I S S U E S I N N U R S I N G

View from the cockpit

What the
AIRLINE INDUSTRY can
teach us about
PATIENT SAFETY

Learn how airline industry best practices can be adapted to create safer health care
environments for our patients. ■ BY JEFFREY N. DOUCETTE, RN, CEN, CHE, CNAA, MS

IN THE EARLY 1970s, as jet travel
began to boom, so did the risks
associated with air travel. From
1982 to 2006, the National Trans-
portation Safety Board (NTSB)
reported 53 jet accidents resulting
in 2,180 fatalities worldwide.
Investigations revealed that 70% of
all airline accidents were linked to
the flight crew’s failure to use all
available resources to solve prob-
lems while in flight.1
Based on these findings, the
Federal Aviation Administration
(FAA) mandated the development
and deployment of crew resource
management (CRM) practices for
all air services that transport pas-
sengers. Implemented in the late
1970s and early 1980s, CRM is
designed to improve recognition
and utilization of all available
resources—personnel, equipment,
and information—to achieve safe
flight operations. Simply stated, it’s
the marrying of technical profi-
ciency with effective crew coordi-
nation. (See History lessons from the
airline industry.)
Along with other improvements
in the airline industry, CRM has
contributed to a remarkable safety
record. Until the air crash in Lex-
ington, Ky., on August 27, 2006,
the NTSB had reported only two
fatalities on major air carriers in
the United States since January
2003. This is the lowest number of
deaths ever recorded for this length
of time in aviation history.2
Like an airplane cockpit, a hos-
pital is a highly technical environ-
ment where the interaction
between man and machine deter-
mines outcomes. Many of the prin-
ciples adopted by the aviation
industry are easily applied to the
health care setting.
Under increasing pressure to
improve safety, health care organi-
zations are starting to implement
CRM strategies to improve team
performance. Let’s take a closer
look at what the airline industry

50 Nursing2006, Volume 36, Number 11 www.nursing2006.com

can teach health care professionals
about safety.
New attitudes about errors
The health care industry has a long
history of dealing with errors and
other safety issues in a reactive and
punitive manner. In recent years,
however, attitudes about dealing
with errors have changed signifi-
cantly. Organizations that once ter-
minated employees for medication
errors are now rewarding them for
voluntary error reporting. With the
help of accrediting bodies and a
new understanding of error pre-
vention, health care organizations
have stopped blaming individuals
for errors and are focusing instead
on changing systems and processes
to minimize risks.
Good person-to-person interac-
tion—in other words, teamwork—
is essential to a culture of safety. In
health care, unfortunately, many
forces work against a team mentali-
ty. Being a good team player is an
acquired skill, but training pro-
grams for nurses and physicians
stress the value of independence
and autonomy.
At the same time, increasingly
sophisticated technology requires
less and less face-to-face interac-
tion. Clinicians routinely send crit-
ical messages by pager, e-mail, and
fax. Other barriers to teamwork
include a reluctance to admit
errors, feelings of invulnerability, a
lack of standardized communica-
tion protocols, and inadequate or
nonexistent standard operating
procedures.
Applying core CRM concepts
All these challenges increase the
difficulty of implementing CRM
in a hospital. Yet in many ways,
the health care industry is a good
fit for CRM programs because in
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general, health care professionals
are dedicated to their work, high-
ly skilled, and well educated.
These strengths foster a positive
environment when organizations
begin to implement the core com-
ponents of any CRM program:
cross-monitoring and situational
awareness.
• Cross-monitoring is a process
for double-checking high-risk
work and verifying or correcting
inaccurate or ambiguous informa-
tion. Poor decision making is the
leading cause of cross-monitoring
failures. Simply stated, you must
know when to ask for cross-
monitoring, or it should be built
into standard operating proce-
dures.
The next time you’re on a com-
mercial airliner, pay attention to
the communication between the
pilots and the flight attendants.
You’ll notice several standard ways
of communicating that may not
have made sense to you until now.
For example, when the boarding
door of the aircraft is closed you’ll
hear an announcement like this:
“Flight attendants, prepare your
doors for departure, cross-check,
and all call.” Flight attendants then
check doors to ensure they’re
closed, engage emergency slides,
and check one another’s work. The
process ends with each flight atten-
dant making a call on the intercom
announcing which door she’s
armed and cross-checked. This
tells the in-flight leader and the
captain that all doors are secured
and have been double-checked by
another flight attendant.
In certain situations, the same
process exists in health care now.
As a nurse, I can’t recall ever
administering blood without a sec-
ond nurse present to verify infor-
mation and identity. Fifteen years
ago, cross-checking blood products
and insulin was generally required
in nursing. Today, nurses who
practice with good common sense
are constantly looking for col-
leagues to cross-monitor their
practice in many other areas as
well, such as with high-alert med-
ications and invasive procedures.
But while the use of cross-
monitoring has improved, it’s still
not as prevalent in health care as it
should be. More should be done to
incorporate this key verification
into standard operating proce-
dures.
• Situational awareness means
being aware of what’s going on
around you. It all boils down to
perception versus reality. Your view
of the situation, coupled with your
expectations and biases, come
together to help you interpret
incoming information. Factors
that reduce situational awareness
include insufficient communica-
tion, group think or mindset, task
overload, and task “underload.”
We’ve all had times when we “zone
out” and miss some big event right
in front of our eyes. Distracted in
some way, we’re not fully present
in the moment. Practicing good sit-
uational awareness means I’m
watching my work and I’m watch-
ing your work, and I’m aware of
the big picture: What that work is
going to accomplish.
Many have referred to situational
awareness as “trust your gut in-
stinct.” When in doubt, speak up!
Failing to speak up contributed
to the worst airline accident in avi-
ation history. On March 27, 1977,
in Tenerife on the Canary Islands,
a Pan American 747 and a KLM
747 collided on the runway, killing
583 of the 644 people on board.
Investigators found that the cause
of the accident was a miscommu-
Nursing2006, November 51

