progress; and to identify, mitigate, and inform the team of any challenges or changes.


Debriefings occur at the end of any procedure or event, ideally prior to any member of the team leaving the OR. Many larger events such as disaster drills, which involve individuals who may be located at other sites, benefit the most from a planned debriefing that can be scheduled within days of the event. Debriefings are focused on a review of the individual, team, tasks, and technical and organizational performance during the procedure. In addition, they're the opportunity to identify any potential hazards and error-provoking conditions that may exist or care transitions that need to occur.4 During these interactions, accountability and authority for each aspect of a patient's care can be identified across the healthcare continuum. Debriefings offer an excellent opportunity to discuss any improvement opportunities to enhance performance for such future events; in healthcare they are rich learning experiences that support optimizing patient outcomes. It's critical that debriefings not be tedious or rote. Effective debriefings focus on selective, nonpunitive reviews of key components and interactions, are interactive with all team members participating, and are completed in a timely fashion.

Adaptability and flexibility (AF) or red flags

Red flags are healthcare's answer to what the naval aviation schools call adaptability and flexibility (AF). It refers to the ability to alter a course of action or change of process when new information becomes available. In healthcare such factors include:

  • ♦ indications that something isn't as it should be
  • ♦ triggers for additional communication to manage risks and prevent error
  • ♦ things just don't feel right
  • ♦ communication failure
  • ♦ the appearance of confusion
  • ♦ task fixation from some member of the team
  • ♦ deviations from operational or clinical norms
  • ♦ individual feelings of being overwhelmed or being rushed.5

In order to mitigate such red flags, functional teams must have open, professional avenues of communication and clear situational awareness. They need to be able to anticipate problems, recognize and acknowledge any change, determine if a standard operating procedure or habitual response is appropriate, offer alternative solutions, provide and ask for assistance, or interact constructively with others.5

Situational awareness (SA)

Situational awareness (SA) is a common, synergistic understanding between team members of what's expected to occur and how it should occur. It's that synergistic balance between perception and reality that results in a common view of any situation, event, or process. It requires that there be a synergy between team members' expectations and biases, available and incoming information, and the occurring event. SA is reduced and compromised by factors that are intrinsic to healthcare such as fatigue, stress, inadequate communication, fluctuating workload, team mindset, “do it because I am the doctor” philosophy, work arounds, changing environmental conditions, inadequate resources, and lack of appropriate staff. It becomes critical that processes and work be designed as a complex matrix of team monitoring, cross-checking, forcing functions, vigilance and strategic automation to support safe practice, and to enhance, acquire, and maintain SA. Such designs drive the team members' perceptions of the activities and tasks that are central to the processing of dynamic events.


1. Kosnik LK, Brown J. In press. The case for crew resource management. OR Nurse. 2007.
2. Makary MA, Holzmueller CG, Thompson D, et al. Operating room briefings: working on the same page. Jt Comm J Qual Patient Saf. 2006;32(6):351–355.
3. U.S. Navy. Naval Aviation Schools Command. CRM seven skills. Available at: Accessed November 30, 2006.
4. Reason J. Managing the Risk of Organizational Accidents. Burlington, Vt: Ashgate Publishing Company; 1997:252.
5. Leonard M, Graham S, Taggart WB. The human factor: effective teamwork and communication in patient strategy. In: Leonard MS, Frandel A, Simmonds T, Vega KB, eds. Achieving Safe and Reliable Healthcare: Strategies and Solutions. Chicago, Ill: Health Administration Press; 2004.
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