Adaptation of Airline Crew Resource Management Principles to Dentistry

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Adaptation of Airline Crew Resource Management Principles to Dentistry Harold M. Pinsky, Russell S. Taichman and David P. Sarment JADA 2010;141(8):1010-1018 10.14219/jada.archive.2010.0316 The following resources related to this article are available online at jada.ada.org (this information is current as of June 24, 2014): Updated information and services including high-resolution figures, can be found in the online version of this article at: http://jada.ada.org/content/141/8/1010

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Adaptation of airline crew resource management principles to dentistry Harold M. Pinsky, DDS; Russell S. Taichman, DMD, DMSc; David P. Sarment, DDS, MS

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Background. The aviation industry uses crew resource management (CRM) to address the human N aspect of error. Dentistry can incorporate these conC U U A ING ED 4 cepts to reduce dental error. The authors provide a RT ICLE checklist to help clinicians mitigate error. Methods. Health care systems have begun to focus on medical error. During the past 30 years, the airline industry has developed mitigation strategies that are being adapted for medicine. CRM involves the use of information, equipment and people to increase safety by targeting early identification of errors. Results. To enhance safety, practitioners must implement forwardthinking strategies. Because human error is inevitable, threat and error management (TEM) techniques are needed to help identify and trap error before it develops into unexpected outcomes. Risk analysis increases situational awareness (SA) of potential dental error. Efficiency increases with early error detection. Conclusions. The authors provide a dental checklist that is divided into “appointment review,” “before procedure,” “procedure,” “before dismissal” and “after dismissal” to organize dental activities in a manner that enhances error detection. Practice Implications. The dental checklist is a tool to incorporate CRM and TEM techniques into the dental care environment to increase SA, safety and efficiency. Key Words. Medical error; dental error; dental checklist; risk management; threat and error management; situational awareness; safety; crew resource management; efficiency. JADA 2010;141(8):1010-1018. I

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he public’s view of a health care facility typically is one of a wellcontrolled and safe environment. Like others in health care, dental care providers strive to provide quality care while doing no harm. Occasionally, however, patients may be harmed as a result of technical and human factors.1 Error in treatment often results from issues not central to the actual procedure being performed.2 While practitioners have developed their own strategies to mitigate errors, there has been little effort to formulate systematic solutions. By contrast, the airline industry has had decades of experience in addressing similar issues.3 Early and dramatic accidents have led to the implementation of systems designed specifically to address adverse human factors in a systematic fashion. The airline industry has adopted crew resource management (CRM) as a foundation for addressing the human aspects of flight.3 Improved safety and efficiency records are testimony to these successful methods, which have been adapted by other industries, including hospitals.1 The results of six governmentsponsored studies suggest that training in decision making reduces

Dr. Pinsky is an airline transport pilot and in private dental practice. Address reprint requests to Dr. Pinsky, 3773 Highlander Way W., Ann Arbor, Mich. 48108, e-mail “[email protected]”. Dr. Taichman is director of the Scholars Program in Dental Leadership and a professor of dentistry, periodontics and oral medicine, School of Dentistry, University of Michigan, Ann Arbor. Dr. Sarment is in private practice in Alexandria, Va.

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errors, and the studies demonstrated improvements in safety ranging between 8 and 46 percent (P = .05).4 Investigators in another study of six large corporations and military entities that adopted CRM strategies reported accident reduction rates of between 36 and 81 percent (P = .02).4 Recognizing the potential of CRM, the medical profession has begun to implement CRM strategies5 to address error.6 The dental profession, however, has yet to adopt CRM strategies systematically. The purpose of this article is to describe the fundamentals of CRM that are applicable to dentistry and suggest how dental professionals can translate these principles into practice. We offer a dental checklist as a first step toward incorporating CRM principles. CREW RESOURCE MANAGEMENT

