Crew Resource Management Principles Research Articles

P.031 SMILES: Sunnybrook-St. Michael’s Integrated Leadership/QI in Endovascular Stroke care – enhancing hyperacute stroke protocols for optimized door-to-intervention times

Background: Hyperacute stroke care demands rapid, coordinated care. Traditional metrics like Door-to-Needle time are pivotal but insufficient for capturing the complexity of endovascular stroke interventions. The SMILES collaboration aims to standardize and optimize protocols for door-to-intervention times, incorporating Crew Resource Management (CRM). Methods: The multidisciplinary initiative integrates both hospitals, ED, neurology, and QI teams. We employed a comprehensive approach: stakeholder engagement, simulation-based learning, process mapping, and literature review. Emphasis was placed on enhancing situational awareness, triage and prioritization, cognitive load management, role clarity, effective communication, and debriefing. Results: The collaboration led to PDSA cycles and development of refined stroke protocols. Interventions included: 1) A ’zero point survey’ for team pre-arrival briefings, enhancing situational awareness and role clarity; 2) Streamlined patient registration to reduce cognitive load and improve triage efficiency; 3) Direct transfer of patients to imaging. Additionally, digital tools were implemented to facilitate communication. Simulation sessions reinforced CRM principles, leading to improved team cohesion and operational performance. Conclusions: The SMILES initiative is grounded in CRM principles by standardizing protocols and emphasizing non-technical skills crucial for high-stakes environments. This improves outcomes but also fosters a culture of safety and efficiency. Future directions include an evaluation of these protocols’ impact on patient factors.

Teamwork Training With a Multiplayer Game in Health Care: Content Analysis of the Teamwork Principles Applied.

In health care, teamwork skills are critical for patient safety; therefore, great emphasis is placed on training these skills. Given that training is increasingly designed in a blended way, serious games may offer an efficient method of preparing face-to-face simulation training of these procedural skills. This study aimed to investigate the teamwork principles that were used during gameplay by medical students and teamwork experts. Findings can improve our understanding of the potential of serious games for training these complex skills. We investigated a web-based multiplayer game designed for training students' interprofessional teamwork skills. During gameplay, 4 players in different roles (physician, nurse, medical student, and student nurse) had to share information, prioritize tasks, and decide on next steps to take in web-based patient scenarios, using one-to-one and team chats. We performed a qualitative study (content analysis) on these chats with 144 fifth-year medical students and 24 health care teamwork experts (as a benchmark study) playing the game in groups of 4. Game chat data from 2 scenarios were analyzed. For the analysis, a deductive approach was used, starting with a conceptual framework based on Crew Resource Management principles, including shared situational awareness, decision-making, communication, team management, and debriefing. Results showed that most teamwork principles were used during gameplay: shared situational awareness, decision-making (eg, re-evaluation), communication (eg, closed loop), and team management (eg, distributing the workload). Among students, these principles were often used on a basic level. Among experts, teamwork principles were used with more open forms of speak up and more justification of decisions. Some specific Crew Resource Management principles were less observed among both groups, for example, prevention of fixation errors and use of cognitive aids. Both groups showed relatively superficial debriefing reflections. Playing a multiplayer game for interprofessional teamwork appears to facilitate the application of teamwork principles by students in all important teamwork domains on a basic level. Expert players applied similar teamwork principles on a moderately high complexity level. Some teamwork principles were less observed among both students and expert groups, probably owing to the artifacts of the game environment (eg, chatting instead of talking). A multiplayer game for teamwork training can elicit the application of important, basic teamwork principles, both among novices and experts, and provides them with a flexible, accessible, and engaging learning environment. This may create time for exercising more complex skills during face-to-face training.

