Crisis Management in Acute Care Settings

Michael St.Pierre • Gesine Hofinger Cornelius Buerschaper • Robert Simon

Crisis Management in Acute Care Settings

Human Factors, Team Psychology, and Patient Safety in a High Stakes Environment

Second Edition

AuthorsDr. Michael St.PierreUniversitätsklinikum Erlangen-NürnbergKlinik für AnästhesiologieKrankenhausstr. 12 91054 ErlangenGermanymichael.st.pierre@kfa.imed.uni-erlangen.de

Dr. Gesine HofingerHohenheimerstr. 10471686 RemseckGermanygesine.hofinger@team-hf.de

Cornelius Buerschaperc/o Gesine Hofinger Hohenheimerstr. 10471686 Remseck Germany

Robert SimonHarvard Medical School Massachusetts General Hospital Director Center for Medical Education65 Landsdowne StreetCambridge, MA 02139USArsimon2@partners.org

ISBN 978-3-642-19699-7 e-ISBN 978-3-642-19700-0DOI 10.1007/978-3-642-19700-0Springer Heidelberg Dordrecht London New York

Library of Congress Control Number: 2011929776

© Springer-Verlag Berlin Heidelberg 2011This work is subject to copyright. All rights are reserved, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilm or in any other way, and storage in data banks. Duplication of this publication or parts thereof is permitted only under the provisions of the German Copyright Law of September 9, 1965, in its current version, and permission for use must always be obtained from Springer. Violations are liable to prosecution under the German Copyright Law.

The use of general descriptive names, registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protec-tive laws and regulations and therefore free for general use.

Product liability: The publishers cannot guarantee the accuracy of any information about dosage and application contained in this book. In every individual case the user must check such information by consulting the relevant literature.

Cover design: eStudioCalamar, Figueres/Berlin

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Springer is part of Springer Science+Business Media (www.springer.com)

As authors we would like to dedicate this book to very special people

… to Ulrike who is the love of my life … Michael

… to my family, Michael, Daniel and Julius, with gratefulness and love … Gesine

… to Diane who makes everything possible and worthwhile … Robert

… and to all our clinician colleagues who helped us shape this book by generously sharing their personal experiences in the face of taking care of critically ill or injured patients when the stakes are high and time is limited. The energy, concern and intelligence they apply every day to the sick and injured is awesome.

vii

Preface

All of life is problem-solving

Sir K.R. Popper

Providing safe patient care in an acute care setting has always been and still is one of the great challenges of health care. On a regular basis healthcare professionals are faced with problems that are sudden, unexpected, and potentially threaten a patients’ life. These problems don’t leave much time for in-depth reflection but demand thought-ful action despite the need for swift decisions. This, as most of us know only too well, is far easier said than done: time pressure, uncertainty, stress, high stakes, erratic team processes, and organizational shortcomings intermingle in an environment that makes good decisions and successful management of paramount importance.

The capability to master these challenges requires more than profound medical knowledge and clinical expertise. A set of skills is needed that enables healthcare professionals to reliably translate knowledge into safe patient care despite varying and often hindering circumstances. These skills are what the following pages are about. You will not encounter any information concerning the clinical management of critical situations throughout the entire book: No guidelines, no algorithms, and no recommendations. Many excellent textbooks have been written on the medical aspects of crisis management in acute medical care settings. Instead, the book at hand focuses on people: on healthcare providers from a vast array of specialties and professions who are expected to manage the unexpected: nurses, physicians, para-medics, and technicians. All of them have their defined set of clinical and human factors–related skills that enable them to manage critical situations. And all of these practitioners can improve their performance by thoughtful application of the basic theories on human decision-making and action presented in this book.

As part of our shared human condition, healthcare providers have inescapable cog-nitive limitations that contribute to errors and hinder successful crisis management. To help healthcare providers better understand their natural strengths and weaknesses as human decision makers, this book attempts to provide an outline of the way the human mind operates when the stakes are high and time is limited. Humans think and act the way they do because natural underlying psychological mechanisms provide an approach to cope with environmental demands. In contrast to a common belief, errors are not the product of an irrational or deficient psychological mechanism but

viii Preface

originate from useful mental and psychological processes. Some of them, like communication patterns, can be changed, others can’t – our perception, attention, motivations, feelings and thoughts are not entirely subject to our will.

