Crew Resource Management Techniques Research Articles

Assuring Increasingly Autonomous Systems in Human-Machine Teams: An Urban Air Mobility Case Study

As aircraft systems become increasingly autonomous, the human-machine role allocation changes and opportunities for new failure modes arise. This necessitates an approach to identify the safety requirements for the increasingly autonomous system (IAS) as well as a framework and techniques to verify and validate that an IAS meets its safety requirements. We use Crew Resource Management techniques to identify requirements and behaviors for safe human-machine teaming behaviors. We provide a methodology to verify that an IAS meets its requirements. We apply the methodology to a case study in Urban Air Mobility, which includes two contingency scenarios: unreliable sensor and aborted landing. For this case study, we implement an IAS agent in the Soar language that acts as a copilot for the selected contingency scenarios and performs takeoff and landing preparation, while the pilot maintains final decision authority. We develop a formal human-machine team architecture model in the Architectural Analysis and Design Language (AADL), with operator and IAS requirements formalized in the Assume Guarantee REasoning Environment (AGREE) Annex to AADL. We formally verify safety requirements for the human-machine team given the requirements on the IAS and operator. We develop an automated translator from Soar to the nuXmv model checking language and formally verify that the IAS agent satisfies its requirements using nuXmv. We share the design and requirements errors found in the process as well as our lessons learned.

Human Factors Approaches and Models in LOC-I Accident Analysis and Prevention: Flight Crew Resource Management Techniques as a Risk Mitigation Tool

Increased cockpit automation on modern jet aircraft aim to reduce the risk of Undesired Aircraft State (UAS) instances such as Loss of Control in Flight (LOC-I). Although LOCI globally accounts for only 9% of all analysed accidents IATA has reported that it was responsible for 58% of all accident fatalities in 2017. The focus of this paper is to answer whether Threat and Error Management and Crew Resources Management (CRM) techniques are an efficient risk management tool when facing a LOC-I threat. Three LOCI final aircraft accident reports were analysed to understand the structure of Human Factors (HF) during these flights. Methods from the HF field such as the Generic Error Modelling System (GEMS) and Skill-, Rule- and Knowledge-based (SRK) error approach provided invaluable insights to identify potential findings. A holistic investigation of cognitive structures in flight path management helped to visualise latent conditions and cognitively demanding tasks during LOC-I in routine operations. Bearing in mind the limited number of cases considered in this paper it should be considered as an overview in LOC-I accident analysis. It shows that leadership and teamwork, as essential aspects of CRM training, can serve as key strategies to mitigate HF problems and LOC-I risks.

Damage control surgery in neonates: Lessons learned from the battlefield

IntroductionMortality for neonates requiring surgery for serious pathology such as NEC, remains high. Damage control surgery (DCS) has evolved as an operative strategy in battlefield trauma that sacrifices the completeness of the initial surgery to address the deadly triad of acidosis, hypothermia and coagulopathy. This approach is now used routinely in sick adults with nontrauma surgical emergencies. Here we describe our experience of using DCS in neonates. MethodNeonates undergoing DCS at our hospital from 1/8/2010 to 30/11/17 had data collected prospectively. Results27 neonates (median age 21 days; gestation 29 weeks; weight 1200 g; M:F 18:9) underwent DCS. Diagnosis (NEC 23, volvulus 2, meconium peritonitis 1, spontaneous perforation 1). Preoperative physiology: median temperature 35.5 °C, lactate 3.7, Activated prothrombin time 49; on a median of 1 inotrope (range 0 to 4); 19 had surgery on the intensive care unit. Surgery involved resection of dead bowel with the ends ligated and the abdomen left open. Operation took 38 min (26–80 min) and crew-resource management techniques were used to optimize efficiency. Second look occurred at 48 h (24–108 h) when the physiology had normalized. There were a total of 32 anastomoses in 18 patients with one leak; 3 patients had stomas for distal rectal disease. Overall mortality was 15% (4/27) or 18% in the NEC group (4/23). ConclusionThough techniques such as “clip and drop” exist, they have not been routinely incorporated into an operative strategy for sick neonates based on physiological derangement. The two benefits from our DCS approach were a low mortality and an avoidance of stomas. This approach deserves more investigation to see whether it is as effective in babies and children with nontrauma associated abdominal catastrophes as it is in adults. Type of studyCase controlled study. Level of evidenceLevel III.

