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Abstract

Crew resource management (CRM) describes a system developed in the late 1970s in response to a series of deadly commercial aviation crashes. This system has been universally adopted in commercial and military aviation and is now an integral part of aviation culture. CRM is an error mitigation strategy developed to reduce human error in situations in which teams operate in complex, high-stakes environments. Over time, the principles of this system have been applied and utilized in other environments, particularly in medical areas dealing with high-stakes outcomes requiring optimal teamwork and communication. While the data from formal studies on the effectiveness of formal CRM training in medical environments have reported mixed results, it seems clear that some of these principles should have value in the practice of cardiovascular surgery.
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INTRODUCTION
Crew resource management (CRM) describes a system
developed in the late 1970s in response to a series of deadly
commercial aviation crashes. This system has been univer-
sally adopted in commercial and military aviation and is now
an integral part of aviation culture. CRM is an error mitiga-
tion strategy developed to reduce human error in situations in
which teams operate in complex, high-stakes environments.
Over time, the principles of this system have been applied and
utilized in other environments, particularly in medical areas
dealing with high-stakes outcomes requiring optimal team-
work and communication. While the data from formal stud-
ies on the effectiveness of formal CRM training in medical
environments have reported mixed results, it seems clear that
some of these principles should have value in the practice of
cardiovascular surgery.
From a broader perspective, why might the principles of
CRM be useful in health care? There is teamwork in almost
every setting in healthcare, and CRM is an error reduction
strategy designed to optimize the performance of teams in
high-stakes situations. The Institute of Medicine, in its
report “To Err Is Human,” estimated that 44,000 to 98,000
deaths per year in the US are caused by medical errors. As a
system and as individuals, medical practitioners must strive
to reduce the morbidity and mortality of errors by reducing
their incidence.
The authors, a former military aviator who is now a medi-
cal student (PCM), and a cardiovascular surgeon (CGT)
with nearly 40 years of experience in medicine and surgery,
have recently compared their experiences in these realms and
herein suggest some strategies developed during the evolu-
tion of CRM that are likely to be useful and effective in the
practice of cardiovascular surgery. We will present the princi-
ples of CRM as learned and utilized in recent military deploy-
ments by one author (PCM) and suggest ways that these
principles are already being or might be applied to modern
cardiovascular surgical teams (CGT).
While the principles of CRM are often laid out as seven
principles, we will outline them as four tenets, and then
describe approaches to put these principles to use in cardio-
vascular surgery. These tenets include:
Mission analysis
• Leadership
Communication & assertiveness
Situational awareness, decision making &
adaptability
A review of the available literature on the application of
principles of CRM in medical environments is summarized
as follows.
In the early 2000s, there were only a few studies exploring
the use of CRM in healthcare. Within the last several years, an
increasing number of pertinent studies have been published.
In “Briefing and Debriefing in the Operating Room Using
Fighter Pilot Crew Resource Management,” McGreevy and
Otten make comparisons between the personalities of fighter
pilots and surgeons, explain the form and content of a fighter
pilot brief and debrief, and make recommendations for apply-
ing the fighter pilot brief and debrief to the operating room
[McGreevy 2007]. Their suggestions for briefing in the oper-
ating room include: giving background on a patient to iden-
tify each as an individual and not just a routine, generic case;
to provide an overview of the impending operation tailored to
complexity (short for a routine case, longer and more in depth
for a complex case); and to lay out the “mission objectives”
with some detail of how the operation will proceed and what
could go wrong at various points, with the intent of engag-
ing participants according to their level of experience. They
also suggest that a specific learning objective for each case
could be shared. Their recommendations for debriefing after
the operation include: a timely, short discussion of what went
well and what did not, with the goal of praising good perfor-
mance and avoiding repeat poor performance. The authors
suggest that videotapes of the operations could be used for
structured review to help improve future performance. The
authors also cite the need for a cultural change among sur-
geons to embrace mistakes and to strive for improvement
through self-reflection.
In a study titled “Crew Resource Management: Using Avi-
ation Techniques to Improve Operating Room Safety,” man-
datory CRM training was implemented for surgeons, nurses,
anesthesiologists, and operating room technicians and assis-
tants at an academic medical center [Grogan 2004]. CRM
techniques such as pre-op checklists and briefings, post-op
debriefings, and read-and-initial files were implemented. A
e Heart Surgery Forum #2017-1807
20 (2), 2017 [Epub April 2017]
doi: 10.1532/hsf.1807
EDITORIAL
Lessons from Crew Resource Management for Cardiac Surgeons
Patrick Marvil, BS, Curt Tribble, MD
Division of Thoracic and Cardiovascular Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
Correspondence: Curt Tribble, MD, Professor of Cardiothoracic Surgery,
University of Virginia Health System, Division of Thoracic and Cardiovascular
Surgery, Box 800679, Charlottesville, VA, 22908; 434-243-9250 (e-mail:
CGT2E@hscmail.mcc.virginia.edu).