Crew Resource Management for Large Unmanned Aircraft Systems Operations

The author explored the application of crew resource management (CRM) principles to commercial flight operations conducted by large unmanned aircraft systems (UAS). Currently, there is no regulatory structure governing the operation of large UAS in commercial flight operations. However, the National Aeronautics and Space Administration (NASA) forecasted the future by demonstrating the feasibility of large remotely piloted UAS flight in June 2018 by flying Ikhana, a modified MQ-9 Predator B aircraft, over a 415-mile route in Class A and in Class E airspace over southern California (Kooser, 2018). Ikhana is a 10,500-pound aircraft with a wingspan of 66 feet capable of climbing to 40,000 feet. In order to establish the viability of CRM as an element of a safety management system to mitigate human factors errors, the research used a cross-case analysis by Neff (2016) of four large UAS accidents to derive a ranked list of the eight most prevalent hard-skill and soft-skill human errors identified as causal to the accidents. An additional study of five Indian Air Force UAS accidents by Sharma and Chakravarti (2005) was referenced and listed eight primarily soft-skill human factors contributing factors. The author applied a CRM teamwork centered template using communications and workload management inputs and situational awareness and threat and error management outputs to analyze and propose mitigations to the contributing human factors errors. The author concluded that a safety management system incorporating CRM principles and supported by appropriate leadership philosophy, policies, procedures, and best practices is an essential element to combat human factors errors and facilitate safe integration of large commercial UAS flight operations into joint use national airspace.

Prevalence and Perceptions of Team Training Programs for Pediatric Surgeons and Anesthesiologists

BackgroundTeam training programs adapt crew resource management principles from aviation to foster communication and prevent medical errors. Although multiple studies have demonstrated that team training programs such as TeamSTEPPS improve patient outcomes and safety across medical disciplines, limited data exist about their application to pediatric surgical teams. The purpose of this study was to investigate usage and perceptions of team training programs by pediatric surgeons and anesthesiologists. We hypothesized that team training programs are not widely available to pediatric surgical teams. Materials and methodsWe performed an online survey of Pediatric Surgery (General, Plastic, Urologic, Orthopedic, Otolaryngologic, and Ophthalmologic) and Anesthesiology members of the American Academy of Pediatrics. The survey inquired about completion and perceptions regarding efficacy of team training programs. Simple descriptive statistics and a Student t-test were used to evaluate the data. ResultsOne hundred fifty-two pediatric surgeons and 12 anesthesiologists completed the survey with a 10% response rate. Over half of the respondents were general pediatric surgeons. Home institutions offered TeamSTEPPS or another crew resource management style team training program for 39% of respondents. Of those with a program, 77% of respondents had completed training. Although most (76%) who participated in team training programs did so by requirement, 90% found it helpful. Of the 61% of surgeons who said their institution did not offer team training programs, 60% said they would participate if one were offered and an additional 32% said they might participate. The biggest barriers to participation were not enough free time or that the team training program was not offered to their department. ConclusionsTeam training programs are considered beneficial among pediatric surgeons and anesthesiologists who have completed them. Unfortunately, despite substantial evidence showing training for team work improves team functioning and patient outcomes, many pediatric surgical teams do not have team training programs at their institutions. Further expansion of team training programs may be valuable to improving a culture of safety in children's hospitals.

Creating a safer operating room: Groups, team dynamics and crew resource management principles

The operating room (OR) is a special place wherein groups of highly skilled individuals must work in a coordinated and harmonious fashion to deliver optimal patient care. Team dynamics and human factors principles were initially studied by the aviation industry to better understand and prevent airline accidents. As a result, crew resource management (CRM) training was designed for all flight personnel to create a highly reliable industry with a commitment to a culture of safety. CRM has since been adapted to health care, resulting in care improvement and harm reduction across a wide variety of medical specialties. When implemented in the OR, CRM has been shown not only to improve communication and morale for OR staff, but also reduce morbidity and mortality for patients. As increasing focus is placed on quality, safety, and high-reliability, surgeons will be expected to participate and lead efforts to facilitate a team approach in this new era of patient care.

Development of a Virtual Crew Resource Management Training Program to Improve Communication.

Crew Resource Management (CRM), a method focused on the management of human error and risk reduction, has shown promise in reducing communication failure in health care. The purpose of this project was to develop a virtual training program in CRM principles of effective leadership and followership, and evaluate the applicability to nurses working in the hospital setting. The intervention included the development of a virtual CRM training program consisting of a self-learning module and virtual simulation. Beta testing of the module was conducted by six nurses, followed by an evaluation of the training program by nurses (n = 5) in a general medicine department. Nurses reported the overall program to be worthwhile (X̄= 5; SD = 0.5), with great applicability to nursing care (X̄= 4.5, SD = 0.5). Nurses completing the simulation activity reported strong agreement to CRM applicability and training effectiveness. The CRM training module proved to be applicable to nursing care and is ready for widespread use to improve patient care and communication. J Contin Educ Nurs. 2017;48(11):525-532.