Aviation-Related Wildland Firefighter Fatalities--United States, 2000-2013.

Airplanes and helicopters are integral to the management and suppression of wildfires, often operating in high-risk, low-altitude environments. To update data on aviation-related wildland firefighting fatalities, identify risk factors, and make recommendations for improved safety, CDC's National Institute for Occupational Safety and Health (NIOSH) analyzed reports from multiple data sources for the period 2000-2013. Among 298 wildland firefighter fatalities identified during 2000-2013, 78 (26.2%) were aviation-related occupational fatalities that occurred during 41 separate events involving 42 aircraft. Aircraft crashes accounted for 38 events. Pilots, copilots, and flight engineers represented 53 (68%) of the aviation-related fatalities. The leading causes of fatal aircraft crashes were engine, structure, or component failure (24%); pilot loss of control (24%); failure to maintain clearance from terrain, water, or objects (20%); and hazardous weather (15%). To reduce fatalities from aviation-related wildland firefighting activities, stringent safety guidelines need to be followed during all phases of firefighting, including training exercises. Crew resource management techniques, which use all available resources, information, equipment, and personnel to achieve safe and efficient flight operations, can be applied to firefighting operations.

National Aeronautics and Space Administration “threat and error” model applied to pediatric cardiac surgery: Error cycles precede ∼85% of patient deaths

BackgroundWe hypothesized that the National Aeronautics and Space Administration “threat and error” model (which is derived from analyzing >30,000 commercial flights, and explains >90% of crashes) is directly applicable to pediatric cardiac surgery. MethodsWe implemented a unit-wide performance initiative, whereby every surgical admission constitutes a “flight” and is tracked in real time, with the aim of identifying errors. The first 500 consecutive patients (524 flights) were analyzed, with an emphasis on the relationship between error cycles and permanent harmful outcomes. ResultsAmong 524 patient flights (risk adjustment for congenital heart surgery category: 1-6; median: 2) 68 (13%) involved residual hemodynamic lesions, 13 (2.5%) permanent end-organ injuries, and 7 deaths (1.3%). Preoperatively, 763 threats were identified in 379 (72%) flights. Only 51% of patient flights (267) were error free. In the remaining 257 flights, 430 errors occurred, most commonly related to proficiency (280; 65%) or judgment (69, 16%). In most flights with errors (173 of 257; 67%), an unintended clinical state resulted, ie, the error was consequential. In 60% of consequential errors (n = 110; 21% of total), subsequent cycles of additional error/unintended states occurred. Cycles, particularly those containing multiple errors, were very significantly associated with permanent harmful end-states, including residual hemodynamic lesions (P < .0001), end-organ injury (P < .0001), and death (P < .0001). Deaths were almost always preceded by cycles (6 of 7; P < .0001). ConclusionsHuman error, if not mitigated, often leads to cycles of error and unintended patient states, which are dangerous and precede the majority of harmful outcomes. Efforts to manage threats and error cycles (through crew resource management techniques) are likely to yield large increases in patient safety.

Improving patient safety using the sterile cockpit principle during medication administration: a collaborative, unit-based project

To implement the sterile cockpit principle to decrease interruptions and distractions during high volume medication administration and reduce the number of medication errors. While some studies have described the importance of reducing interruptions as a tactic to reduce medication errors, work is needed to assess the impact on patient outcomes. Data regarding the type and frequency of distractions were collected during the first 11 weeks of implementation. Medication error rates were tracked 1 year before and after 1 year implementation. Simple regression analysis showed a decrease in the mean number of distractions, (β = -0.193, P = 0.02) over time. The medication error rate decreased by 42.78% (P = 0.04) after implementation of the sterile cockpit principle. The use of crew resource management techniques, including the sterile cockpit principle, applied to medication administration has a significant impact on patient safety. Applying the sterile cockpit principle to inpatient medical units is a feasible approach to reduce the number of distractions during the administration of medication, thus, reducing the likelihood of medication error. 'Do Not Disturb' signs and vests are inexpensive, simple interventions that can be used as reminders to decrease distractions.