Online address: http://journal.hsforum.com
e Heart Surgery Forum #2017-1807
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read-and-initial file is a way to disseminate information to
ensure that the teams are up to date on chosen topics. The
results presented in this paper showed that wrong-site sur-
geries and retained foreign bodies decreased from seven to
zero over one year. Malpractice expenses decreased from
$793,000 over four years to zero dollars over the next four
years. Sustainment training in CRM was not part of the plan,
and briefs and debriefs waned as a result. Wrong site surger-
ies and retained foreign bodies increased as the time interval
after the original CRM training lengthened.
A study titled “Aviation and Healthcare: a Comparative
Review with Implications for Patient Safety” that analyzed
the convergence and divergence in the realms of aviation and
healthcare concluded that the transfer of lessons from avia-
tion to healthcare has to be nuanced to optimize the useful-
ness of the principles of CRM in healthcare. [Kapur 2015].
Another conclusion of this paper was that healthcare should
emulate aviation by involving specialists in human factors and
in the psychological aspects of patient safety.
A consistent theme of these papers is that CRM might
gain additional traction in healthcare when it can be shown to
affect the bottom line. A study that addressed that issue enti-
tled “What is the Return on Investment for Implementation
of a Crew Resource Management Program at an Academic
Medical Center?” describes a health-system-wide implemen-
tation of CRM with a focus on the return on investment. The
cost of the training was $3.6 million over three years. The
return on investment was defined as a reduction in avoidable
events with an estimate of the potential for cost savings. Sav-
ings to the medical center were estimated to be between $12.6
and $24.4 million over three years. The authors of this study
concluded that the return on investment for implementing
CRM could be quite significant [Moffatt-Bruce 2017].
MISSION ANALYSIS
Mission analysis is defined as the process of developing short-
term, long-term, and contingency plans while coordinating,
allocating, and monitoring resources. In military aviation, there
are frameworks for analyzing commonly executed missions. An
example of such a mission is the ship to shore helicopter inser-
tion of troops into a combat zone. Military pilots start with these
frameworks and fill in details for the particular mission at hand
based on friendly and enemy situations on the battlefield, weather,
distances to be flown, nighttime illumination, etc. Thorough
preparation removes as much uncertainty as possible for the con-
duct of the mission and includes planning as detailed as where a
pilot would expect to see the moon on the horizon when making
a turn at a route checkpoint. Military pilots organize and plan not
only for what will occur but also for what may occur to remove
as much uncertainty as possible. Decisions regarding “go/no-go”
criteria are made in the ready room before a mission begins to
ease the decision-making burden of the mission commander in
flight, and to prevent a bias towards continuing a mission in the
heat of the moment if circumstances change and dictate that the
mission should be aborted.
During mission execution, resources available are continu-
ously monitored and coordinated to optimize their contribution
towards the mission. If resources drop below a certain thresh-
old and mission accomplishment becomes out of reach, then
the decision is made to abort the mission. For example, troop
transport helicopters need armed escorts from either attack
helicopters or fighter jets. If armed escort becomes inadequate,
then the exposure risk to the transport helicopters might be
judged too high to complete the mission.
The principles of mission analysis as applied in cardiovas-
cular surgery are readily apparent in the growing use of mul-
tidisciplinary teams to make decisions about programs as well
as about individual patients. While some of the first of these
multidisciplinary teams were developed in the transplant arena,
they are now becoming common in other areas of thoracic and
cardiovascular medicine and surgery, such as tumor boards,
valve teams, and heart teams focused on ischemic cardiac dis-
ease. It is our observation that these types of teams are very
valuable but are likely under-utilized currently. A strategy that
can be employed in this team environment is called scenario
planning, which has the objective of outlining as many of the
possible outcomes and issues as possible, with the goal of being
as prepared as is feasible for these issues.