While individual performance obeys certain rules, the same is true for teamwork. Acute medical care is not delivered by one person; instead it is provided through the combined efforts of professionals from various disciplines and specialties cooperat-ing for a patient’s sake. Thus, knowledge of successful strategies for improving team performance will create a safer and more effective clinical environment.

Errors in health care are not only the result of individual and team limitations. A third consideration is the systemic causes that are deeply embedded in the architecture of healthcare organizations and resistant to change. The total of these individual, team related, and organizational factors that influence our decisions and actions are called “the Human Factors.” This book is meant to explain and make accessible the “Human Factors” in acute care crisis situations. It is our firm belief that raising Human Factors to a higher level of importance in organizational design and individual and team performances will make our efforts on behalf of our patients more effective and safer.

There are two ways you may want to read the book: You may follow through the text according to its inner logic, or you may prefer to read selected chapters. The book has a modular character in which every chapter stands alone and can be read without knowledge of previous ones. To avoid excessive redundancy basic concepts are explained only once and then cross-referenced.

Every chapter follows the same internal logic: A case study from an acute care specialty illustrates central aspects of the subject matter and is then used as the ref-erence point for further exposition of the topic. Every chapter tries to provide answers to the same questions: “What is the relevance of the matter? Which prob-lems can be explained by this particular Human Factor? What can we transfer into our clinical task environment and how can we apply the knowledge to improve patient safety?” To enhance practicability the chapters on individual and team fac-tors (Chaps. 5–13) offer “tips for daily practice” that are meant to comprise helpful clinical advice. Every chapter ends with a short “in a nutshell” paragraph summariz-ing the essentials of the chapter.

The first part of the book addresses basic principles of errors, complexity, and •human behavior. Chapter 1 sets the stage by providing a survey of published data on the incidence of human error and accidents in acute medical care. A body of research underscores the significance of Human Factors in the development and the prevention and management of errors in a clinical high-stakes environment. Chapter 2 describes the characteristics of acute clinical care as a complex task domain where errors are bound to happen. Chapter 3 contrasts two current per-spectives on error and provides workable definitions on error. In Chap. 4 we provide a rough picture of the “psycho-logic” of human behavior that will enable the reader to understand how humans arrive at decisions.The structure of the second part follows the structure of human action as a problem-•solving process. It focuses on the limitations that our basic cognitive architecture

ixPreface

and thinking patterns of the human brain impose on making decisions and taking action. The individual chapters outline human perception (Chap. 5), information processing (Chap. 6), goals and plans (Chap. 7), attention (Chap. 8), and the impact of stress (Chap. 9). Chapter 10 focuses on how healthcare providers can arrive at good decisions, the ultimate goal of the problem-solving process.Part III broadens the perspective by shifting the focus from the individual health-•care provider to the team and to the human factors involved in team processes. The characteristics and pitfalls of teamwork (Chap. 11) are followed by an out-line of communication (Chap. 12) and leadership (Chap. 13), the two main fac-tors of successful teamwork.Part IV focuses on the influence that organizations have on the performance of •healthcare providers. Basic organizational theories and systemic models that enhance patient safety are presented (Chap. 14). The final chapter (Chap. 15) provides an outline for a comprehensive concept of organizational development that will help healthcare institutions to avoid and better manage clinical errors.Every book needs a fertile soil to grow on. This book grew out of a longstanding

cooperation between a physician with acute medical care background (anesthesia, intensive care, prehospital emergency medicine) providing simulation-based team training at his institution (St.Pierre) and three psychologists who have spent their professional lives doing research, training development, and training people in the different facets of “acting in critical situations” (Hofinger, Buerschaper, Simon). For each of us the project of writing a book on human factors and team psychology in acute medical care provided ample opportunity to grapple and understand the exper-tise of our combined disciplines. The result of this delightful process has been a text that is rooted in the clinical environment of acute clinical care wrapped in a cohesive theoretical framework of cognitive, social, and organizational psychology.

