In our discussion about the book Crew
Resource Management for the Fire Service, Senator Lubnau mentioned that
under duress 60% of FIRE FIGHTER
errors are those of COMMISSION -where we carry out a task
incorrectly and the rest are errors of OMMISSION - where we neglected to carry
out a task element.
Dr. Carla Pugh was kind enough to discuss The
University of Wisconsin groups study assessing how residents either succeeded
or failed to recognize that an operative error occurred (typically errors of
commission or omission) and then comprehend the steps necessary to adapt to the
new uncertain situation- ie reverse/salvage the error. (D’Angelo AL, Pugh CM et al. Error
Management: Do residents identify operative errors as reversible.)
This brings to light the two problems we
face: 1. Do we rehearse the case in advance to identify the most likely
critical points where a mistake is going to be made so we can pause and assure
that happens.
This was one area that Dr. Pat Croskerry advised is an opportunity in critical
thinking we often avoid but need to address. It is also an area that Dr’s Zenati and
Tarola in West Roxbury are working on in which they are using the HUB system to
automatically introduce alerts during
cardiac bypass and valve procedures whereby critical steps need to be focused
on and avoid errors of omission. 2. Do we have the capability to understand
when an error occurs what mechanics are needed to salvage / reverse the error?
I am hoping Dr. Pugh and I have more opportunities to discuss this.
www.crisismanagementleadership.com
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