From the Cockpit to the Operating Room: Combatting Medical Error Through Crew Resource Management

Illustrated by Haley Pak

On December 28, 1978, United Airlines Flight 173 silently glided through the night sky over the sleeping suburbs of Portland. At 6:15 PM, it struck the ground, killing 10 and severely injuring 23 passengers and crew [8]. The plane was supposed to have landed just an hour before at Portland International Airport with all 152 passengers alive [8].

In the final report, investigators state that “the probable cause of the accident was the failure of the captain to monitor properly the aircraft’s fuel state and to properly respond to the low fuel state and the crew members’ advisories regarding fuel state,” adding that “[the captain’s] inattention resulted from preoccupation with landing gear malfunction…” [8]. More specifically, United 173 was holding over Portland because the crew was troubleshooting an indication that the landing gear (wheels) was not extended for landing. The captain in particular was so consumed by the issue that he was distracted from noticing the little fuel remaining. This was in part because of “a breakdown in cockpit management and teamwork” whereby the captain took on too many tasks by troubleshooting the landing gear, blinding him from seeing the “bigger picture” regarding fuel (sometimes called “task saturation”) [8]. Moreover, this distracted him from hearing the multiple comments from other crew members regarding low fuel. The report notes that the other crew members were also not assertive enough because “the stature of a captain…may…force another crew member to yield his right to express an opinion” [8]. Thus, the other crew members likely felt intimidated by the captain’s high position and authority, resulting in a breakdown in teamwork and communication where a minor landing gear issue evolved into a major accident. 

Eleven years later, on July 19, 1989, United Airlines Flight 232 barrel-rolled in a ball of flames across the runway as it made an emergency landing at Sioux Gateway Airport. About an hour prior, an engine explosion resulted in a loss of hydraulics and therefore most controls of the aircraft, leaving the engines as the only way to control the crippled jet. Although the crash killed 111 passengers and crew, it was a miracle United 232 was even able to land [7]. When placed in a flight simulator set to the same conditions that United 232 was in, many other test pilots crashed far before reaching the simulated airport. The investigation concluded that United 232 “could not have been successfully landed on a runway” [7]. Despite this conclusion, the crew of United Airlines Flight 232 was able to control the aircraft and make it to the nearest airport, saving 185 lives [7]. 

After reviewing audio recordings of cockpit conversations, the final report attributed the miracle of United Flight 232 to the fact that the flight crew demonstrated good teamwork in “discussion of procedures, possible solutions and courses of action” when trying to land [7]. Compared to the crew of United 173, the captain of United 232 provided leadership while encouraging communication/teamwork and remaining open to inputs from other crew members. Additionally, other crew members were not intimidated by the captain’s authority and were active in all stages of the flight. For example, a United Airlines pilot flying as a passenger decided to help the crew and was tasked by the captain with handling the throttles [7]. By giving such an important task to another pilot, the captain showed that he trusted his crew members and valued their input in landing the plane. United 232 and United 173 demonstrated that when in the presence of individuals with differing levels of authority, proper teamwork, task management and open communication can mean the difference between crashing a perfectly flyable plane and flying a plane that should have crashed otherwise. 

Why was the behavior of the crew so different in these two accidents? The primary reason was because of the implementation of Crew Resource Management (CRM) in the airline industry prompted by accidents such as United 173. CRM is an umbrella term for a set of skills that emphasize teamwork and communication. More specifically, the Federal Aviation Administration (FAA) states that CRM training and practice “were derived primarily from management training approaches and stressed interpersonal teamwork while preserving a leadership chain” in response to “ uneven distribution of workload during critical situations such that one crew member, usually the captain, became overloaded while others were not effective contributors to resolution of the situation at hand” [13]. United Airlines Flight 173 exemplified the airline industry prior to CRM where the lack of teamwork, uneven workload and a perceived hierarchy that stifled communication led to many preventable accidents. These accidents prompted the development and implementation of CRM that directly addressed these problems, contributing to the success of United Airlines Flight 232 and improving airline safety up to the present day [3]. 

Healthcare in America and especially the field of surgery shares many characteristics with the airline industry. Helping patients requires teamwork, communication and proper leadership. Additionally, healthcare workers often have to make quick decisions, ones where small mistakes can have devastating consequences. In fact, medical errors are estimated to cause 250,000 deaths annually, making it the third leading cause of death in America according to Johns Hopkins University [5].  

To understand what factors are behind this high rate of medical errors, it is useful to provide an example of one. In one such incident, a resident notices that a patient is presenting symptoms that could indicate a serious infection. However, when he voices his concerns to the attending physician, the attending dismisses it as a commonplace infection and not serious, recommending that the resident discharge the patient. The resident disagrees but has to give the patient over to another resident at the end of his shift. When he comes back the next day, he learns that the patient was discharged and died from a rare, deadly form of a Varicella infection [1]. In this example, a barrier of communication between the resident and the attending physician meant that the attending physician did not adequately listen to and consider the resident’s position, recommending the discharge of a patient with a serious and fatal infection. The paper also adds that since the attending was seeing multiple patients, he wasn’t able to focus on the specific one that the resident had concerns about, instead dismissing it as a common infection and recommending patient discharge [1].

