About the "dirty dozen" and its last four members you can read here:
1. These Human Factors Complete the "Dirty Dozen"
In the third part of the series about the "dirty dozen" we occupy ourselves with various types of lack:
- Lack of Resources
- Lack of Teamwork
- Lack of Assertiveness
- Lack of Awareness
All four endanger safety and may cause mistakes. Therefore, we must keep them in mind in crew resource management as sources of avoidable mistakes, when knitting our safety nets, as well as when elucidating the cause of an error.
2. Lack of Resources Limits Us in Many Aspects
2.1. What Are Our Resources?
Crew resource management teaches us to apply our resources as a team wisely. These comprise our equipment, and time, financial resources, and, last but not least, our team members, and help from other teams.
Each of our team members brings along his or her knowledge, skills, and professional attitude. During training courses we optimise these resources, preferably as teams.
There is Almost Always a Lack of Time
Here, we want to highlight one aspect of time. In the emergency medical service, we always have got the ten seconds to plan for the next ten minutes. It is better if we invest these seconds and coordinate our next steps in a critical and complex situation than getting roped into a chaos, which deteriorates our patient's situation.
Lack of Equipment
In the emgerency medical service, there are devices, which are considered too expensive in relation to their benefit. For a long time, among these haemostatic bandages, which are used to pack deep, heavily bleeding wounds, were counted.
Luckily for our patients, we indeed have to apply these bandages rarely. However, if we need them, we really need them to spare our patients an unnecessary loss of blood.
This brings us to our next topic: Money. Where is the red pencil not being applied? When does this compromise our safety due to a lack of resources? When would it be better not to save money in the wrong place as the consequences will endanger safety and the reputation and cost more than the initial investment?
Personnel and Team Members
Sometimes, personnel is scarce due to financial reasons. In this case, it carries even more weight if an additional lack occurs due to illness, holidays, and training courses.
In addition, the formation of our team matters. On some days, we have a well-rehearsed team consisting of experienced experts. On others, we have mainly unexperienced members with us.
We know that we have to keep our knowledge and skills up to date. Thus, we want to reserve time for exciting training courses. Also our attitude which we bring along to work, is an ideational resource.
2.2. How to Master this Member of the "Dirty Dozen" successfully
Especially time and financial resources are no easy topics as we have to admit frankly. Only together with the policy-makers in upper management we achieve improvement.
The following thoughts help us:
- planning time wisely and recognising the really important items
- assessing the necessary investment correctly
- What Equipment do we really need?
- What is unnecessary or obsolete and could make room for new material?
- What improvements do we achieve with our innovations?
- How do we put together our teams meaningfully? How do we share the workload reasonably?
- What training courses can we put into practise successfully?
- Items, of which you can think
3. How to Avoid Lack of Teamwork
3.1. Teamwork Spans Many Aspects
As a team, we should use our resources productively, especially in complex situations. In order to achieve this, we need to know who in our team masters what tasks securely and can take on what role.
Then, we need to communicate without any loss of information, distribute our tasks and make decisions. We need to process important information continuously and without missing vital hints.
3.2. Joint Training is Crucial
As a team, we need to be well familiar with the aspects mentioned above. For thinking about them for the first time, being right in the middle of a call in emergency medicine or in an unforeseen situation on a transatlantic flight is not the appropriate point in time.
Rather, we think about them when we are off work and during simulation exercises and train the right communication, decision making models, and how to distribute the workload. The following prevails:
Train together who work together.
3.3. Just as Important as Training: Debriefing
A team has applied the wrong medication? Someone hasn't heard a crucial hint of a relative concerning the patient's allergy?
Now we are in demand as a team during our debriefing session. We won't be successful if we blame and lecture someone we consider the culprit. With such behaviour we rather induce fear and cover-up of mistakes.
In modern emergency medical service, we aim at constructive debriefing sessions whith one clear goal:
To elucidate the root cause of our mistake. In many cases, there is not only one reason for an error, but a chain of events.