The clinical relevance and the practicability of this book have been our major concern. We strove to make the book accessible to the people who provide health-care in critical situations. We tried to formulate the text in an easy to read language, devoid of psychological insider language. As we tried to build every chapter around a case study from different acute clinical care environments we hope to have man-aged to bring even more sophisticated psychological theories “down to earth.” In writing this book we had nurses, technicians, paramedics, and physicians as target groups in mind. Hopefully they all will be able to benefit from our effort.

For us, this book has been a teamwork experience at its best. The process of writ-ing this book has been a challenging yet fruitful time for each of us. We were grate-ful to learn a great deal from the different perspectives clinicians and psychologists have on the same problem and from the divergent approaches in problem solving. We hope that the reader will benefit from this process as well. And because all of us contributed to every chapter, we all take the responsibility for the inevitable errors as well. We are grateful for any remarks concerning the content of this book or errors in the text.

With the advent of the Second Edition, we worked to improve the language and sharpen the description of the concepts and examples presented in the book. This

x Preface

was accomplished by adding a native English speaker and experienced educational psychologist (Simon). By adding a fourth author and giving him substantial author-ity in the book’s content, we found ourselves striving for clarity of expression and building on emerging research findings. Thus we found ourselves happily taking the opportunity to collectively revisit, rethink, and rewrite a number of the concepts presented in the earlier book. The result, we hope, is a much better written book in terms of how it’s written and how well the psychology and human factors principles are explained.

xi

Acknowledgments

Our ideas have been shaped by many colleagues of whom we want to single out only one: Dietrich Doerner, head of the Department of Psychology, University of Bamberg has been a great teacher and we are grateful for the many years of cooperation. His book “Logic of Failure” has been a great inspiration to us of how even the most sophisticated matters of psychology can be made accessible and readable. In addi-tion, we would like to thank our colleagues of the Department of Psychology at the University of Bamberg, Germany, for their friendship, support, and ideas. Prof. Schüttler, chair of the Department of Anesthesiology, University of Erlangen, has been and still is one of Germany’s leading proponents of simulation based training in acute medical care. His personal support has encouraged us to pursue our goal of providing a comprehensive handbook on Human Factors for healthcare providers. On the North American side of things, the authors would like to express gratitude to the Harvard Medical School faculty members, Jeffrey B. Cooper, Daniel B. Raemer, and Jenny W. Rudolph from the Center for Medical Simulation. These three have influenced us, especially the fourth author, to do our best to be true to the scholarship of psychology and human factors while doing our best to make it accessible to the healthcare community. Simon’s contribution to the book could not have happened without their influence, support, and patience with the book writing process.

Many healthcare professionals, both physicians and nurses, have contributed to the final version of this book. Their critical review of the manuscript and their help-ful corrections added much to the clarity and understandability of our thoughts. The new edition benefitted substantially from the clinical and psychological expertise of Walter Eppich, MD, M.Ed who provided outstanding support in helping to revise Chaps 9, 10, 12 and 14. As with the earlier edition we are also indebted to the very practical assistance of Alina Lazar MD and D. Jonathan Bernardini MD, who were both anesthesia residents at Harvard Medical School for editing the case studies.

Last not least our families have contributed considerably to the success of our work: thank you to Ulrike St.Pierre, Michael Brenner, Diane Simon, and to twelve children and eight delightful grandchildren who, all-in-all, make our lives so much richer.