CRM has been defined as making use of all available resources—information, equipment and people—to achieve safe and efficient flight operations.7 Flying an airplane and practicing dentistry are highly technical endeavors that take years of training and practice to achieve high levels of competence. Both pilots and dentists perform complex procedures that require expertise and team participation. Continuous improvements in areas such as workplace design and materials combined with increasing complexity are hallmarks of both the airline industry and dentistry, in which information, equipment and people are integral to successful flight and clinical outcomes. The airline industry started focusing on CRM three decades ago after pilots and psychologists recognized that human error was the source of most accidents.3,8,9 The results of early analyses demonstrated consistently that a chain of often minor individual mistakes led to catastrophic events. Error rates cannot be reduced by technology alone. Investigators conducted accident analyses, the results of which revealed that responsibility could be traced to all members of the team, and blame often could not be attributed to a single person.3,8,10 These findings are in striking contrast to commonly held beliefs in the health care industry, which, until recently, has singled out individual accountability and addressed technical errors by modifying or enhancing isolated individual skills.11 CRM relies on group interaction to process information, make use of proper equipment and engage all people involved. To accomplish this, the team leader listens to team members and

solicits their feedback in an environment that encourages people to offer their observations. However, the team leader ultimately is responsible and makes the final decisions. Mazzocco and colleagues12 reported that teamwork reduced mortality and major complications in surgical patients. The flight deck and the dental office bear many similarities. Both are composed of a few people with significant responsibilities. Increasingly, both have access to outside support. For example, an airline captain relies on all onboard crew members, company dispatchers and air traffic control personnel to prepare for and safely accomplish a flight. Pilots are trained repeatedly to incorporate out-of-cockpit resources in their decision-making process. On the other hand, dentists have not yet developed a systematic approach to incorporating essential elements of CRM. This is surprising in that oral health care providers have a wealth of out-of-office resources (such as specialists, physicians and other health care professionals; dental societies and associations; vendors; continuing education courses; and Internet resources) they can access easily by using a CRM framework to provide optimal care to patients. SAFETY AND RISK

The dictionary defines safety as “the condition of being safe from undergoing or causing hurt, injury, or loss.”13 The Federal Aviation Administration (FAA) has defined system safety as “the application of special technical and managerial skills in a systematic, forward-looking manner to identify and control hazards throughout the life cycle of a project, program, or activity.”14 Consequently, any discussion of safety and risk requires consideration of forward-looking techniques and strategies. Risk analysis is a tool to interpret data15 that combines technical information (for example, issues related to bonding of fifth-generation versus seventh-generation resinbased composite) and human aspects (for example, a procedural error during placement of a resin-based composite restoration). Human error during placement does not necessarily lead to an unsuccessful final restoration. If both human and ABBREVIATION KEY. CRM: Crew resource management. FAA: Federal Aviation Administration. TEM: Threat and error management. SA: Situational awareness. WHO: World Health Organization.

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tify details that are unappreciated by the untrained eye. This concept can be described by the term “situational awareness” (SA), which Endsley18 defined as the “perception of the elements in the environment within a volume of time and space, the comprehension of their meaning, and the projection of their status in the near future.” EFFICIENCY Jones and Endsley19 conducted a study in As noted in the definition of CRM, safety and effiwhich they identified the lack of SA as a significiency are linked and are an integral part of the cant source of error in aviation. When pilots are process. Both the pilot and dentist must execute disoriented or gradually overwhelmed by the need tasks at a rapid pace to be efficient. One way to to perform a number of tasks, their SA decreases. maximize safety is to avoid risk and take on only As a result, the margin of safety often is reduced simple tasks. Flying a plane in daylight and clear and errors may compound to the point at which weather with no wind and no mountains or the pilots may lose control of the airplane. This treating one patient per day would may result in a tragic outcome lower risks simply by reducing the (Figure 120). Unfortunately, loss of The mitigation of SA can happen to any pilot regardnumber of exposures to potential error is the less of experience. A tragic accident threats. Limiting behavior in this fundamental building occurred in 1977 in Tenerife, way, however, is not a practical Canary Islands, when two 747 airsolution to improve safety. For an block on which all planes collided in the fog, resulting airline pilot or a dentist to succeed, crew resource in significant loss of life. The capsome exposure to threats is management tain of the plane taking off was inevitable. principles are based. among that airline’s most One goal of CRM is to increase technical aspects of composite placement have been controlled consistently, the likelihood is increased that the restoration will provide longterm service. A detailed, methodical risk analysis of past procedures ensures that future procedures, such as placement of resin-based composites, will be increasingly safe.

