Team resource management: cutting the swiss cheese.

An important article in this months Emergency Medicine Journal (abstract only, subscription required)  looks at the new, and increasingly popular exploration of leadership and followship skills in emergency department roles.
Although concerned mainly with emergency department physicians, these skills transpose well to nurses working in any clinical team environment.

You can also listen to a podcast on the topic here.

Training in these non-technical competencies (also known as Crew Resource Management (CRM) or NOTECHS) develops interpersonal and cognitive skills, attitudes, behaviours and situational awareness that give staff the tools to perform at high levels under stressful situations whilst trapping or mitigating any errors as the inevitable swiss cheese holes line up in these sorts of circumstances¹.

Humans make errors in predictable and patterned ways. Novices make errors due to incomplete knowledge, while experts make errors due to the intrinsic hazards of semi-automated behaviour. When humans work in complex systems such as the National Health Service, the opportunities for error-inducing conditions are almost unlimited and may be exaggerated by culture and system deficiencies. Very often, no harm results from ‘routine’ errors, but eventually the consequences of these familiar and generally tolerated conditions may coincide and culminate in a disastrous outcome. An error-prone department will also significantly degrade the value of staff and the atmosphere of the workplace. We become more error prone when we experience fatigue, stress, illness, overload, inexperience or complacency, not uncommon among emergency physicians.

4 Triggers are listed as most likely leading to errors in staff working in complex systems:

• Interruptions and distractions
• Tasks required out of the normal sequence
• Unanticipated new tasks
• Interweaving multiple tasks.

The authors go on to very briefly outline some of these notech skills including the use of the SBAR communication tool  and “The Magnificent Seven” which consists of:

1. Briefings and debriefings
2. Checklists when appropriate
3. Effective question types
4. Assertion techniques
5. Closed-loop communication
6. Standardising handover
7. Red flags indicating loss of situation awareness.

Unfortunately, the article does not really unpack these Magnificent Seven to any extent and I would have been keen to read more on this. The article concludes:

To improve patient safety in the ED, the principles of CRM and its application must be supported by decision-makers and accompanied by organisational improvements. Although CRM/ human factors training is a relatively new concept in emergency medicine, its role in preventing errors and improving safety in other specialities is well recognised, particularly in anaesthesia and critical care. With the ED posing similar levels of risk, it is time to embrace this concept and improve patient safety.

I must say my experience has been that nursing has been a little ahead of the physicians curve in recognising the importance of developing strong team intelligence skillsets.

If you have read this blog for any length of time you would know that I find this topic very interesting and here are some of my own thoughts around it. You might like to pick out a couple to check out:

• SBAR communication tool and effective telephone communication.
• A Nursing documentation template.
• Intubation checklist.
• Safe nursing is like safe sex.
• Minimising IVI errors.
• Medication errors.
• Leaders and First Followers.
• Nurse as Servant Leader.

1. In the ‘Swiss cheese’ model, system failures may be represented as holes in the existing layers of defense. When these holes line up, shit happens. The holes are said to result from “active failures made by people and also the latent conditions of the organisational system” [↩]