nication between the KLM captain
and the air traffic control tower.
Even worse, the first officer on
board the KLM aircraft knew that
the instructions given by the tower
were intended for the Pan Ameri-
can flight, but didn’t speak up for
fear of retribution from the senior
captain.
Following a script
Crew resource management prin-
ciples work because they’re based
on a predetermined set of behav-
ior standards and expectations,
none more important than those
centered around communication.
Need proof? Try this experiment
with your colleagues at work.
Ask someone in the group to
recite the safety briefing from his
last passenger flight. Assuming
he’s flown more than once in the
past few years, he’ll at least get you
through the instructions on how
to fasten your seat belt. Then ask
this: “If oxygen is needed and
you’re traveling with a small child,
what do you do first?” Again, he’s
likely to know that he should put
on his mask first, then help the
child.
Nearly all airline passengers
know the basics of the FAA re-
quired safety briefing. Why? Be-
cause it’s been carefully scripted so
it’s easy to remember in an emer-
gency.
Now, ask the same group of
colleagues to recite the first three
steps of the policy addressing the
most common emergency that
occurs in your unit. Interestingly,
most people can’t do this. And
even if they can, the steps are
rarely the same from person to
person, unit to unit, and especial-
ly from hospital to hospital. Yet
throughout the airline industry,
from airline to airline, the safety
briefing is basically the same.
In certain health care situations,
52 Nursing2006, Volume 36, Number 11
History lessons from the airline industry
Developed by the airline industry, CRM is a comprehensive system for improv-
ing crew performance that lets individuals examine how their behaviors affect
decision making and teamwork.
Initially, CRM was designed to address the high percentage of performance
errors and the dichotomy in the cockpit between ranking captains and more
junior first officers and flight engineers. But in time, CRM evolved to include all
crew members, including gate agents and baggage handlers. The entire team
is engaged in ensuring safe operations, from initial flight planning to postflight
debriefing.
Addressing attitudes and behaviors
Crew resource management isn’t a quick fix that can be implemented overnight,
a training program for a “few problem cases,” or an attempt by management
to dictate crew actions. Rather, it focuses on the attitudes and behaviors of
crew members in these areas:
• interpersonal communication
• standard operating procedures
• situational awareness
• problem solving and decision making
• leadership and “followership”
• stress management
• critique.
Although airline industry workers readily accept the CRM philosophy, putting
it into action is a more formidable task. Much like key members of the
health care team, pilots are conditioned to believe that they’re automated,
performance-oriented beings capable of amazing feats. Personality profiles of
pilots demonstrate that they have difficulty acknowledging their moods, feelings,
and especially weaknesses. These personality traits can be broadly applied to
many of the people you meet each day in your health care organization.
Barriers to safety
Over time, seven major themes have been shown to adversely affect crew per-
formance: lack of crew support (especially during busy times), failure to follow
standard operating procedures, stress when adapting to unusual or emergency
situations, priorities and distractions that distort judgment, emotional problems,
management pressure, and the “get home-itis” phenomenon.
Many of these flaws were in evidence last August, when Comair flight 5191
crashed while attempting to take off from the wrong runway in Lexington, Ky.,
killing nearly everyone on board. The initial investigation revealed that the air
traffic control tower wasn’t staffed to FAA minimum standards, and that the
sole air traffic controller on duty was distracted by administrative duties after
giving flight 5191 clearance to depart. Because he wasn’t watching the run-
way, he didn’t see that the pilot had turned down the wrong runway. In this
case, a lack of situational awareness—a core component of CRM—cost 49 peo-
ple their lives.
direct, scripted communication is tine, day-to-day conversation isn’t
essential. During a code, for exam- practical. Even so, critical commu-
ple, you’d expect someone in the nications between health care pro-
room to give very direct orders to fessionals can be standardized or
intubate, administer medications, “scripted” to prevent misunder-
and so on, following advanced car- standings and prevent errors. The
diac life support (ACLS) guide- SBAR technique provides such a
lines. framework in the health care set-
Of course, scripting every rou- ting.
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How SBAR enhances
communication
Developed at Kaiser Permanente of
Colorado, SBAR stands for situa-
tion, background, assessment, and
recommendations. This mnemonic
provides a framework for conversa-
tions between clinicians about situ-