At a more granular level, planning for individual cardiovas-
cular surgical cases that involve large, multidisciplinary teams
requires the sharing of detailed information. It has been esti-
mated that about 100 different individuals play an important
role in the care of each cardiac surgical patient. When all of
these individuals are notified of the plan, they can each commu-
nicate efficiently with the rest of the protagonists to ask ques-
tions or offer suggestions. We have implemented this aspect
of CRM by using email to circulate plans the night before a
planned procedure. We have found this strategy to be very
useful [Tribble 2016a].
The next use of the CRM principle of mission analysis in
cardiovascular surgery is the timeout that now routinely occurs
in the operating room, just prior to the start of the planned
operation. We have found it valuable to not only review the
plans and possible issues that might arise, but to also ensure
that any supplies or equipment will be available when needed,
especially if these items are somewhat unusual. A particularly
useful and effective part of the timeout in the operating room
is to identify each member of the operating room team by
their first names. Furthermore, it is worth stating during the
timeout that even the most inexperienced participants may
see or think of something that others are overlooking, and
they are encouraged to speak up if that occurs. A particularly
empowering way to describe this possibility is to say explicitly
that everyone in the room will obviously have a slightly differ-
ent view of what is going on in the case and, therefore, each
participant should be encouraged to “say something if you see
something” [Calland 2002].
The principle of debriefing in CRM can be employed in
both an informal and formal manner. The informal process of
reflection and debriefing can be accomplished both by initial
verbal brainstorming and feedback right after the operation
and by encouraging participants, especially the primary pro-
tagonists (such as the primary surgeon and the assistants), to
write out their reflections in notebooks. An example of a more
formal process of debriefing is the Morbidity and Mortality
Editorial—Marvil and Tribble
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© 2017 Forum Multimedia Publishing, LLC
conferences that are almost universally used in surgical services.
As Atul Gawande once wrote, “it isn’t reasonable to ask that we
achieve perfection. What is reasonable to ask is that we never
cease to aim for it.” [Tribble 2016b].
LEADERSHIP
Leadership in CRM includes directing and coordinat-
ing personnel, stimulating teamwork, delegating tasks, laying
expectations, focusing resources on crucial aspects of the mis-
sion, providing feedback, and creating and maintaining a pro-
fessional atmosphere.
In the military, a commander lays out his or her command-
er’s intent, which is the desired end result for a given mission.
This process allows everyone involved to focus and allocate
resources based on a granular assessment of the primary goal of
the mission. Once the commander’s intent is laid out, in theory
the mission can be accomplished without further input from the
commander, as might be the case if the commander becomes
a casualty or the lines of communication are disrupted. While
the commander’s focus is generally on big-picture expectations,
more detailed expectations can also be set in order to optimize
the chances for success.
A leader needs to provide feedback on how his or her expec-
tations are being met as the mission progresses, to allow those
in the chain of command the opportunity to adjust their efforts.
For example, this feedback could take the form of a one-phrase
radio transmission regarding the shape of a formation of heli-
copters. A leader should strive to set the tone for the whole
mission, which will create or erode the professional atmosphere
depending on the approach utilized. Proper planning, prepa-
ration, and competence regarding the mission at hand are all
parts of setting the tone for a professional organization.
It has been recognized that there are two types of leadership
in an aircrew. Designated leadership is leadership by authority,
position, rank, or title. Functional leadership is leadership by
knowledge or expertise, and it allows the most qualified indi-
vidual to take charge of a situation temporarily. For example, an
enlisted crew chief in the back of a helicopter might have many
more years of experience than either pilot in the cockpit, and
his expertise needs to be valued and incorporated in the trajec-
tory of the mission.
Caring for patients who require cardiovascular surgical
operations is clearly a team activity. Everyone on these teams
plays a vital role in achieving optimal outcomes for the patients.
As noted earlier, these teams include a surprisingly large
number of practitioners. As the leader of these large, complex,
and highly professional teams, the cardiovascular surgeon must
treat all members of these teams with the respect that they are
due. It is also essential to convey a sense of optimism that a
procedure has a chance—probably even a good chance in most
circumstances—of helping the patient achieve a good outcome,
particularly if everyone involved does their part conscientiously
and well. This sense of optimism can be infectious. We often
remind our team members of the old saying that “the vast
majority of our patients will do well, though not by much,”
which conveys the appropriate optimism while reminding all
involved that everything matters and nothing is neutral. On a
similar note, the leaders of such teams should always strive to
use the language of commitment, while avoiding the language
of complaint [Tribble 2014].