March 2011Erlangen Michael St.PierreRemseck Gesine HofingerBerlin Cornelius BuerschaperCambridge Robert Simon

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Contents

Part I Basic Principles: Error, Complexity, and Human Behavior

1 The Human Factors: Errors and Skills . . . . . . . . . . . . . . . . . . . . . . . . . 31.1 Human Factors in Healthcare: The Problem . . . . . . . . . . . . . . . . . . . 51.2 Levels of Human Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

1.2.1 The Individual . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81.2.2 The Team . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81.2.3 The Organization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91.2.4 The Health Care System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

1.3 Errors in Acute Patient Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91.3.1 Errors in the Prehospital Emergency Medical Service . . . . . . 101.3.2 Errors in the Emergency Department. . . . . . . . . . . . . . . . . . . . 121.3.3 Errors in the Intensive Care Unit . . . . . . . . . . . . . . . . . . . . . . . 131.3.4 Errors in Anesthesia and Postoperative Patient Care . . . . . . . . 15

1.4 The Human Factors: Skills for Acute Patient Care . . . . . . . . . . . . . . 151.5 “The Human Factors”: In a Nutshell . . . . . . . . . . . . . . . . . . . . . . . . . 18References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

2 The Challenge of Acute Healthcare . . . . . . . . . . . . . . . . . . . . . . . . . . . . 232.1 Medical Emergencies and Critical Situations . . . . . . . . . . . . . . . . . . 252.2 Complexity and Human Behavior . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

2.2.1 Complexity: A Characteristic of the Task Environment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

2.2.2 Complexity: An Obstacle for Solving Problems for the Decision Maker . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

2.3 Tackling Complexity: Becoming an Expert. . . . . . . . . . . . . . . . . . . . 322.4 The Skills, Rules, Knowledge (SRK) Framework:

Progression Toward Expert Status . . . . . . . . . . . . . . . . . . . . . . . . . . . 352.4.1 Skill-Based Behavior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 352.4.2 Rule-Based Behavior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 362.4.3 Knowledge-Based Behavior and Problem-Solving . . . . . . . . . 37

2.5 “The Challenge of Acute Medical Care”: In a Nutshell . . . . . . . . . . 37References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

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3 The Nature of Error. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 413.1 What Is an “Erorr”? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

3.1.1 Person-Based Approach. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 433.1.2 System-Based Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

3.2 How Can Errors Be Classified? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 453.2.1 Execution Failure Versus Planning Failure . . . . . . . . . . . . . . . 453.2.2 Errors in Problem-Solving . . . . . . . . . . . . . . . . . . . . . . . . . . . . 473.2.3 Active Errors Versus Latent Conditions. . . . . . . . . . . . . . . . . . 483.2.4 Errors in Teamwork . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

3.3 Proficiency and Probability of Error . . . . . . . . . . . . . . . . . . . . . . . . . 503.4 Violations and Migrations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

3.4.1 Violations and Abnormal Routines . . . . . . . . . . . . . . . . . . . . . 513.4.2 Remedial Strategies for Errors and Violations. . . . . . . . . . . . . 53

3.5 The Dynamics of Accident Causation . . . . . . . . . . . . . . . . . . . . . . . . 543.5.1 A Window of Opportunity for Errors. . . . . . . . . . . . . . . . . . . . 543.5.2 Keeping the Balance: Systemic View

and Personal Responsibility . . . . . . . . . . . . . . . . . . . . . . . . . . . 563.6 “The Nature of Error”: In a Nutshell . . . . . . . . . . . . . . . . . . . . . . . . . 57References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58

4 The Psychology of Human Action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 614.1 The “Psycho-Logic” of Cognition,

Emotions, and Motivation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 634.2 Principles of Human Behavior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63

4.2.1 Bio-Psychosocial Foundations of Behavior . . . . . . . . . . . . . . . 644.2.2 Action. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64

4.3 Motivation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 674.3.1 From Needs to Intention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 674.3.2 “Overall Competence Assessment”

and the Need for Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 694.4 Emotions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71

4.4.1 What Are Emotions and Feelings?. . . . . . . . . . . . . . . . . . . . . . 714.4.2 Emotions and Human Action Regulation . . . . . . . . . . . . . . . . 72

4.5 Knowledge, Memory, and Learning. . . . . . . . . . . . . . . . . . . . . . . . . . 744.5.1 Knowledge and Schemata . . . . . . . . . . . . . . . . . . . . . . . . . . . . 744.5.2 Memory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 754.5.3 Learning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 764.5.4 Thinking. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 774.5.5 Metacognition: Thinking About Thinking. . . . . . . . . . . . . . . . 77