ations requiring immediate atten-
tion and action.
You can download the SBAR tool
from the Institute for Healthcare
Improvement (IHI) Web site.3 The
tool consists of two documents:
• a worksheet that outlines how to
structure a report to a physician
about a critical situation following
the SBAR format
• guidelines that explain how to
use SBAR in more detail.
Although both documents use a
report to a physician as an exam-
ple, the tool can be adapted to
communications involving any
health care professional.
To illustrate how to use SBAR,
let’s assume you’re calling a health
care provider to report a change in
the patient’s condition.
Situation. When placing the
call, state your name and unit, the
name and room number of your
patient, and the problem. If the
problem is serious, also state the
patient’s code status.
Describe the problem in a simple
and straightforward manner. For
example, you might say something
like this: “This is Jeff calling from
the ICU. I’m calling about Donald
Smith in room 410. Mr. Smith’s
potassium is currently 6.5.” This is
a factual and concise description of
the situation.
Background. Once you’ve stat-
ed the most urgent part of the mes-
sage, introduce relevant back-
ground information. This could in-
clude the reason that the patient
was hospitalized, his mental status,
current vital signs, patient com-
plaints, pain level, and physical
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assessment findings. To be current,
report vital signs and other assess-
ment findings obtained within 30
minutes of your call. Always in-
clude your patient’s mental status
because this can be the earliest in-
dicator of subtle changes in his
condition.
You might provide background
for Mr. Smith as follows: “Mr.
Smith is being hospitalized for an
acute MI. He’s not complaining of
pain and is awake, alert, and ori-
ented. His vital signs taken 15 min-
utes ago are BP 110/60, heart rate
70, respiratory rate 16. The ECG
shows a sinus rhythm with peaked
T waves.”
A ssessment. In this part of the
report, give your assessment of the
situation. If the situation is unclear,
try to isolate the problem to the
body system that may be involved.
Also say how severe the problem
appears to be. If the problem may
be life-threatening, state this clear-
ly.
For some nurses, taking this step
is challenging. Typically, experi-
enced nurses know what to do in
most situations. But they may be
conditioned to stop at the back-
ground phase and wait for someone
else to give an order to validate
their thinking. The assessment and
recommendation phases let you use
your critical thinking skills and
make appropriate suggestions for
patient care.
In Mr. Smith’s case, your assess-
ment might sound like this: “Mr.
Smith’s potassium level is high and
he’s beginning to show mild ECG
changes. At this point, I believe Mr.
Smith is stable.”
Recommendations. In the final
phase of the SBAR framework, state
what you think would help resolve
the situation. This could include
medications, lab work, X-rays, car-
diac monitoring, physician evalua-
tion, or transfer to a critical care
unit. Clarify how often vital signs
should be reevaluated after an
intervention and find out under
what circumstances you should call
back the person giving the orders.
For example, “I recommend that
we discontinue Mr. Smith’s supple-
mental potassium, repeat his ECG,
and repeat his potassium level in 4
hours. I’ll call you back if we see
any more ECG changes or if Mr.
Smith develops pain. Would you
like to change his vital sign sched-
ule? Is there any other reason I
should call you back?”
From concept to implementation
The concepts and constructs of
CRM clearly apply to the health
care setting, but implementing
change can be daunting. The best
approach is to begin in procedural
areas such as the operating room,
cardiac catheterization lab, and
special procedures, where CRM
concepts are most easily translated
into the work routine. Then the
process can be gradually rolled out
to other parts of the facility.
Although CRM is a great tool
for improving safety, it can’t work
unless it’s implemented in a cul-
ture of safety. A commitment to
patient safety must be embraced
by everyone at every level in the
workplace. ‹›
REFERENCES
1. Helmreich R, et al. The evolution of crew re-
source management training in commercial avi-
ation. International Journal of Aviation Psychol-
ogy. 9(1):19-32, 1999.
2. National Transportation Safety Board, http://
www.ntsb.gov. Last accessed October 3, 2006.
3. Institute for Healthcare Improvement, http://
www.ihi.org. Last accessed October 3, 2006.
RESOURCES
Morey J, et al. Error reduction and performance
improvement in the emergency department
through formal teamwork training: Evaluation
results of the MedTeams project. Health Sciences
Research. 37(6): 1553-1581, December 2002.
Sexton JB, et al. Error, stress, and teamwork in
medicine and aviation: Cross sectional surveys.
British Medical Journal. 320(7237):745-749,
March 18, 2000.
Jeffrey N. Doucette is associate operating officer for
emergency services at Duke University Hospital in
Durham, N.C.
Nursing2006, November 53