Participant evaluation of simulation training using crew resource management in a hospital setting in Hong Kong.

A simulation team-based crew resource management training programme was developed to provide a unique multidisciplinary learning experience for health care professionals in a regional hospital in Hong Kong. In this study, we evaluated how health care professionals perceive the programme. A cross-sectional questionnaire survey was conducted in the Multidisciplinary Simulation and Skills Centre at Queen Elizabeth Hospital in Hong Kong. A total of 55 individuals in the departments of Obstetrics and Gynaecology, Anaesthesiology and Operating Theatre Services, Intensive Care Unit, and Accident and Emergency participated in the study between June 2013 and December 2013. The course content was specially designed according to the needs of the clinical departments and comprised a lecture followed by scenarios and debriefing sessions. Principles of crew resource management were introduced and taught throughout the course by trained instructors. Upon completion of each course, the participants were surveyed using a 5-point Likert scale and open-ended questions. The participant's responses to the survey were related to course organisation and satisfaction, realism, debriefing, and relevance to practice. The overall rating of the training programme was high, with mean Likert scale scores of 4.1 to 4.3. The key learning points were identified as closed-loop communication skills, assertiveness, decision making, and situational awareness. The use of a crew resource management simulation-based training programme is a valuable teaching tool for frontline health care staff. Concepts of crew resource management were relevant to clinical practice. It is a highly rated training programme and our results support its broader application in Hong Kong.

Fatigue proofing: The role of protective behaviours in mediating fatigue-related risk in a defence aviation environment

In the military or emergency services, operational requirements and/or community expectations often preclude formal prescriptive working time arrangements as a practical means of reducing fatigue-related risk. In these environments, workers sometimes employ adaptive or protective behaviours informally to reduce the risk (i.e. likelihood or consequence) associated with a fatigue-related error. These informal behaviours enable employees to reduce risk while continuing to work while fatigued. In this study, we documented the use of informal protective behaviours in a group of defence aviation personnel including flight crews. Semi-structured interviews were conducted to determine whether and which protective behaviours were used to mitigate fatigue-related error. The 18 participants were from aviation-specific trades and included aircrew (pilots and air-crewman) and aviation maintenance personnel (aeronautical engineers and maintenance personnel). Participants identified 147 ways in which they and/or others act to reduce the likelihood or consequence of a fatigue-related error. These formed seven categories of fatigue-reduction strategies. The two most novel categories are discussed in this paper: task-related and behaviour-based strategies. Broadly speaking, these results indicate that fatigued military flight and maintenance crews use protective ‘fatigue-proofing’ behaviours to reduce the likelihood and/or consequence of fatigue-related error and were aware of the potential benefits. It is also important to note that these behaviours are not typically part of the formal safety management system. Rather, they have evolved spontaneously as part of the culture around protecting team performance under adverse operating conditions. When compared with previous similar studies, aviation personnel were more readily able to understand the idea of fatigue proofing than those from a fire-fighting background. These differences were thought to reflect different cultural attitudes toward error and formal training using principles of Crew Resource Management and Threat and Error Management.

Implementing Simulation in Air Medical Training: Integration of Adult Learning Theory

This article suggests the construct of medical simulation education in the air medical industry can integrate principles of crew resource management by training in the same environments that flight crews function. The multidisciplinary crew-centered approach to designing simulation education can improve overall crew performance and reinforce safety in daily operations. This concept is far from novel and has a proven track record in the aviation industry, but air medical medicine can benefit from this proven system as well. In an article titled “Teams, Leaders, and Organizations: New Directions for Crew-oriented Flight Training,” 1 Hackman states that “it is the team, not the aircraft or the individual pilot, that is at the root of most accidents and incidents.” Simulation in aviation has a long history, dating back to early decades of the industry. With cockpit or crew resource management (CRM) becoming a staple of the air medical industry, we find ourselves on the precipice of using simulation to teach the foundational concepts of CRM. Consistent with Hackman’s statement, medical errors in the air medical industry may be caused by system errors and a breakdown in team functions. It is important to acknowledge that all air medical team members are adults and, therefore, adult learning theory becomes relevant and potentially influential; it is, in fact, referenced frequently in current “educational simulation” literature. Respected adult education theorists include Jean Piaget, John Dewey, D.A. Kolb, Malcolm Knowles, and many others; although each theorist has their respective tenets, there appears to be a shared commonality to the science behind adult learning and education. It is generally accepted that adults operate on the following common principles:

The Effect of Multiprofessional Simulation-Based Obstetric Team Training on Patient-Reported Quality of Care: A Pilot Study.

