Crisis Resource Management (CRM)

Transcription

1 Crisis Resource Management (CRM) Goals Develop an understanding of the cognitive and technical actions involved in managing a critical event (thinking and doing) Advance the ability to generate a differential diagnosis for common critical events Develop an understanding of crisis resource management as it pertains to managing a critical event (How you go about it) Objectives Manage critical events and review performance of mandatory and recommended steps compared to ideal case management Practice skills in crisis event management Present a complete differential diagnosis during case debriefings for events that occurred during crisis events Adopt a methodical approach to avoiding accidents Think about crisis event management Recognise key types of error during crisis event management Learn appropriate workload distribution during crisis events Recognize leadership skills valuable to the management of crisis events Learn to observe and critique others behavior and actions 1

2 What is Crisis Resource Management? Origins in Crew Resource Management. Developed by Dave Gaba, MD., Howard SK, Gaba DM, Fish KJ, et. al. Anesthesia Crisis Resource Management Training: Teaching Anesthesiologists to Handle Critical Incidents. Aviation, Space, and Environmental Medicine 1992; 63: Gaba, D., et. al. Crisis Management in Anesthesiology Churchill Livingstone, New York, NY, Successful strategies improving air crew performance and safety Use of written check lists Use of established procedures in responding to crisis Training in decision making and crew coordination Systematic practice in handling crisis situations including the use of part-task trainers and full-mission simulators What is a CRISIS? Webster: a time of great danger or trouble whose outcome decides whether possible bad consequences will follow. How does a crisis arise? Retrospectively usually identify underlying triggering events Events that trigger problems do not occur at random. They emerge from three underlying conditions: Latent errors Predisposing factors Psychological precursors 2

3 Example Latent errors in anesthesia Lie dormant in system. Only become evident when thy combine with other factors and breach the systems defences: Scheduling of cases Assignment of personnel Priorities to rapid turnover Anaesthetic equipment User interfaces Manufacturing defects Failure of supply Predisposing factors Patients underlying disease Type surgery planned Psychological precursors Fatigue Boredom Illness Drugs Environmental Noise Room illumination Triggering Events Patient Surgery Anaesthesia Equipment 3

4 What happens to a problem? Self-limited or exist without threat to the patient Increase in severity Trigger new problems What is an incident? A problem that will not resolve on its own What is a critical incident? An incident that directly causes an adverse patient outcome How do we make complex decisions during patient care? Parallel processing Multi-tasking Iteration (repetition / step by step process for desired outcome) A comprehensive Model of Dynamic Decision Making and Crisis Management Involves parallel processing and multi-tasking at multiple levels of mental activity, with a primary loop of observation, decision, action, and re-evaluation Classic decision making Careful comparison of evidence with various causal hypotheses that could explain it Followed by careful analysis of all possible actions and solutions Powerful approach, however, slow and works poorly with incomplete information 4

5 Recognition-primed decision making Responses arise from precompiled rules or response plans dealing with specific type of events During pre case planning, experienced anaesthetists mentally arrange and compile responses based on patients condition, the surgical procedure, and the problems to be expected Supervisory control and activities coordination Distributing work load over time Distributing work load over resources Changing nature of the tasks Types of errors in crisis decision making Capture error: A common action taking over for the intended action ( force of habit ) Description error: Correct action performed on the wrong target ( flipping the wrong switch ) Memory error ( Forgetting an item ) Sequence error ( Performing an action out of sequence ) Fixation errors: Faulty re-evaluation, inadequate plan adaptation, loss of situation awareness o This and only this: failure to revise diagnosis despite evidence to contrary o Everything but this: failure to commit. An extended search for information o Everything is OK. No problem despite evidence What are your Resources? Yourself!!! Other health provider personnel Equipment Cognitive aids. (Medical records, drug labels, drug infusion sheets, checklists, etc External resources (Consultants, lab, blood bank, radiology, etc) Case management behaviors Anticipate Maintain vigilance Use all information The burden of proof the patient is safe is on YOU. 5

6 Crisis Management Principles Know your environment Anticipate & plan Take a leadership role Communicate effectively Call for help early enough Allocate attention wisely & use all available information Distribute the workload & use all available resources Crisis Management Take command Declare Emergencies Early Good communication Distribute the work load Call for help Optimize you actions Repeatedly re-assess Document 6