4.6 Hazardous Attitudes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 784.7 “Principles of Human Behavior”:

In a Nutshell . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81

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Part II Individual Factors of Behavior

5 Human Perception: The Way We See Things . . . . . . . . . . . . . . . . . . . 855.1 From Stimulus to Sensation: Sensory Physiology . . . . . . . . . . . . . . 875.2 From Sensation to Consciousness: Basic

Concepts of Memory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 895.2.1 Short-Term Memory or Working Memory . . . . . . . . . . . . . . 895.2.2 Long-Term Memory (LTM). . . . . . . . . . . . . . . . . . . . . . . . . . 92

5.3 “Gestalt” Theory and Meaningful Patterns: The Organization of Visual Perception . . . . . . . . . . . . . . . . . . . . . . 925.3.1 Hypothesis-Based Perception . . . . . . . . . . . . . . . . . . . . . . . . 945.3.2 Hypotheses Are Knowledge Dependent . . . . . . . . . . . . . . . . 95

5.4 Recognition and Creating Meaning . . . . . . . . . . . . . . . . . . . . . . . . . . 975.4.1 That’s So Typical! Expectancies . . . . . . . . . . . . . . . . . . . . . . 97

5.5 Perception and Emotion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 985.6 Tips for Clinical Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 985.7 “Perception” in a Nutshell . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99

6 Information Processing and Mental Models: World Views . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1016.1 The Organization of Knowledge: Schemata

and Mental Models. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1036.2 Are We Too Lazy to Think? Economy, Competence,

and Safety. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1056.2.1 Too Lazy to Think: Resource Protection . . . . . . . . . . . . . . . . 1056.2.2 Beware of Drowning! Guarding the Feeling

of Competence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1066.2.3 Certainty and Order: The Avoidance

of Ambiguity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1076.3 Wishful Thinking and Reality: Distortion

of Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1076.3.1 Biased Search for Information . . . . . . . . . . . . . . . . . . . . . . . . 1086.3.2 Distortion and Suppression . . . . . . . . . . . . . . . . . . . . . . . . . . 1086.3.3 Minimum Acquisition of Information . . . . . . . . . . . . . . . . . . 108

6.4 Filling in the Blanks: Inadequate Mental Models . . . . . . . . . . . . . . 1096.4.1 Fixation Error: Maintaining Mental

Models Despite the Evidence. . . . . . . . . . . . . . . . . . . . . . . . . 1096.4.2 A Simple Mental Model About Complex Problems . . . . . . . 1106.4.3 Knowledge Errors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110

6.5 Probabilities, Ambiguity, and Risk . . . . . . . . . . . . . . . . . . . . . . . . . 1116.5.1 Assessment of Probability: Rules of Thumb

for Everyday Life . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113

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6.5.2 Problems in Dealing with Probabilities . . . . . . . . . . . . . . . . . 1156.5.3 No Risk, No Fun? How to Deal with Risk. . . . . . . . . . . . . . . 116

6.6 Tips for Clinical Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1176.6.1 Some Advice on Information Processing

and Mental Models. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1176.6.2 Some Advice on Risk Taking. . . . . . . . . . . . . . . . . . . . . . . . . 118

6.7 “Information Processing and Mental Models”: In a Nutshell . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119

7 Goals and Plans: Turning Points for Success . . . . . . . . . . . . . . . . . . . 1217.1 Setting and Elaboration of Goals . . . . . . . . . . . . . . . . . . . . . . . . . . . 123

7.1.1 What Is a Good Goal? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1247.1.2 Problems with Setting Goals . . . . . . . . . . . . . . . . . . . . . . . . . 126

7.2 Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1297.2.1 Appropriate Planning in Complex Situations . . . . . . . . . . . . 1307.2.2 Mistakes and Problems with Planning . . . . . . . . . . . . . . . . . . 131

7.3 Tips for Clinical Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1337.3.1 Goals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1337.3.2 Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134

7.4 “Plans and Goals”: In a Nutshell . . . . . . . . . . . . . . . . . . . . . . . . . . . 134References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135