efficiency, which can reduce error through repetition (that is, an oral surgeon likely is more efficient than a general practitioner in performing third molar extractions). It is somewhat paradoxical, then, that increased repetition (which achieves efficiency) can increase risk simply by increasing the number of exposures. The more often a procedure is performed, the more likely a statistically improbable event will occur. Therefore, efficiency increases safety but also increases the chance of error. CRM techniques, when incorporated properly, should increase efficiency and safety through better management of the human element,16 while reducing the time needed to perform a procedure, as well as minimizing costs and loss of goodwill associated with error.17 SITUATIONAL AWARENESS

To an untrained observer, virtually any airplane flight deck or any dental procedure appears complex. However, to the trained professional, each of these domains is replete with nuances that often are obvious to those with similar training and experience. If a trained professional were to observe another trained professional performing a procedure, it is likely that he or she would iden1012

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experienced. Similarly, a catastrophic airline crash occurred in 1972 in the Florida Everglades when three experienced crew members on the flight deck diverted their attention while attempting to change a light bulb used to indicate the position of the landing gear. No one noticed that the autopilot was engaged in the wrong mode, and the airplane slowly descended until it crashed. These accidents illustrate a common theme: a loss of SA. Examples in dentistry of a loss of SA include losing count of the number of anesthetic carpules administered during a procedure and allowing a material to set during an impression or cementation procedure owing to a delay resulting from doing “one last little thing.” A simple and common example of loss of SA is missing an exit on the highway because of a distraction. This loss of SA has minimal consequences. If the car is low on fuel, however, and the next exit is 10 miles ahead, the consequences could be more significant. ERROR

The mitigation of error is the fundamental building block on which all CRM principles are based.2,3,21 Although error is a complex subject, we

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THREAT

Maximum Situational Awareness

REQUIRED TASK EFFORT (%)

will discuss two types of errors—those of omission and those of commission. Omission, or inaction, may constitute an error.22 In contrast, errors of commission are acts performed improperly or in the wrong sequence or time frame. Each type of error can be divided further into actions that are too great or small in scope or are in the wrong direction.23,24 Errors in all aspects of health care are wellknown.2,6 Because human error is inevitable, it is impossible to practice dentistry without making mistakes. Figure 225 demonstrates the possible error pathways during treatment. However, the simple process of discussing and reviewing error in detail increases our understanding of what constitutes an error. This ultimately can lead to improvements in patient safety and practice efficiency.

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Task Saturation Attention Available

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Airplane Flight

Preflight

Takeoff

Cruise

Landing

Taxi to Gate

Dental Checklist

Appointment Review

Before Procedure

Procedure

Before Dismissal

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Figure 1. Association between task saturation and situational awareness in airline flights and dentistry. Each phase of the airline flight corresponds to a phase on the dental checklist. The margin of safety decreases as the task saturation increases. Adapted from U.S. Department of Transportation, Federal Aviation Administration.20 Managed Event Recognized

The goal of safety is to avoid error or Preventable Ideal More Care Adverse mitigate negative consequences of Patient Event Error Interactions error. Phrases such as “I should have,” “if only I had” or “next time I will” are Not Undocumented retrospective responses to one’s recogniRecognized Error tion of having made an error. Error is best mitigated in a prospective manner. Active No No Adverse Patient Outcome Treatment Error Event The practice of CRM addresses potential errors prospectively by considering them as threats. A threat is anything Unavoidable More Care that increases the complexity of a Event 26 situation. Although the concept of a threat is Figure 2. Possible outcome pathways that a patient may encounter during dental intuitive, threats range from the muncare. Adapted from Hickam and colleagues25 from Agency for Healthcare Research dane (such as forgetting to look at a and Quality, Rockville, Md. radiograph) to the spectacular (such as a broken root tip during an extraction). Fatigue is number of hours for which medical residents can a known threat because people do not perform be on call in accredited graduate medical educaoptimally when tired. In a cross-sectional survey, tion programs in recognition of the potential Sexton and colleagues27 found that pilots were adverse effects of fatigue on safety.30 The rules less likely than surgeons to deny the effects of regarding how long medical residents can be on fatigue on performance (26 versus 70 percent, call and awake represent efforts to recognize just respectively). Why do pilots recognize that a nathow long a physician can remain functionally ural event such as fatigue is a threat more than alert.30 do surgeons? The answer lies in training and Though no similar formal guidelines exist for culture.28 dentists, oral health care professionals often tacitly recognize fatigue as a threat (for example, by Pilots follow specific FAA rules to mitigate the preferring to perform complex procedures early in effects of fatigue on performance.29 Similarly, the day when they are fresh and alert). They may increasing restrictions have been placed on the JADA, Vol. 141