COMMUNICATION AND ASSERTIVENESS
Communication is at the heart of any team effort, as good
communication is essential for a team to be effective. However,
it takes training, practice, and thought to be an effective commu-
nicator. Communication involves clearly and accurately sending
and acknowledging information, instructions, commands, and
feedback. As a sender one must be accurate and timely. Pilots
think about what they are going to say over the radio before they
say it, to minimize transmission time while clearly communicat-
ing critical information. There can be no room for misinterpre-
tation, and nothing can be left to the imagination.
As a receiver one must acknowledge and perhaps repeat,
rephrase, clarify, or provide feedback. This is the second part
of the two-way process. A pilot instructs his or her copilot and
expects a response acknowledging, understanding, and with
intent to comply. For example, if a pilot instructs the copilot to
descend from 100 feet to 50 feet during a low-level flight, the
copilot might acknowledge with something as simple as, “Roger,
down to 50 feet.” Conversely, the pilot must also acknowledge
communication from the copilot to endorse the validity of the
copilot’s input to the accomplishment of the mission. Another
aspect of communication is timeliness. A military pilot who was
shot at from a certain location on the ground needs to inform the
air control agency and other aircraft operating within the same
area as soon as possible. If the pilot waits too long after the inci-
dent, then other aircraft may be exposed to the danger of flying
over the threat area.
Assertiveness, as defined in CRM, is providing information
without being asked, making suggestions, asking questions, main-
taining one’s position until facts prove that a different course is
needed, and stating opinions in a respectful manner. In aviation,
there can be a cockpit gradient. When there is a senior pilot and
a junior copilot, the junior copilot might be reluctant to speak up
and state an opinion or state that he or she senses that something
is wrong. The senior pilot might have treated the more junior
pilot in such a way that the more junior pilot is reluctant to speak
up. Before the principles of CRM became commonly used, there
was often a steep power gradient in the cockpit, in which the
senior pilot would not be questioned. Rank and experience both
can contribute to this cockpit gradient. CRM dictates that it is
up to the senior pilot to level this gradient both when laying out
the expectations prior to flight as well as through actions taken
during the flight. Junior pilots are taught that they have the
responsibility of voicing their opinions and providing input in a
respectful, timely manner.
Another phenomenon that can interfere with assertiveness in
aviation is called the sandbag syndrome. This entity is described
as the feeling of comfort that can arise when someone else seems
to have a situation under control. A junior pilot can easily drift
into trusting the senior pilot in a scenario such as a difficult instru-
ment approach under conditions of low visibility and ceilings.
The copilot might think that a deviation from course or altitude
is intentional, when in fact the senior pilot might be suffering
e Heart Surgery Forum #2017-1807
4
from vertigo and should, therefore, be verbally challenged if
deviations from normal protocol become apparent. A comple-
mentary approach might be the “trust but verify” approach, in
which a junior pilot inherently trusts the experience of someone
more senior but remains ready to speak up when something is
happening that does not seem appropriate.
One of the important principles of optimal communication in
a cardiovascular operating room is to adhere to the CRM strat-
egy of call and response. For instance, it has been said that those
actually doing these operations are living life in a coffee can, by
which we mean that one must maintain one’s visual focus on a
very small operative field. However, the surgeon must commu-
nicate effectively and reliably with the other five or so groups
who are also working with them. These groups include the anes-
thesiologists, the perfusionists, the scrub nurses, the circulating
nurses, and the physicians’ assistants. One of the CRM principles
commonly used to optimize communication during these com-
plex cases is that of call and response. For instance, if the sur-
geon asks that the flow of the heart lung machine be reduced, the
perfusionist is expected to respond by repeating the request to
acknowledge its accurate reception. Another CRM principle that
should be adhered to in the cardiovascular operating room is the
reduction in hierarchy. This leveling of the environment can be
accomplished in many ways including the use of less authoritar-
ian or hierarchal language, such as by using first names, and by
encouraging the active participation of all in the room in offer-
ing observations or suggestions. When addressing differences of
opinion, one must constantly employ the venerable tradition of
respectful argumentation. A valuable way to think constructively
about differing views is to ask oneself what might be true about
what someone has suggested [Tribble 2014].
SITUATIONAL AWARENESS, DECISION MAKING,
ADAPTABILITY
In CRM, situational awareness is described as the degree
of accuracy by which perception mirrors reality. Situational
awareness also includes detecting and commenting on devia-
tions and identifying and acknowledging problems. One
way to prepare for having good situational awareness is by
a thorough briefing prior to the start of the mission. Thor-
ough does not mean that it has to take more than a few min-
utes. Being thorough involves talking through the critical
things that will be needed, the critical points in a mission,
and verifying the contingencies and expectations in order to
increase each team member’s situational awareness. In order
to maintain situational awareness one must continuously use
all available information to update and revise the perceptions
of the team members.