If this sounds familiar, this is because it demonstrates a breakdown in communication and teamwork that doomed United Airlines Flight 173 in the absence of CRM. Moreover, this is by no means a unique story. In a report ordered by the United States Senate, researchers from the Agency for Healthcare Research and Quality found that communication problems and inadequate information flow were among the top factors that contributed to the majority of medical errors [12]. In a separate paper focused on surgical errors in New York hospitals, researchers also found that “communication failures” and “team issues: informal norms and hierarchy” were in part to blame [2]. In observing interpersonal dynamics in operating rooms, researchers reached similar conclusions, noting that “while informants valued open communication, they continued to operate in a hierarchical culture which…threatened safety because less powerful members had limited input in decision making, and were reluctant to speak up” [4]. Karen Mazzocco painted a clearer connection between communication/teamwork and patient outcome, finding that the lack of behaviors associated with teamwork was “significantly associated with any complication or death” in surgery [6]. Thus, issues addressed by CRM in aviation such as a lack of open communication and teamwork are not only present in the healthcare setting but are prevalent and have a major impact on patients. Therefore, CRM could prove to be a useful solution to these issues, improving patient outcome by reducing medical errors. 

CRM could theoretically be a solution to preventing medical errors. However, could adapting principles from aviation for use in healthcare actually work? Some have tried to answer this exact question by attempting to do just that. In 2006, nurses and physicians working in the obstetric department underwent CRM training that involved “real‐life examples of topics such as: situation monitoring to maintain appropriate work load distribution and anticipate the unexpected, mutual support to provide performance feedback to team members…” among others [11]. This was followed by subsequent team meetings focused on how staff can further implement CRM. Researchers found that following CRM training, there was a significant drop of “adverse events” (including, for example, maternal death and birth trauma) from 305 to 187 events [11]. Additionally, there was a statistically significant drop in the Adverse Outcome Index that measured the severity of the measured adverse outcomes [11]. It appeared that CRM training and meetings could have contributed to the decline in adverse events, likely due to better communication and teamwork between staff as a result of CRM implementation. 

A similar study analyzed a Vermont hospital’s implementation of CRM training among staff working in the ICU. This training utilized “didactics, case-study discussions, “hands-on” team-building exercises and simulated operating room brief and debrief sessions” and continued every six to 12 months for two years [10]. Following CRM training, researchers noticed common medical errors such as “wrong site surgeries and retained foreign bodies decreased from a high of seven in 2007 to none in 2008” [10]. Although it increased to five a year after CRM training ended, the researchers point out that “malpractice expenses (payouts and legal fees) totaled $793,000 (2003–2007), but have been zero since 2008” [10]. Once again, it appears that CRM training was associated with a decrease in medical errors, although continual training might be necessary to maintain those improvements. Additionally, the benefits of CRM training go beyond just helping patients but also helping physicians and hospitals by reducing malpractice expenses. 

Perhaps the strongest evidence demonstrating the efficacy of CRM in a healthcare setting has been from the Veterans Health Administration (VHA). In 2006, the VHA implemented CRM training on a national level to 74 of its facilities. The training involved learning sessions and follow-up interviews that emphasized the ability to “challenge each other when they identify safety risks; conduct checklist-guided preoperative briefings and postoperative debriefings; and implement other communication strategies such as recognizing red flags, rules of conduct for communication, stepping back to reassess a situation [etc.]” [9]. When compared to 34 other facilities that received no CRM training, the 74 facilities with CRM training “experienced a significant decrease of 18% in observed mortality” [9]. Furthermore, increasing the frequency of CRM training sessions also further decreased mortality, with researchers stating that “for every quarter of training, the mortality rate decreased 0.5 per 1000 procedure deaths” and “for every increase in degree of briefing and debriefings mortality rate was reduced by 0.6 per 1000 procedures” [9]. The reduced mortality that the VHA saw from implementing CRM supports the notion that CRM is a useful tool in preventing medical errors and improving patient outcome. Moreover, the dose-response relationship between CRM implementation and decreased mortality further strengthens the argument that CRM implementation is not only associated with but likely directly causes decreased patient mortality. 

The root causes of medical errors in healthcare stem from the same issues that plagued the airline industry. The breakdown in communication and teamwork within a hierarchical structure can sometimes jeopardize safety, putting both passengers and patients at risk. Although the use of CRM in hospitals and healthcare is relatively new and uncommon, those that have experimented with CRM have demonstrated its efficacy and utility in preventing medical errors and improving patient outcome. Thus, hospitals and other healthcare facilities should continue to introduce and implement CRM training for its staff in order to protect patients and provide the best care possible. By doing so, maybe the healthcare industry will see less stories similar to United 173 and more stories similar to United 232 – stories where proper teamwork and communication between individuals can prevent potentially deadly mistakes and save countless lives. 

Edited by: Haleigh Pine
Illustrated by: Haley Pak




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