8 Attention: The Focus of Consciousness . . . . . . . . . . . . . . . . . . . . . . . . 1378.1 The Control of Action: Attention, Vigilance,

and Concentration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1388.1.1 Attention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1398.1.2 Vigilance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1418.1.3 Concentration. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1428.1.4 Divided Attention. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1428.1.5 Attentional Capacity: A “Bucket Theory” . . . . . . . . . . . . . . . 143

8.2 Open for News: Background Control and the Horizon of Expectations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143

8.3 Situation Awareness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1458.4 Disturbances of Attention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146

8.4.1 “Rien ne va plus”: Fatigue . . . . . . . . . . . . . . . . . . . . . . . . . . . 1468.4.2 I’d Rather Be in Bed: Sleepiness and Sleep. . . . . . . . . . . . . . 1478.4.3 Nothing to Do: Monotony . . . . . . . . . . . . . . . . . . . . . . . . . . . 1508.4.4 Tightly Focused: Too Much Concentration

and Missing Background Control . . . . . . . . . . . . . . . . . . . . . 1518.5 Tips for Clinical Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1518.6 “Attention” in a Nutshell . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152

9 Stress . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1559.1 What Is Stress?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157

9.1.1 When Does Stress Start? It’s a Matter of Appraisal! . . . . . . . 1579.1.2 The Stress Response: Fight or Flight . . . . . . . . . . . . . . . . . . . 159

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9.1.3 Chronic Stress . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1639.1.4 Moderate Stress Can Boost Performance. . . . . . . . . . . . . . . . 165

9.2 Stress Outside the Normal Range . . . . . . . . . . . . . . . . . . . . . . . . . . 1669.2.1 Overwhelmed: The Cognitive Emergency Reaction . . . . . . . 1669.2.2 Devastated: Post-traumatic Stress Disorder (PTSD) . . . . . . . 167

9.3 Teams Under Pressure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1699.4 Coping Mechanisms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169

9.4.1 Emotion-Focused Coping Mechanism: Yelling at People? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170

9.4.2 Cognitive Coping Mechanism: Try to See Things Differently! . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171

9.4.3 Resilience: A Fourfold Strategy. . . . . . . . . . . . . . . . . . . . . . . 1719.4.4 Leading Teams Out of Stress . . . . . . . . . . . . . . . . . . . . . . . . . 174

9.5 The Role of Organizations in Reducing Stress . . . . . . . . . . . . . . . . 1749.6 “Stress”: In a Nutshell . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176

10 Strategies for Action: Ways to Achieve Good Decisions. . . . . . . . . . . 17910.1 Strategies for Good Actions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180

10.1.1 Making Decisions Naturally: “Dual-Process” Theory . . . . . . . . . . . . . . . . . . . . . . . . . . . 180

10.1.2 “Good Decisions” in the High-Stakes Environment of Acute Medical Care . . . . . . . . . . . . . . . . . 182

10.1.3 Maximum “Efficiency and Divergence” . . . . . . . . . . . . . . 18310.1.4 Five Steps of a Good Strategy . . . . . . . . . . . . . . . . . . . . . . 18410.1.5 Decisional Aids . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185

10.2 Strategies for Coping with Error . . . . . . . . . . . . . . . . . . . . . . . . . . 18810.2.1 Detect Errors Early. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18810.2.2 Mitigate the Effects of Errors . . . . . . . . . . . . . . . . . . . . . . . 189

10.3 Tips for Clinical Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19010.4 “Strategies for Action”: In a Nutshell . . . . . . . . . . . . . . . . . . . . . . 191References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 192

Part III The Team

11 The Key to Success: Teamwork . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19511.1 The Team . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197

11.1.1 Why Teamwork Has Come into Focus Only Lately . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197

11.1.2 Why Teamwork Is Necessary. . . . . . . . . . . . . . . . . . . . . . . 19811.1.3 What Is a Team?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20011.1.4 The Strength of Teamwork. . . . . . . . . . . . . . . . . . . . . . . . . 200

11.2 Team Performance: Input Factors . . . . . . . . . . . . . . . . . . . . . . . . . 20111.2.1 Individual Characteristics. . . . . . . . . . . . . . . . . . . . . . . . . . 20111.2.2 Team Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20311.2.3 Task Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20411.2.4 Characteristics of the Performance Environment. . . . . . . . 205