This study aimed to explore whether multiprofessional simulation-based obstetric team training improves patient-reported quality of care during pregnancy and childbirth. Multiprofessional teams from a large obstetric collaborative network in the Netherlands were trained in teamwork skills using the principles of crew resource management. Patient-reported quality of care was measured with the validated Pregnancy and Childbirth Questionnaire (PCQ) at 6 weeks postpartum. Before the training, 76 postpartum women (sample I) completed the questionnaire 6 weeks postpartum. Three months after the training, another sample of 68 postpartum women (sample II) completed the questionnaire. In sample II (after the training), the mean (SD) score of 108.9 (10.9) on the PCQ questionnaire was significantly higher than the score of 103.5 (11.6) in sample I (before training) (t = 2.75, P = 0.007). The effect size of the increase in PCQ total score was 0.5. Moreover, the subscales "personal treatment during pregnancy" and "educational information" showed a significant increase after the team training (P < 0.001). Items with the largest increase in mean scores included communication between health care professionals, clear leadership, involvement in planning, and better provision of information. Despite the methodological restrictions of a pilot study, the preliminary results indicate that multiprofessional simulation-based obstetric team training seems to improve patient-reported quality of care. The possibility that this improvement relates to the training is supported by the fact that the items with the largest increase are about the principles of crew resource management, used in the training.

The TeamSTEPPS Approach to Safety and Quality.

Despite advances in patient safety since the landmark Institute of Medicine Report To Err is Human was published, adverse events and medical errors remain a persistent problem throughout health care. Safety experts have examined the practices in high-risk industries that maintain outstanding safety records for strategies to address the problem. Those efforts led to the development of Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS), a patient safety program that incorporates the principles of crew resource management and teamwork successfully used by industry into the health care setting. Evidence supports that the knowledge, skills, and attitudes, that comprise the core of TeamSTEPPS program, can improve safety and outcomes when used by members of the health care team. Successful implementation should assist the transition of health care workers from functioning as individual experts to performing as members of expert teams.

Targeted communication intervention using nursing crew resource management principles.

Targeted communication intervention using nursing crew resource management principles.

Coaching to Improve the Quality of Communication During Briefings and Debriefings

Communication breakdowns have been identified as a root cause of many medical errors. Sentinel events occurring in surgery comprise a significant number of these events. Despite the addition of briefings and debriefings in the OR and the introduction of crew resource management principles, communication problems continue to occur in the surgical setting. The purpose of this research was to evaluate coaching as an intervention to improve the quality of OR briefings and debriefings. A retired orthopedic surgeon conducted coaching that included all members of the perioperative team. The quality of both briefings and debriefings significantly improved after the coaching intervention. Analysis of the results of this study suggests that coaching should be considered as an intervention to improve communication during surgical procedures, especially during briefings and debriefings.

Lessons in Flying

Providing timely, high-quality, guideline-based care to patients with acute coronary syndromes (ACS) who present to the emergency department is critically dependent on cooperation, coordination, and communication between emergency medicine physicians and cardiologists. However, to achieve sustained improvement at the individual institution level, consistent implementation of quality improvement (QI) activities is needed. We describe a QI initiative for ACS care in the emergency setting that combined clinical education with a curriculum based on crew resource management (CRM) principles-a set of tools and techniques for communication, teamwork, and error avoidance used in the aviation industry and with proven applicability in the healthcare setting. Educational training sessions were open to multidisciplinary healthcare teams at 3 hospital sites, and participants were provided practical tools and resources to enhance communication, teamwork, and patient-centered care. Through patient chart reviews, participant surveys, and clinician interviews, baseline assessments of clinical performance measures and team communication-, logistics-, and skills-based efficiencies were performed and reported before the educational training was delivered at each QI site. Reviews of pre- and postinitiative participant surveys demonstrated improvement in knowledge and confidence in the delivery of appropriate and effective ACS care; however, reviews of pre- and postinitiative patient charts revealed limited process improvements. Altogether, this multicenter study of a continuing medical education program based on CRM principles was associated with improvements in provider knowledge and confidence regarding the delivery of appropriate ACS care, but had limited impact on clinical performance measures.

