Crisis Resource Management : Crisis Resource Management Crisis Resource Management : Crisis Resource Management Ability, during an emergency, to translate knowledge of what needs to be done into effective real world activity Resources : Resources Self
Other personnel on scene
Cognitive aids (checklists, manuals)
External resources Incident Management Process : Incident Management Process Self-Management : Self-Management Core Cycle : Core Cycle Observation Action Decision Reevaluation Observation : Observation Human close attention is limited to one or two items
“Supervisory Control” must decide:
What information to attend to
How to observe it Observation : Observation Errors
Not observing frequently enough
Not observing optimum data stream Observation : Observation Causes of Errors
Lack of vigilance (ability to sustain attention)
Failure to attend to all relevant information
Information overload Verification : Verification A change is observed
An artifact (false data)?
A transient (true data--short duration)? Verification : Verification Repeat observation
Observe a redundant channel
Correlate multiple related variables (P, BP)
Activate a new monitoring modality
Recalibrate instrument/test its function
Replace instrument with back-up
Ask for a second opinion Problem Recognition : Problem Recognition Do observations indicate problem?
What is its nature, importance? A common error is to observe problem signs but fail to recognize them as problematic Problem Recognition : Problem Recognition Do cues observed match pattern known to represent a specific problem?
Yes?--Apply solution for that problem
No?--Apply heuristic (rule of thumb) Heuristics : Heuristics Generic Problems
“Too Fast, Too Slow, Absent”
“Difficulty with Ventilation”
“Hypoperfusion” Generic Problems Allow Use of Generic Solutions to Buy Time Heuristics : Heuristics Frequency gambling
“If it eats hay and has hoofs, it’s probably a horse, not a zebra.” Heuristics : Heuristics Similarity matching
The situation more or less resembles one I’ve handled before
Therefore, I’ll proceed like it is the same Dangers of Heuristics : Dangers of Heuristics By definition, don’t always work
Ignore some information that is present
Yield adequate, but not optimal decisions Advantages of Heuristics : Advantages of Heuristics A good solution applied now may be better than a perfect solution applied later For example, after the patient is dead! Prediction of Future States : Prediction of Future States What will probably happen if…?
Influences priority given to problems
Failure to predict evolution of a catastrophe
Failure to assign correct priorities during action planning Action Planning : Action Planning Precompiled Responses : Precompiled Responses Cue trigger predetermined/structured responses
Allow for quick solutions to problems
Can fail if problem:
Is not due to suspected cause
Does not respond to usual treatment Abstract Reasoning : Abstract Reasoning Essential when standard approaches not succeeding
Searching for high level analogies
Deductive reasoning from deep knowledge base
Can be time-consuming Action Implementation : Action Implementation Sequencing
Actions must be prioritized, interleaved with concurrent activities
Rapidity and ease Certainty of success
Cost in attention/resources Action Implementation : Action Implementation Workload Management Strategies
Distributing work over time:
Distributing work over resources
Changing nature of task (altering standards of performance) Action Implementation : Action Implementation Mental simulation of actions can help identify hidden flaws in plans
If I do what I plan to do, what is going to happen?
Will it work?
Will it work, but will it create or complicate another problem? Reevaluation : Reevaluation Did action have an effect?
Is problem getting better or worse?
Any side effects?
Any problems we missed before?
Was initial assessment/diagnosis correct? Reevaluation : Reevaluation Essential to preventing “Fixation Errors” Fixation Errors : Fixation Errors “This And Only This”
Failure to revise plan, diagnosis despite evidence to contrary Fixation Errors : Fixation Errors “Everything But This”
Failure to commit to definitive treatment of major problem Fixation Errors : Fixation Errors “Everything’s OK”
Belief there is no problem in spite of evidence there is Fixation Errors : Fixation Errors “If everything is going so well, why isn’t the patient getting better?” Team Management : Team Management Effective Team Decision-Making : Effective Team Decision-Making Situation Awareness
Shared Mental Models
Resource Management Situation Awareness : Situation Awareness Recognizing decision must be made or action must be taken
What is risk?
Do we act now?
Do we watch, wait?
Are things going to deteriorate in future? Metacognition : Metacognition Determining overall plan, information needed to make decision
Thinking about thinking
Being reflective about:
What you’re trying to do
How to do it
What additional information is needed
What results are likely to be Metacognition : Metacognition Stop and think
If we do this (or don’t do it) what is likely to happen?
When is a decision good enough? Metacognition : Metacognition Teams that generate more contingency plans make fewer operational errors
Effective teams emphasize strategies that kept options open
Effective teams are sensitive to all sources of information that could solve problem Shared Mental Models : Shared Mental Models Exploiting entire team’s cognitive capabilities
Assure all team members are solving same problem Shared Mental Models : Shared Mental Models Strategies
Explicit discussion of problem
Closed loop communication
Volunteering necessary information
Providing reinforcement, feedback, confirmation Resource Management : Resource Management Assuring time, information, mental resources will be available when needed
Keep team leader free
Keep long enough time horizon to anticipate changes in workload Practical Crisis Management : Practical Crisis Management Take Command : Take Command Be sure everyone knows who is in charge
Decide what needs to be done
Prioritize necessary tasks
Assign tasks to specific individuals
Control should be accomplished with full team participation
Leader should be clearinghouse for information, suggestions Take Command : Take Command Take Command : Take Command “Authority with Participation”
“Assertiveness with Respect” Declare Emergencies Early : Declare Emergencies Early Risks of NOT responding quickly usually far exceed risks of not doing so. Emergency Event Time-Severity Relationship Curve : Emergency Event Time-Severity Relationship Curve Good Communication = Good Teams : Good Communication = Good Teams Do NOT raise your voice
If necessary ask for silence
State requests clearly, precisely
Avoid making statements into thin air
Close the communication loop
Listen to what people say regardless of job description or status Communicating Intent : Communicating Intent Here’s what I think we face
Here’s what I think we should do
Here’s what we should keep our eye on
Now, TALK TO ME Good Communication = Good Teams : Good Communication = Good Teams Concentrate on what is right for the patient rather than on who is right Distribute Workload : Distribute Workload Assign tasks according to people’s skills
Remain free to watch situation, direct team
Look for overloads, performance failures Optimize Actions : Optimize Actions Escalate RAPIDLY to therapies with highest probability of success
Never assume next action will solve problem
Think of what you will do next if your actions do not succeed or cannot be implemented
Think of consequences before acting Reassess--Reevaluate--Repeatedly : Reassess--Reevaluate--Repeatedly Any single data source may be wrong
Cross-check redundant data streams
Use ALL available data