Why not use the same kind of system that the aviation industry has used for more than 25 years to reduce pilot error and accidents in the skies to reduce medical errors in EMS? That was the general idea when the National Highway Traffic Safety Administration convened a focus group in response to a larger initiative from the Institute of Medicine to establish ways to reduce errors made in the EMS delivery.

Estimates from allied health professions say between 44,000 and 98,000 people die each year in United States due to medical errors, of which 7,000 die from medication errors. Understanding that similar casualties may be present in EMS delivery, the NHTSA focus group recommended applying proven aviation principles to reduce these errors.

Aviation has used crew resource management, also known as cockpit resource management, since it was developed in 1977 by psychologists to reduce aircraft accidents. At the time, 73% of aircraft losses were caused by crew failures rather than technical or mechanical problems, according to the NTSB. By the end of the 1980s, most airlines had extensive crew resource management training programs. More recent studies indicate 80% of aircraft accidents are related to human error, despite the highly automated nature of modern aircraft.

United Airlines has created a program called C/L/R, Command/Leadership/Resource Management, for its pilots that encompasses the captain's authority, crew climate and decision-making, and situational awareness.

Similar programs have been applied to the nuclear power industry, offshore oil rigs and railroads. The medical profession also has begun implementing crew resource management to help reduce errors in the operating room during surgery. Now, the International Association of Fire Chiefs and some forward-thinking fire chiefs have embraced this concept and have undertaken the goal of moving the fire service toward crew resource management in day-to-day operations of fire-based EMS.

Most training programs in crew resource management incorporate seven major skills:

1. An adaptable and flexible approach

   Crews must have the ability to alter a course of action when new information becomes available. Fire and EMS crews often have routine calls that escalate into more serious emergencies. Maintaining adaptability requires the team to recognize and acknowledge change and determine if an SOP is appropriate and/or offer an alternative solution. This type of action requires that the team members provide and ask for assistance and interact constructively with others. This type of response can be established by an open atmosphere and understanding the mission of the crew.

2. Assertiveness

   Members must be willing to actively participate, state and maintain a position until the facts show another option is better. This requires initiative and courage to act. This also requires a comfort level in the position and knowing that when a comfort level is exceeded, people should speak up. Implementing an assertive team requires experience and removing lack of confidence and fear of reprisal.

3. Communication

   Senders and receivers have certain responsibilities, and the system design needs to remove barriers to communication, such as attitudes, task overload and cultural distractions.

4. Situational awareness

   Accurately perceiving the situation is crucial. Factors such as fatigue, task overload or underload, insufficient communication, degrading operating conditions, and an “invincible” philosophy impair the decision-maker's ability to process incoming information.

5. Mission analysis

   Develop short-term, long-term and contingency plans to coordinate, allocate, and monitor crew and fire department resources. Mission analysis has three phases: pre-incident planning and training references, incident monitoring and reporting changes, and lastly interactive post-incident analysis.

6. Effective decision-making

   Good decision-making in high-risk and technical operations has a sequence of events that include assessing the problem, verifying information, identifying solutions, anticipating consequences, informing others of decisions and of the rationale behind them, and evaluating decisions and their consequences. Decision-making in crew resource management uses a model called AESOP to respond to hazards. This model can be applied to the fire service after a hazard has been detected. The crew evaluates the potential impact on the operations based on the impact of the Apparatus, Environment, Situation, Operations and People. Good decision-making benefits from teamwork, extra time to make a decision, alert crew members and decision strategies based on experience.

7. Strong leadership

   This includes the ability to encourage fire-based EMS crews to work together. The leader has the responsibility for crew performance; direct actions; and asking for assistance from additional companies, the hospital or other crews.

So how do we apply aircraft standards to the fire service? Crew resource management principles are in place in several fire departments. For example, Miami-Dade (Fla.) Fire Rescue uses a checklist and communication protocols to help providers in the field decide whether to give clot-dissolving drugs to heart-attack victims. Each member of the three-person crew has a specific responsibility, and everyone is aware of situations that could produce a poor outcome. Like the technical skills required to fly aircraft, skills for EKG analysis and drug administration are essential, but it's the non-technical or human factors — communication, situational awareness, leadership and decision-making — that make the operation safe.

Another example can be found in King County, Wash. When the BLS engine crew arrives, the EMT/firefighter interviews the patient, the driver/operator takes a complete set of vital signs and the company officer records the information on a run sheet and obtains a history. Required fields on the company officer's report ensure nothing is missed on the assessment. When a Medic One unit arrives, one paramedic goes to the officer for the history and the other falls in behind the EMT, listening and building on the EMT's findings. The group makes a decision after confirmation of findings and then generates a plan for the care of the patient.

I observed a dozen calls in the King County system; every call went exactly the same, even though the unit worked with three different fire departments. Whether it was with the Renton Fire Department or the Auburn Fire Department, the crews participated in the communication and collaborated on decisions. At no time did it seem like the BLS crews couldn't offer information, and the information they provided to the ALS crews was an integral part of the decision.

IAFC leaders are holding discussions to take this system nationwide. We already have some of the tools; an important one is the checklist in the form of an ICS tactical worksheet or prehospital care report. Much like a preflight checklist, certain benchmarks must be met in an EMS call to ensure prehospital providers make an accurate decision for the patient. We must have vital signs, a medical history and allergy sensitivities before medications or evasive procedures are administered.

Compliance through simulation is another resource making headway in the fire service. Many departments use emergency scene management computer simulations. A similar comparison can be made to aircraft crew initial and refresher training, which requires simulation time during which crew resource management is evaluated and employed. The American Heart Association's Advanced Cardiac Life Support employs a similar simulation with algorithms and feedback loops.

Crew resource management can have a tremendous impact on quality improvement. For example, we could apply crew resource management to completion of the prehospital care report. Many EMS managers struggle with billing information and medical documentation. Using a run report in a checklist format may provide a consistent, complete report.

Failed airways continue to plague the prehospital arena. Applying crew resource management to securing a difficult airway could help reduce hypoxic brain injuries. Consider the checklist applied when securing an airway and continuous monitoring. The officer scribing the report or checklist calls out a series of questions related to breath sounds, capnometry and pulse oximetry. The paramedic reports back to the officer each of these findings in a systematic fashion, increasing the communication and situational awareness regarding the patient's ventilation status.

There is much to be gained by applying crew resource management to every aspect of fire service operations, but it will require rethinking some of the non-technical skills with which we operate. Our customers deserve the same safety standards for their emergencies that ensure their safety when they board a commercial aircraft. After all, this is what the fire service does best: teamwork.

Bruce Evans is the fire science program coordinator at the Community College of Southern Nevada as well as an adjunct faculty member for the National Fire Academy's EMS and injury prevention courses. A captain at the Henderson (Nev.) Fire Department, he has a master's degree in public administration and an associate's degree in fire management.

Online Tools

Institute of MedicineTo Err Is Human: Building a Safer Health System
http://books.nap.edu/books/0309068371/html/index.html

Coast Guard
CRM training materials
www.uscg.mil/hq/g-w/g-wk/wks/wks1/ppt/CRM%20Refresher2002.1.ppt

Department of Transportation
Patient Safety in Emergency Medical Service Roundtable: Report & Recommendations
www.nhtsa.dot.gov/people/injury/ems/patient_safetyems/executive_summary.htm

Thomas Jefferson University School of Medicine
Crew Resource Management and its Applications in Medicine
www.ahcpr.gov/clinic/ptsafety/chap44.htm