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Introduction: Code teams respond to cardiopulmonary arrest (CPA) events and must be able to act immediately as a team to effectively manage these emergencies. Teamwork amongst the code team during these responses are critical for efficient and effective resuscitation actions. Code team members are trained and skilled to respond to CPA events, but are often deficient in teamwork skills during resuscitation. Findings from previous research at the study organization to assess teamwork perception by code team members showed deficits in perception of teamwork related to leadership, communication, and mutual team support. The purpose of this study was to determine the effect of a two-hour training program using simulation, debriefing, and review of Crew Resource Management principles related to CPA events on perception of teamwork of code team members. Methods: The study was conducted in one large tertiary teaching hospital. Code team members who routinely respond to CPA events were invited to participate in a two-hour teamwork training program. A pre-test, post-test design was used for the study. A sample of resident physicians (MDs), nurses (RNs), and respiratory therapists (RTs) participated in a two-hour teamwork training program for CPA events. After informed consent, subjects participated in a mock CPA event in a simulation lab while being evaluated for teamwork skills by trained observers. After the simulation, subjects and observers rated teamwork performance during the simulation using the Team Emergency Assessment Measure (TEAM) tool on a 1–4 scale, including a global rating (1–10 scale). Next, a debriefing of the event was done, followed by a didactic presentation with group discussion on teamwork skills during CPA emergencies, using Crew Resource Management and TeamSTEPPS principles. Key areas of emphasis were on leadership, communication, and mutual support during CPA events. Subjects then participated in a second simulation of a different CPA event and were encouraged to use principles they had just learned in the program. Immediately following, subjects and observers again rated teamwork performance using the TEAM tool and completed evaluations on the program. Results: Seventy-three code team members participated in the study: 18 MDs (25%), 23 RNs (32%), and 30 RTs (41%) in small groups over a 12 week period. Significant improvement in the average TEAM score was noted by both participants and observers after the teamwork training program. Participants’ mean TEAM pre-test score was 3.3 and post-test score was 3.7 (p<.001) on a 1–4 scale. Observers’ mean scores improved from 3.0 to 3.7 (p<.001). Participants’ global rating score (1–10 scale) increased from 7.7 to 8.8 (p<.001) and observers’ global rating scores increased from 7.3–9.0 (p<.001). While observers rated the TEAM scores significantly lower than those of participants on the 1st simulated event, no differences were found after the 2nd simulation evaluation or on either of the global ratings (p<.05) Participants rated the simulation and training program as being beneficial, effective, enjoyed interprofessional team learning, and supported incorporating team training in future CPA training. Conclusions: A two-hour teamwork training program incorporating simulation and teamwork principles improves perceptions of teamwork from both trained observers and code team members. It was possible to incorporate teamwork principles into a two-hour training session versus a longer workshop program on team training. The program was effective in conveying key concepts relating to teamwork during CPA events in an interprofessional learning environment and participants were able to learn from each other, respecting contributions and roles from members of the code team. While long term retention of concepts and sustainability was not assessed in this study, a potential area for study on how team training for CPA events translates into behaviors during actual CPA emergencies may enhance knowledge in this area of practice.

Challenges and Models of Success for Patient Safety and Quality of Care

Audrey Lyndon, PhD, RNC, CNS-BC, FAAN, is an assistant professor In the Department of Family Health Care Nursing, UCSF School of Nursing, San Francisco, CA. The perinatal safety movement began in 1999 with the now classic publication “High Reliability Perinatal Units: An Approach to the Prevention of Patient Injury and Medical Malpractice Claims” in which the authors described the characteristics of high-reliability perinatal units (Knox, Simpson, & Garite, 1999). Early adopters used this model and applied human factors principles and the aviation principles of crew resource management to generate momentum focused on flattening hierarchies and improving teamwork in perinatal care (Leonard, Graham, & Bonacum, 2004). Momentum was generated by the series of Institute of Medicine (IOM) reports on safety and quality (IOM, 2001; Kohn, Corrigan, & Donaldson, 2000; Page, 2004), and the Joint Commission Sentinel Event Alert on Preventing Infant Death and Injury During Delivery further highlighted the contributions of communication breakdowns, poor teamwork, and other systems problems to serious and potentially preventable adverse outcomes in perinatal care (Joint Commission on Accreditation of Healthcare Organizations, 2004). Many organizations have made significant strides in advancing perinatal safety and quality in the intervening years (Burke, Grobman, & Miller, 2013; Pettker et al., 2009; Pettker et al., 2011; Simpson, Knox, Martin, George, & Watson, 2011), but challenges remain.