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fosters CRM and team participation by providing an opportunity for open dialogue. An example of TEM in dentistry is when dentists discuss with team members the effect of a complex extraction on Harder Many Reversible Outcome specific team members’ roles, on the to Manage Distractions Less Likely schedule or both. A morning office huddle is another example of TEM. The common purpose of TEM in aviation, medicine and dentistry is to increase SA so that Easier Few Reversible Outcome safety issues (threats) are identified and to Manage Distractions More Likely addressed early, thereby preventing an error or enabling the team to recover easily from an error and move on. Figure 3. Relationships between threat and error management, situational awareness (SA) and the final outcome. The higher the SA, the easier it is to manage Figure 323 illustrates how early identhreats before they become errors and the more likely that earlier identification tification of a threat results in early reswill lead to a better outcome. Source: Helmreich and colleagues.23 olution, with reduced negative conseavoid complex procedures after lunch, when postquences.3 The best outcomes result consistently prandial fatigue occurs. These practice habits, when SA is reestablished. For example, when a although not recognized overtly as such, assist dentist excavates tooth decay with the use of a the practitioner in maintaining SA. Threats rubber dam and the team is prepared for a pulp occurring during a loss of SA may lead to errors of exposure and none occurs, the outcome likely is satpotentially greater magnitude than those that isfactory. However, when he or she excavates tooth might occur when SA is optimal. This type of decay without the use of a rubber dam and an expopractice modification illustrates the use of CRM sure occurs for which the team is not prepared, the techniques to reduce error. outcome may be less than satisfactory. By planning for an exposure, the dentist can reduce the threat of THREAT AND ERROR MANAGEMENT a poor outcome. Threat and error management (TEM) has evolved Taken a step further, if the patient is treated as an aspect of CRM to enable participants to idenwithout the use of a rubber dam and has diabetes tify and trap errors early to reduce unexpected out(a threat) and the dentist has not planned for this comes.31 Although eliminating error is not realistic, adequately in the pretreatment patient evaluation it is best to mitigate risk at its earliest stages. For (another threat), the patient might experience syncope in conjunction with an exposed pulp; this could example, poor weather increases the threat of an result in a poorer prognosis for the tooth owing to airplane’s crossing an active runway while taxiing. The captain and first officer practice TEM by verpoor TEM. A possible irreversible outcome would be balizing the expected taxi route, keeping the map that the tooth ultimately needs to be extracted. visible at all times for reference, taxiing slowly and This example demonstrates that a prognosis for a tooth may depend on external factors. discussing expected landmarks as they proceed. Admittedly, the above situation is rare, yet denThey perform required tasks in a “heads-down” tists perform millions of caries excavations each position and review the checklist only when year. Undoubtedly, a certain percentage of these stopped. By maintaining SA, pilots have decreased result in an untoward outcome as a result of operthe chance of an error’s occurring. ator error. Supporting data2,3,21,32 from the airline In medicine, physicians can envision similar complications when performing an invasive proindustry and from hospital operating departcedure in a patient who has a complex health hisments suggest that TEM techniques, when used tory (for example, uncontrolled diabetes, smoking properly, can reduce the error rate resulting from and congestive heart failure). A brief TEM-based dental procedures. discussion among all team members during which HEALTH CARE CHECKLIST they review patient-specific issues immediately before the procedure can reduce the chance of a In an effort to help professionals maintain SA and negative outcome. Furthermore, this discussion practice TEM routinely, organizations have advoThreat and Error Management

