Friday, April 15, 2016


      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.

Kenneth A. Lipshy, MD, FACS

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