It Takes a Village: Commitment to Teamwork Improves Patient Safety

Professional Issues Poster Presentation Purpose for the Program Teamwork and effective communication have a profound effect on patient care; in the delivery room this means the best possible care for mothers and infants. With that goal in mind, our obstetrics team implemented a crew resource management initiative. Although the principles of crew resource management are relatively new to the health care environment, the literature supports the value of training health care teams in the principles of crew resource management.

Anaesthesia Emergencies

K. Ruskin & S. Rosenbaum ( eds ) Oxford University Press , January 2011 ISBN 978-0-19-53971-3 , 432 pp., Price £26.00 Anaesthesia Emergencies is one in a series of ‘emergencies’ handbooks from the American Oxford University Press. It aims to be a complete reference guide to the management of peri-operative emergencies and is sized to fit easily in your scrubs pocket. Initially produced for the American market, most of the text has been corrected for the British reader. However, the ASA difficult airway algorithm is on the inside cover and there are referrals to epinephrine and acetaminophen in the text. The legal references in the blood transfusion and organ donation summaries also refer to American law which renders them of little use to the practising UK anaesthetist. In a crowded ‘handbook’ market, this book’s main selling point is its comprehensive content. All the emergencies are covered in painstaking detail, with some journal references for background reading. By covering definitions, presentation, pathophysiology and differential diagnoses as well as the usual management, each section makes a perfect short answer question revision topic. The book opens with an interesting chapter about managing aviation emergencies using the principles of crew resource management, followed by chapters considering anaesthetic emergencies in broad strokes like ‘Airway’ and ‘Equipment’. Within these chapters, the emergencies are laid out alphabetically, so airway fires take a more prominent position than failed intubation, for example. You will find all the information you need to manage your emergency including drug doses and treatment regimens. There is a lot of information packed into a tight space: paediatric, obstetric and neurosurgical emergencies, amongst others. I found the immediate management boxes very helpful, as were some of the photos, including how to connect a cannula to a jet ventilator via a Luer connector. The advice was concise and ties in with the recommendations from other expert groups, e.g. the American Heart Association for managing tachy- and bradycardias. The content is comprehensive and extremely well organised, but the formatting makes it difficult to read in comparison with other handbook guides such as the unrelated Oxford Handbook of Anaesthesia. Although there are a few text boxes and photos to break it up, the repetitive pattern and lack of colour makes it a difficult book to follow. The addition of some coloured text boxes and diagrams would make it easier to find important information in the heat of an emergency. In summary, this handbook has some excellent content, but it is let down by its formatting from being a truly useful pocket guide.

The Role of the Operating Room Nurse Manager in the Successful Implementation of Preoperative Briefings and Postoperative Debriefings in the VHA Medical Team Training Program

To improve communication within surgical teams, Veterans Health Administration (VHA) implemented a Medical Team Training Program (MTT) based on the principles of crew resource management. One hundred two VHA facilities were analyzed. Nursing leadership participation in the planning stages of the program was compared with outcomes at follow-up. Nurse manager participation in planning was associated with higher rates of implementation of preoperative briefing and postoperative debriefing. Nurse managers are a critical component in the planning phase of team training programs focused on OR clinical staff.

Adaptation of Airline Crew Resource Management Principles to Dentistry

The aviation industry uses crew resource management (CRM) to address the human aspect of error. Dentistry can incorporate these concepts to reduce dental error. The authors provide a checklist to help clinicians mitigate error. Health care systems have begun to focus on medical error. During the past 30 years, the airline industry has developed mitigation strategies that are being adapted for medicine. CRM involves the use of information, equipment and people to increase safety by targeting early identification of errors. To enhance safety, practitioners must implement forward-thinking strategies. Because human error is inevitable, threat and error management (TEM) techniques are needed to help identify and trap error before it develops into unexpected outcomes. Risk analysis increases situational awareness (SA) of potential dental error. Efficiency increases with early error detection. The authors provide a dental checklist that is divided into "appointment review," "before procedure," "procedure," "before dismissal" and "after dismissal" to organize dental activities in a manner that enhances error detection. The dental checklist is a tool to incorporate CRM and TEM techniques into the dental care environment to increase SA, safety and efficiency.