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cated the use of safety checklists. Adapting an items in a sequence that facilitates identification idea from the airline industry, the World Health of potential threats at the earliest point to mitiOrganization (WHO) developed a surgical checkgate negative consequences. It is beyond the scope list to be incorporated into the hospital surgical of this report to provide procedure-specific checksetting.33,34 Its purpose is to ensure a baseline lists, although developing these would be a logical SA.35 In medical settings, use of this checklist has extension of CRM theory as applied to dentistry. been shown to improve safety, with postoperative The items on our proposed checklist are general complications and death rates reduced by as in nature, allowing each practitioner to customize much as 36 percent.32,36 them to meet the specific needs of his or her pracA safety checklist is founded on the principle tice. Dental practices should use the checklist for that human error is inevitable. It helps people each patient encounter. The outpatient dental focus on the tasks at hand, reflects the fact that visit is divided into five phases, as described people lose SA over time and experience difficulty below. Each phase contains items that are appromaintaining focus, and helps clinicians establish priate for a generic timeline. The dentist or a team guidelines for care. Reading a checklist aloud member should read aloud each challenge and allows for a standardized set of prescribed and confirm its completion orally, preferably by using choreographed communications among team a team approach. The clinician or a team member members that takes little time to perform. Each then performs remaining tasks as appropriate. team member has a role. Any break After finishing each phase of the in the chain will cause all team checklist, the designated team A safety checklist is members to take notice and correct member should state, for example, founded on the the situation. Any member of the “appointment review checklist comprinciple that human team can be empowered to use a plete.” This choreographed dialogue checklist. is similar to that which occurs on error is inevitable. Hospital operating departments airplane flight decks for each and have adopted a time-out procedure37 every commercial flight. in which one person is responsible for requesting Appointment review. This phase, equivalent that all parties stop what they are doing and conto an airplane’s preflight, encompasses items that firm that they have addressed the various items need to be accomplished before initiating a on the checklist. Confirming the use of prophyplanned dental procedure. Although each item lactic antibiotics and that the proper instruments may or may not involve an action, the intent of are in place are examples of ensuring that tasks this phase is to lay a foundation on which all have been performed before the initiation of profuture action is built (such as review the patient’s cedures. Taking a moment to discuss a plan of dental and medical histories, screen for oral action is an example of performing something on cancer, confirm the availability of equipment and the checklist. A direct challenge and response to materials). each item, preferably orally, allows all involved Before procedure. This phase, equivalent to an opportunity to ensure that checklist items are an airplane’s takeoff, is the first time that the completed. This ensures that SA remains high, clinician actually will do something that could whether the team is treating the first patient of have an irreversible consequence (for example, the day or the last. The team’s consistent use of a administering anesthetic, removing gross caries checklist for each patient and procedure is a posito determine a definitive treatment plan). Verbaltive step toward reducing errors and increasing ization of the plan allows for increased SA and efficiency. This is much like the pilot’s perthreat recognition, which are particularly imporforming safety checks during each phase of tant if the clinician needs to deviate from the plan flight,37 because time is not wasted recovering unexpectedly. from missed items covered by the checklist.2 Procedure. During this phase, which is equivalent to an airplane at cruise, the clinician, with DENTAL CHECKLIST the assistance of the dental team, performs the Our proposed dental checklist (Figure 4) is based bulk of the required work (for example, after on our experiences, on the WHO surgical checkremoving gross caries, proceeding with a course of list33,34 and on the 2007 American Dental Associaaction such as restorative treatment, temporization guide for dental records.38 We positioned tion, root canal therapy or extraction). JADA, Vol. 141

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Dental checklist for outpatient dental visits.* CHALLENGE

RESPONSE Completed

Appointment Review

Verbalize medical history; medications current, updated, reviewed Verbalize premedication status Review allergies (medications, materials) Update dental history (such as periodontal examination, oral cancer screening, temporomandibular joint) Review notes from other health care providers, including specialists Review treatment plan documentation Verbalize procedure; confirm if informed consent required Verbalize that radiographs and/or study models are available Verbalize that all equipment and materials are available Verbalize the level of assistance required Review special instructions, needs for today’s procedure Before Procedure

Verbalize anesthetic method, location, expected amount Verbalize critical steps in sequence Verbalize potential deviations from treatment plan Procedure

Perform preliminary procedure (such as caries removal, gross debridement) Determine final procedure and inform patient Verbalize new critical steps in sequence Before Dismissal

Review with patient the treatment performed Review with patient postoperative instructions and care Prescribe medications (verbalize that no contraindications exist) Complete referral forms Inform patient of next step After Dismissal

Review unexpected events Inform team members of necessary follow-up items Review any equipment problems Complete laboratory prescriptions Record legible notes in patient’s dental record * Sources: World Health Organization33 and American Dental Association Council on Dental Practice and Division of Legal Affairs.38

Figure 4. Five-phase dental checklist.