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11.3 Team Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20611.3.1 Team Formation and Positive Working Climate . . . . . . . . 20611.3.2 Establish Team Leadership. . . . . . . . . . . . . . . . . . . . . . . . . 20611.3.3 Solve Conflicts in a Constructive Way . . . . . . . . . . . . . . . . 20711.3.4 Communicate and Share Your Mental Models . . . . . . . . . 20811.3.5 Coordinate Task Execution. . . . . . . . . . . . . . . . . . . . . . . . . 20911.3.6 Cross-Monitor Teammates . . . . . . . . . . . . . . . . . . . . . . . . . 20911.3.7 Share Workload and Be Mindful

of Performance Limits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21011.3.8 Apply Problem-Solving Strategies. . . . . . . . . . . . . . . . . . . 21011.3.9 Improve Teamwork Skills . . . . . . . . . . . . . . . . . . . . . . . . . 210

11.4 Why Teamwork Can Go Wrong . . . . . . . . . . . . . . . . . . . . . . . . . . 21111.4.1 Deficits of the Individual . . . . . . . . . . . . . . . . . . . . . . . . . . 21311.4.2 Deficits of the Team . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213

11.5 Tips for Daily Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21611.6 “Teamwork”: In a Nutshell . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 218

12 Speech is Golden: Communication. . . . . . . . . . . . . . . . . . . . . . . . . . . . 22112.1 Organizing the Chaos: Functions of Communication . . . . . . . . . . 223

12.1.1 Building and Maintaining Team Structure . . . . . . . . . . . . . 22312.1.2 Coordinating Team Process and Task Execution . . . . . . . . 22312.1.3 Enabling Information Exchange. . . . . . . . . . . . . . . . . . . . . 22412.1.4 Facilitating Relationships . . . . . . . . . . . . . . . . . . . . . . . . . . 224

12.2 Understanding Communication . . . . . . . . . . . . . . . . . . . . . . . . . . . 22512.2.1 Basic Assumptions About Communication . . . . . . . . . . . . 22512.2.2 Sources and Squares: Theories of Communication . . . . . . 22612.2.3 It’s Not What You Say, It’s the Way You Say It:

Nonverbal and Paraverbal Communication . . . . . . . . . . . . 23112.3 General Disturbance of Communication . . . . . . . . . . . . . . . . . . . . 231

12.3.1 Misunderstanding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23212.3.2 Relational Problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 233

12.4 Poor Communication in Critical Situations . . . . . . . . . . . . . . . . . . 23512.4.1 Unspecified Receiver . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23512.4.2 Problems with Speech: Articulation and Terms. . . . . . . . . 23612.4.3 Information Overload . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23612.4.4 Becoming Tight-Lipped . . . . . . . . . . . . . . . . . . . . . . . . . . . 23612.4.5 “Resolving” Conflicts by Passivity

or Aggressiveness. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23712.4.6 Poor Listening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23712.4.7 Mingling Relational and Content Components . . . . . . . . . 23812.4.8 Clarifying Relationships at the Wrong Time . . . . . . . . . . . 239

12.5 Safe Communication in Critical Situations . . . . . . . . . . . . . . . . . . 23912.5.1 Give Luck a Bit of a Boost . . . . . . . . . . . . . . . . . . . . . . . . . 23912.5.2 Communicate Congruently . . . . . . . . . . . . . . . . . . . . . . . . 23912.5.3 Select the Same Aspects of a Message. . . . . . . . . . . . . . . . 240

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12.5.4 Raise the Issue of Communication Failure. . . . . . . . . . . . 24012.5.5 Speak Unambiguously, Avoid Ambiguity . . . . . . . . . . . . 24112.5.6 Close the Communication Loop. . . . . . . . . . . . . . . . . . . . 24112.5.7 Brief Team Members . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24112.5.8 Search Actively for Information. . . . . . . . . . . . . . . . . . . . 24212.5.9 Advocacy, Assertion, and the