Another principle of CRM is to avoid a fixation on one
piece of data while ignoring other available data points. An
example of this pitfall occurred during the departure phase
of a routine maintenance flight (to set up and test aircraft
systems) in Iraq, when one of the authors (PCM), his copilot,
and even the crew chief in the back of the helicopter became
engrossed in a fluctuating engine gauge. All three were star-
ing at and discussing the engine performance, and no one
was focused on flying the aircraft. The weather was marginal
with heavy mist reducing visibility and obscuring the hori-
zon, and the departure path took the helicopter over a large
lake very soon after takeoff. While the three crew members
were focusing on the engine gauge, the aircraft was descend-
ing towards the water. The pilot and copilot did not notice
both audible and visual warnings regarding the helicopter’s
low and continuously decreasing altitude, and the weather
reduced the normal visual cues for this descent that might
have been picked up in the pilots’ peripheral vision. Eventu-
ally the copilot glanced at the radar altimeter and, realizing
the very low altitude, pulled power to the engines to arrest
the descent and begin climbing, a scant few seconds before a
well-functioning helicopter would have impacted the water.
It has been asserted that cardiovascular surgeons make a
life or death decision approximately every 10 seconds during
a typical cardiovascular operation. In fact, most would agree
that about 75% of great surgical outcomes are attributable to
good judgment while only 25% are dependent on technique.
Obviously, all on the team must maintain an awareness of
all that is going on in the room at all times, including the
activities of the anesthesia team, the perfusionists, the physi-
cians’ assistants, and the nursing team. However, at times
the surgeons must have intense focus on the technical task
at hand, potentially blocking out most, if not all, stimuli in
the room. Thus, one of the skills the surgeons must develop
in the realm of situational awareness is the ability to cycle
regularly from the immediate task of the moment back to
a more global awareness of the conditions and activities of
the room. That is, one must be able to develop a rhythm of
shifting between focus and awareness. Another instinct we
try to inculcate in our cardiac surgical trainees is the need
to think constantly on what one will do next, particularly if
the original plan does not seem to be unfolding as planned.
Another aspect of the situational awareness principle in
CRM is to avoid distractions. One of the most subtle types
of distractions in a cardiovascular operating room is an
uncommon condition. An example of this type of distrac-
tion has been described by astronauts as becoming “space
stupid” when working under conditions of weightlessness,
where objects are no longer affected by gravity. While ordi-
nary cardiovascular operations will not include a condition
as unusual as weightlessness, there are certainly times when
an unusual or unexpected circumstance arises that can throw
the team out of its usual rhythm. In such situations, one
must recognize and, if possible, regain control of the dis-
traction to avoid allowing it to negatively affect the tasks of
the moment. When such distractions do inevitably arise, one
does have a choice of how one will react, and it is optimal
to strive to maintain grace under pressure while regaining
control of the situation.
Summary
In the end, pilots are not doctors and nurses are not flight
crew, but there seem to be more similarities than differences.
In looking at a few characteristics of pilots and their stan-
dardized approach to missions, we can draw some parallels
between them and cardiovascular surgeons. Both groups may
have unrealistic attitudes regarding the effect of stressors on
Editorial—Marvil and Tribble
5
© 2017 Forum Multimedia Publishing, LLC
their performance, such as the belief that their personal prob-
lems do not affect their work. This sense of personal invul-
nerability is a negative aspect of the culture and can lead to
degraded performance.
As we come to accept that errors are an inevitable result
of natural human limitations of performance in complex sys-
tems, we can look for mitigation strategies for those errors.
It can be difficult in healthcare to admit errors when those
errors directly impact patients’ outcomes and lives. However,
we must embrace the reality that error is inherent in our work
in order to seek out means for its reduction. And the prin-
ciples of CRM can be one of those means.
Further studies are required to better correlate CRM
to outcomes that matter to the hospital administrators and
healthcare managers, physicians, and nurses, which include
both patient-oriented outcomes and financial considerations.
The culture of medicine is becoming more open to error-
reduction measures such as CRM in its attempts to progress
towards providing the safest and most effective care possible.