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Before dismissal. This phase, equivalent to an airplane’s landing, is when the clinician or an assigned team member completes all items requiring the patient’s presence (for example, providing postoperative instructions, confirming the use of proper analgesics). After dismissal. During this phase, which is equivalent to an airplane’s taxiing to the gate after a flight, the team leader ensures that all details of the patient’s visit have been finalized (such as writing progress notes, preparing laboratory prescriptions, discussing the case with a dental specialist or physician). In aviation, checklists are specific to different airplanes and phases of flight. The dental office should adapt its checklist to accommodate specific needs. The active use of a checklist is valuable for general dentists as well as specialists, and it is applicable to all dental procedures, ranging from the most common (such as routine caries removal) to the most complex. We should note that airlines modify checklists regularly, even for airplanes that have been in service for many years. Checklists evolve to incorporate new information or technological enhancements. In addition, checklists for identical airplanes differ from airline to airline, yet they accomplish the same goal. Similarly, dental professionals should recognize that although the specific checklists will evolve continuously to accommodate changes, it is the consistent use of the checklist that remains constant.39 In this report, we introduced the concept of CRM as it relates to dentistry. A clear limitation of this work is the lack of specific peer-reviewed studies demonstrating that CRM is effective in dentistry. However, the fundamental concepts and principles of CRM are evident in the dental literature, absent the specific and direct terminology. For example, several studies in different fields of dentistry used checklists.40-45 In a study that had clear CRM overtones, Haak and colleagues46 demonstrated that a course in communications improved dental students’ competence when they interacted with their patients. Good communication is fundamental to CRM. In addition, Le and colleagues47 conducted a study in which they determined that 50 percent of third- and fourth-year dental students were unable to operate emergency oxygen equipment satisfactorily. Although it was clear that students possessed the didactic knowledge, they were unable to perform the procedures adequately in a simulated setting. The authors identified the problems as being

driven by human factors and, consequently, used TEM techniques (periodic simulation exercises) to address the students’ deficiencies. However, there are clear limitations to incorporating CRM—as designed for the airline flight deck—into dentistry. For example, airline flying often involves multiple crew changes, which result in frequent personnel turnover. Dentists, on the other hand, often work in the same setting for extended periods, with infrequent personnel changes. In addition, two equally skilled professionals working as a team are on the airplane’s flight deck, while a single practitioner typically performs dental procedures. Nevertheless, the concept of CRM provides opportunities for all members of the health care team to participate in the delivery of more effective and safe patient care. CONCLUSIONS

Our purpose has been to describe aspects of CRM and provide a checklist applicable to dentistry. There is substantive value in borrowing CRM concepts from the airline industry, as incorporated by the medical profession and by hospitals. A checklist is an organizational tool that empowers each member of the dental team. It helps people organize their thoughts, identify errors and increase SA. SA is increased by using a CRM team approach to practicing effective TEM. Optimal TEM incorporates the use of standard operating procedures, as reflected by the items on the checklist. We believe that the dental profession would be well served by implementing CRM strategies to reduce errors. We propose that practitioners begin by incorporating this dental checklist or a modified version into their practices and using it on a consistent basis. We hope this article fosters a discussion among clinicians regarding ways in which they can incorporate CRM into their practices. We encourage people to tailor the checklist to fit their specific needs. In addition, we propose that readers pause for a moment to reflect on this question: If you needed to undergo a dental procedure, would you feel more comfortable if the dental team practiced the fundamentals of CRM by using a challengeand-response checklist? ■ Disclosure: None of the authors reported any disclosures. This project was supported in part by funds from the University of Michigan’s Scholars Program in Dental Leadership (UM-SPDL). The authors extend their sincere thanks to Harold Crosthwaite, DDS, MS; Josef Kolling, DDS, MS; Fredrick Lurie, DDS; Ross Nelson; Stephanie Nunez; Debra A. Pinals, MD; and David J. Pinsky, MD.

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