If a mistake, which may have substantial consequences such as the application of an inappropriate medication, has occurred, the case is anonymised after the debriefing session and made available for as many colleagues as possible as an opportunity to learn.
3.4. Team Means: "Together Everyone Achieves More"
We need our professional attitude to work as a team. We are all just human beings and don't get along with everyone in the same way. We will accomplish much, though, if we collaborate goal-oriented and matter-of-factly during working hours.
Furthermore, we should be aware of the fact that we matter as a team member in our respective role, especially if we fully contribute with our skills. In doing so, we strengthen the morals of our team and prevent the attitude that the other team members will take care of the tasks.
4. Lack of Assertiveness - Errors Are Not Uncovered
4.1. Using Assertiveness to Point out Mistakes
If a team member has noticed an error, he or she needs the attention of the team so that the appropriate steps can be taken. This holds true, for instance, if someone in the operating theatre has noticed that a surgeon has become unsterile by touching a non-sterile object in his or her proximity.
To avoid that the patient now contracts an infection due to contamination of the wound with germs, the surgeon has to don a sterile gown or gloves again. It dos not matter, whether the surgical nurse, someone from anaesthesia, or a technician has pointed out the fact.
4.2. Assertiveness as a Principle in the Entire Company
We all know that this type of assertiveness is not always put into practice easily. There had been a strict hierarchy among physicians in hospitals for a long time. This meant that the consultant was always right, even though the speak up of the resident was legitimate and could have saved the patient.
Therefore, it falls on the policy-makers to establish a company culture in which a speak up and pointing out mistakes are possible at any time in order to avoid harm to a patient or other dangerous situations.
If a team member has pointed out an error or dangers plausibly and has used arguments matter-of-factly, the team should explore those and only continue to work after the situation has been clarified sufficiently.
4.3. How to be Courageous
Especially in strictly hierarchial work environments, we need to summon all of our courage if we have noticed an error, or potential dangers. We should state such observations calmly and without any judgement. Constructive suggestions serve as underpinning.
5. Lack of Awareness Causes Errors
As you are well aware by now, our situational awareness includes space, time, our resources and information. Please take a few moments to consider the situational awareness in your own work environment and potential consequences if it lacks. Below, you can find examples from aviation and the emergency medical service:
- in aviation, for instance, the distance to the ground or mountains hidden in the fog
- in the emergency medical service: Dangers on a heavily trafficed road, or on a construction site
Awareness of Time
- in aviation time until landing, according adjustment of velocity, altitude, etc.
- during resuscitation fixed points in time to control the heartrhythm, apply medication, time we may take to intubate (interruption of the chest compressions necessary)
- generally speaking, our equipment and team, but also potential help from other teams, in the emergency service this also includes pedestrians and relatives (f. ex. staying at the light switch of a stairway, while the team carries the patient downstairs in a rescue sheet)
- in aviation, paying attention to information on windspeed and wind shear is essential during the approach
- in the emergency medical service, for instance, information on the patient's medication is important (possible interactions)
The consequences in the examples above may be substantial if we don't pay attention. Therefore, we discuss and practise also situational awareness during team trainings.
6. All Members of the "Dirty Dozen" at a Glance
In the order of the blog articles, you can find here the complete "dirty dozen" at a glance. Please use the opportunity to recapitulate, or to transfer the human factors and how to deal with them to your own work environment.
- Lack of Communication
- Lack of Knowledge
- Lack of Resources
- Lack of Teamwork
- Lack of Assertiveness
- Lack of Awareness
A huge compliment to you, dear readers, for having followed the important topic "the dirty dozen" so attentively.
7. In the Next Blog Article We Will Start with Maintenance Work
What is Maintenance Resource Management, MRM? In the next blog article, we will discover, why it has developed from CRM, what role it plays with respect to safety, and what precise principles exist.
You can find more blog articles at the bottom of my blog page.
Author: Eva-Maria Schottdorf
Date: March 30th 2022