Abstract 281: First successful implementation of Crew Resource Management techniques adapted form the aviation industry to an Argentine Hospital

Introduction: Medical errors are a frequent cause of morbidity and mortality in hospitals worldwide. Poor teamwork and communication skills rather than lack of technical knowledge have been identified as a common factor in numerous studies. Objective: To promote a safer medical practice through the adoption of Crew Resource Management (CRM) procedures directly adapted from the aviation industry for the first time in Argentina. Methods: Starting in 2009 we organized a hybrid team of two physicians/amateur aviators and two expert airline pilots with a significant background on safety analysis and CRM training . The setting for the initial experience was a teaching hospital with high volume cardiovascular and organ transplantation departments. CRM training has been offered at least once a year in a non compulsory manner to the entire spectrum of healthcare personnel, including medical and nursing students. Courses are structured in two day sessions divided in several chapters and workshops: Introduction, statistics, leadership, communication skills, and avoidance of risky behaviors. Slides, full text articles and reports are available for permanent consultation by personnel along with discussion forums at the Moodle based site of the program. Results: Satisfaction levels among attendees has consistently averaged 92%. Following training, briefings and debriefings have been implemented as standard procedures along with checklists both at Intensive Care, Operating Rooms and General Ward. No wrong side or wrong patient interventions have been reported over 3 years, while in 1/9500 surgical procedures a misidentification of a patient occurred with successful detection at the second crossed check on admission to the OR. Overdosing was reported in 1 every 4960 admissions, none fatal or disabling. Conclusions: Choosing a hybrid team of physicians and airline pilots rather than physicians or nurses alone as facilitators was a key factor to spark interest in teamwork factors and to avoid fear of punishment following reports. Despite cultural differences, CRM can be as feasible and successful in a Latin American hospital environment as previously shown in several centers in the United States.

Improving Patient Safety and Optimizing Nursing Teamwork Using Crew Resource Management Techniques

This project describes the application of the "sterile cockpit rule," a crew resource management (CRM) technique, targeted to improve efficacy and safety for nursing assistants in the performance of patient care duties. Crew resource management techniques have been successfully implemented in the aviation industry to improve flight safety. Application of these techniques can improve patient safety in medical settings. The Veterans Affairs (VA) National Center for Patient Safety conducted a CRM training program in select VA nursing units. One unit developed a novel application of the sterile cockpit rule to create protected time for certified nursing assistants (CNAs) while they collected vital signs and blood glucose data at the beginning of each shift. The typical nursing authority structure was reversed, with senior nurses protecting CNAs from distractions. This process led to improvements in efficiency and communication among nurses, with the added benefit of increased staff morale. Crew resource management techniques can be used to improve efficiency, morale, and patient safety in the healthcare setting.

Timing and teamwork—An observational pilot study of patients referred to a Rapid Response Team with the aim of identifying factors amenable to re-design of a Rapid Response System

BackgroundRapid Response Teams aim to accelerate recognition and treatment of acutely unwell patients. Delays in delivery might undermine efficiency of the intervention. Our understanding of the causes of these delays is, as yet, incomplete. AimTo identify modifiable causes of delays in the treatment of critically ill patients outside intensive care with a focus on factors amenable to system design. MethodsReview of care records and direct observation with process mapping of care delivered to 17 acutely unwell patients attended by a Rapid Response Team in a District General Hospital in the United Kingdom. Delays were defined as processes with no added value for patient care. ResultsEssential diagnostic and therapeutic procedures accounted for only 31% of time of care processes. Causes for delays could be classified into themes as (1) delays in call-out of the Rapid Response Team, (2) problems with team cohesion including poor communication and team efficiency and (3) lack of resources including lack of first line antibiotics, essential equipment, experienced staff and critical care beds. ConclusionWe identified a number of potentially modifiable causes for delays in care of acutely ill patients. Improved process design could include automated call-outs, a dedicated kit for emergency treatment in relevant clinical areas, increased usage of standard operating procedures and staff training using crew resource management techniques.

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.

Using web‐based simulation learning to deal with shoulder dystocia

Simulation-based learning can provide education and training to individuals in a variety of industries. The military, aviation and nuclear power industries have seen demonstrable improvement in critical event handling through the use of this type of learning when coupled with crew resource management techniques. Simulation training is also emerging in the healthcare field as an effective patient safety and risk management tool. In the area of obstetrics, healthcare risk managers can have an impact on injury and claim reduction rates related to shoulder dystocia by advocating for and implementing simulation training for obstetrical providers. This article will describe a shoulder dystocia simulation training program that uses a high-fidelity mannequin, and illustrate the impact that the healthcare risk manager can have in reducing injuries due to shoulder dystocia.