Medico-Legal Journal (2001) Vol. 68 Part 4, 113–114
^Medico-Legal Society 2001
113
Editorial: CRM – Clinical or Crew Resource
Management?
Dr Donald Bentley, MSc, FRCP, FRCPCH
Consultant Paediatrician
Readers of the British Medical Journal in March
2000 might have been forgiven for thinking that they
had chosen an aeronautical publication in error. The
cover sported a picture of a crashed and bisected
Lear executive jet, in collision with a van on the
runway with the caption “Reducing Error, Improving
Safety”. We were reminded that health care kills
many more people than aviation, with only one death
per eight million passenger flights contrasting with
850,000 annual adverse health care incidents within
the National Health Service. In America medical
error is responsible for between 50,000 and 100,000
unnecessary deaths every year and at least a million
excess injuries.
This special edition of the BMJ included several
major contributions on the topic of medical errors,
their epidemiology, reporting and, most importantly,
how their frequency can be reduced. Much of this
information derives from the American experience1
and the publication of “To Err is Human” by the
Institute of Medicine of the National Academy of
Sciences received considerable attention not only
from the media but also from Congress and even the
President.2
The University of Texas has been responsible for
much of the original and ongoing literature on the
subject of Crew Resource Management and the
lessons that medicine can learn from civil aviation.
Helmreich, from the Department of Psychology,
points out that both pilots and doctors overestimate
their ability to function without flaw when working
under the pressures of time, fatigue or stress.3 Other
relevant pressures include workload, fear, cognitive
overload, impaired interpersonal communication and
bad decision-making. Although the author concedes
that the operating theatre and intensive care unit are
different from the aircraft cockpit there are still many
common principles that apply to both situations.
Research into air accidents by the National
Aeronautics and Space Administration has found
that about 70% involve human error resulting from
both physiological and psychological factors. Data
from the Aviation Authorities in both the USA and
the UK show that poor collaboration between the
flight deck crew at times of near misses or actual
accidents is associated with an adverse outcome for
passengers. This link, which is not too surprising, has
also been reported with patient outcome in intensive
care units where there is sub-optimal cooperation
between nurse and physician.4 An analysis of 500
separate clinical negligence claims suggested that
7% were due to a failure of communication and 12%
to an error of judgement.5
The aviation industry was responsible for the
introduction of Crew Resource Management (CRM)
into aircrew training programmes, which previously
had focused almost exclusively on the technical
aspects of the job. CRM represented a mammoth step
within a somewhat conservative guild of professionals
because it included training in leadership, monitoring,
cross-checking and decision-making. CRM is now
mandatory for airline pilots in the UK and is also
recommended worldwide for aircrews. Does this
professional lack of enthusiasm sound familiar?
It is no surprise that when senior airline pilots
were invited and, subsequently, compelled, to be
involved with CRM they strongly advocated that
such training regimes should be targeted at cabin
crew attendants rather than pilots. Similar bleatings
have been heard from senior surgeons who believe it
should be directed towards Health Care Assistants
and nurses – plus ça change, plus c’est la même
chose. Despite such lack of enthusiasm other specialties such as anaesthesia have recommended that CRM
should become a central part of their professional
training and continuing professional development.6
There is, currently, no system within the National
Health Service for error recording and the sharing of
adverse experiences, although this should shortly
change with the most recent publication from the
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114
Medico-Legal Journal 68/4
Chief Medical Officer.7 There needs to be a blame-free
culture which will allow voluntary sharing of information concerning actual and averted accidents to
facilitate their future prevention. Although consultants
do not, as yet, carry logbooks it is likely that such
records, in some form, will be required in the future.
Medicine needs to move away from a culture of
personal blame and recrimination to one of system
analysis and awareness. The focus at Bristol was,
and remains, on the deficits of the two surgeons, with
little attention to the political, financial and managerial
anomalies that allowed the situation to develop and
continue. Who was monitoring Audit and Clinical
Governance at the Kent hospital where Ledward
operated unchecked for so many years? It all seems
so simple with the benefit of hindsight so that Jean
Ritchie could correctly conclude, “better NHS
management should have picked up the problems
earlier … proper and effective leadership was
lacking”. It is essential that organisations, rather than
individuals, benefit from so-called adverse events
and all involved in health care provision can learn
from the experience of the major airlines and other
industries. If this change of emphasis is combined
with training throughout all levels of health management there is likely to be an important fall in the
frequency of “near-hits”, let alone major catastrophes. Perhaps, in time, the Bristol experience may be
recognised as a helpful catalyst for this process. The
relevant parts of this proposed training include skills
in problem solving, feedback techniques, human
limitations, leadership and the interaction between
personality and behaviour. Is leadership not a key
component of effective Clinical Governance in addition to corporate responsibility for clinical standards?
Developments in CRM, Clinical Governance and
evidence-based medicine are likely to have significant effects within the realm of clinical negligence. It
should lead to a reduction in the number and severity
of medical accidents and one immediate effect would
be to reduce the costs of the Clinical Negligence
Scheme for Trusts. The Litigation Authority could use
its considerable muscle to encourage Trusts to adopt
training protocols to improve communication and
leadership skills, although it has shown little enthusiasm so far to take a pro-active role in risk prevention.
If this approach can be achieved by consensus
then mandatory legislation or political coercion
should not be required. The lessons of Clinical
Resource Management (vs Crew Resource
Management) will not only feature in the syllabus of
the pilots training manual but will also become a key
component of undergraduate and postgraduate
education. The combination of clinicians with
experts in pilot training and human resource management is likely to provide an important resource to
control the rising tide of clinical negligence.
GERONTE: “… the heart is on the left and the
liver is on the right.”
SGANARELLE: “… yes, in the old days that was
so, but we have changed all that, and we now practise medicine by a completely new method.”
Le Médecin malgré lui (1667)
Molière.
Declaration of Interest
Dr Bentley is a partner and Director of Medical
Affairs to TEREMA, an organisation which offers
training in team co-ordination, communication, leadership and behavioural awareness.
References
1. M R Cohen, “Why error reporting should be
voluntary”, British Medical Journal (2000) 320;
728–9. James L Reinersten, “Let’s talk about
error”, British Medical Journal (2000) 320; 730.
2. L T Kohn, “To err is human. Building a safer
health system”, Washington, DC: National
Academy Press 1999.
3. Robert L Helmreich, “On error management;
lessons from aviation”, British Medical Journal
(2000) 320; 781–5.
4. J G Baggs, M H Schmitt, A I Mushlin, et al,
“Association between nurse–physician collaboration and patient outcomes in three intensive care
units”, Critical Care Medicine (1999) 27;
1991–8.
5. Lynch, Christopher, Coker, Adeyemi, Dua, John,
A, “A clinical analysis of 500 medico-legal
claims evaluating the causes and assessing the
potential benefit of alternative dispute resolution”, British Journal of Obstetrics and
Gynaecology (1996) 103; 1236–1242.
6. Peter J Shirley, “Crew resource management
training should be mandatory in anaesthesia”,
British Medical Journal (2000) 321; 508–9.
7. An Organisation with a Memory, HMSO 2000.
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