If the principles of CRM are to become more fully incor-
porated in healthcare, exposure to these principles should
be introduced in any healthcare curriculum and continue
throughout the careers of healthcare providers. CRM in avia-
tion is in its sixth generation. What might the sixth generation
of CRM in healthcare look like, and how much error reduc-
tion is possible by the time that sixth generation is reached?
As the principles of Crew Resource Management con-
tinue to be incorporated into medicine, in particular in sur-
gical practices, cardiovascular surgeons and their teams can
increasingly utilize these principles on a day-to-day basis to
enhance the smooth functioning of their teams, even without
extensive training and the substantial attendant institutional
costs. Though certainly some additional training within
these complex teams would be useful. In this brief review, we
have suggested ways that cardiovascular surgeons can apply
many of the principles of Crew Resource Management to
their practices for the benefit of their patients.
REFERENCES
Calland JF, Guerlain S, Adams RB, Tribble CG, Foley E, Chekan EG.
2002. A systems approach to surgical safety. Surg Endosc 16:1005-14.
Grogan E, Stiles R, France D, et al. 2004. The impact of aviation-based
teamwork training on the attitudes of health-care professionals. J Am
Coll Surg 199:843-8.
Kapur N, Parand A, Soukup T, Reader T, Sevdalis N. 2015. Aviation
and healthcare: a comparative review with implications for patient
safety. JRSM Open 7:2054270415616548.
McGreevy J, Otten T. 2007. Briefing and debriefing in the operating
room using fighter pilot crew resource management. J Am Coll Surg
205:169-76.
Moffatt-Bruce S, Hefner J, Mekhjian H, et al. 2017. What is the return
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Forum 19:112-5.
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consequence of failure. Heart Surg Forum 19:1-4.
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Safety in aviation has often been compared with safety in healthcare. Following a recent article in this journal, the UK government set up an Independent Patient Safety Investigation Service, to emulate a similar well-established body in aviation. On the basis of a detailed review of relevant publications that examine patient safety in the context of aviation practice, we have drawn up a table of comparative features and a conceptual framework for patient safety. Convergence and divergence of safety-related behaviours across aviation and healthcare were derived and documented. Key safety-related domains that emerged included Checklists, Training, Crew Resource Management, Sterile Cockpit, Investigation and Reporting of Incidents and Organisational Culture. We conclude that whilst healthcare has much to learn from aviation in certain key domains, the transfer of lessons from aviation to healthcare needs to be nuanced, with the specific characteristics and needs of healthcare borne in mind. On the basis of this review, it is recommended that healthcare should emulate aviation in its resourcing of staff who specialise in human factors and related psychological aspects of patient safety and staff wellbeing. Professional and post-qualification staff training could specifically include Cognitive Bias Avoidance Training, as this appears to play a key part in many errors relating to patient safety and staff wellbeing.
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We would like to outline some of the principles of using language to transmit the lessons of our discipline to our protégés. We will discuss three ‘languages’ we believe are important to the practice of medicine and especially to the teaching and learning of our discipline of cardiothoracic surgery: the language of science, the language of performance, and the language of memory.
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Both the Institute of Medicine and the Agency for Healthcare Research and Quality suggest patient safety can be enhanced by implementing aviation Crew Resource Management (CRM) in health care. CRM emphasizes six key areas: managing fatigue, creating and managing teams, recognizing adverse situations (red flags), cross-checking and communication, decision making, and performance feedback. This study evaluates participant reactions and attitudes to CRM training. From April 22, 2003, to December 11, 2003, clinical teams from the trauma unit, emergency department, operative services, cardiac catheterization laboratory, and administration underwent an 8-hour training course. Participants completed an 11-question End-of-Course Critique (ECC), designed to assess the perceived need for training and usefulness of CRM skill sets. The Human Factors Attitude Survey contains 23 items and is administered on the same day both pre- and posttraining. It measures attitudinal shifts toward the six training modules and CRM. Of the 489 participants undergoing CRM training during the study period, 463 (95%) completed the ECC and 338 (69%) completed the Human Factors Attitude Survey. The demographics of the group included 288 (59%) nurses and technicians, 104 (21%) physicians, and 97 (20%) administrative personnel. Responses to the ECC were very positive for all questions, and 95% of respondents agreed or strongly agreed CRM training would reduce errors in their practice. Responses to the Human Factors Attitude Survey indicated that the training had a positive impact on 20 of the 23 items (p < 0.01). CRM training improves attitudes toward fatigue management, team building, communication, recognizing adverse events, team decision making, and performance feedback. Participants agreed that CRM training will reduce errors and improve patient safety.