Two-Challenge Rule. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24212.5.10 Listen Actively . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24512.5.11 Address Conflict in a Constructive Way. . . . . . . . . . . . . . 24612.5.12 Don’t Forget to Debrief and to Give Feedback . . . . . . . . 247

12.6 Tips for Daily Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24812.7 “Communication”: In a Nutshell . . . . . . . . . . . . . . . . . . . . . . . . . . 248References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 250

13 Leadership . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25313.1 The Case for Leadership . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 255

13.1.1 Leadership in Everyday Life . . . . . . . . . . . . . . . . . . . . . . . 25613.1.2 Leadership in a Critical Situation. . . . . . . . . . . . . . . . . . . . 257

13.2 Leadership Theories. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25713.2.1 Approaches to Leadership . . . . . . . . . . . . . . . . . . . . . . . . . 25713.2.2 “Great Man” Theories . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25813.2.3 Trait Theories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25813.2.4 Behavioral Theories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25913.2.5 Situational and Contingency Theories . . . . . . . . . . . . . . . . 25913.2.6 Shared Leadership Theory . . . . . . . . . . . . . . . . . . . . . . . . . 260

13.3 A Conceptual Framework for Leadership. . . . . . . . . . . . . . . . . . . . 26013.3.1 Leadership Personality . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26013.3.2 Leadership Behavior. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26113.3.3 Leadership Situation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26313.3.4 Leadership Success . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 263

13.4 Leadership Tasks in a Critical Situation . . . . . . . . . . . . . . . . . . . . . 26313.4.1 Organize the Team, Encourage, Promote,

and Facilitate Good Teamwork . . . . . . . . . . . . . . . . . . . . . 26413.4.2 Apply Problem-Solving Strategies Verbally . . . . . . . . . . . 26513.4.3 Articulate Clear Goals . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26513.4.4 Make Decisions Through Collective Input

of Team Members. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26513.4.5 Delegate and Coordinate Task Execution. . . . . . . . . . . . . . 26613.4.6 Monitor Workload Balance Within

and Across Teams. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26713.4.7 Reevaluate the Situation Regularly and Verbally . . . . . . . . 267

13.5 Leadership Problems in Critical Situations. . . . . . . . . . . . . . . . . . . 26713.5.1 Without a Leader: When Nobody

Shows the Way . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26813.5.2 Misled into Action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26813.5.3 Tasks Executed? Failure to Monitor. . . . . . . . . . . . . . . . . . 268

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13.5.4 Strain: Leadership and Emotional Pressure . . . . . . . . . . . . 26913.5.5 Change in Leadership: Change in Function . . . . . . . . . . . . 26913.5.6 “I’m in the Driver’s Seat!”:

Leadership and Power . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26913.5.7 “There Is Only Room for One of Us!”:

Conflicts Among Coequals. . . . . . . . . . . . . . . . . . . . . . . . . 27013.5.8 Handing Over Responsibility:

The “Revolving-Door” Effect . . . . . . . . . . . . . . . . . . . . . . 27013.5.9 Invulnerable: Immunization Against Criticism . . . . . . . . . 270

13.6 Situational Leadership . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27113.7 Tips for Daily Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27213.8 “Leadership”: In a Nutshell . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 273References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 273

Part IV The Organization

14 Organizations and Accidents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27914.1 Organizations as Systems: Different Perspectives . . . . . . . . . . . . . 28114.2 Organizations, Human Error, Reliability, and Ultrasafety . . . . . . . 283

14.2.1 Human Factors Engineering Approach . . . . . . . . . . . . . . . 28314.2.2 Normal Accident Theory . . . . . . . . . . . . . . . . . . . . . . . . . . 28414.2.3 High Reliability Theory . . . . . . . . . . . . . . . . . . . . . . . . . . . 28514.2.4 Ultrasafe Systems. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 287

14.3 Organizational Sources of Error. . . . . . . . . . . . . . . . . . . . . . . . . . . 28914.3.1 Key Systems Issues for Addressing Error

and Safety in Acute Medical Care . . . . . . . . . . . . . . . . . . . 28914.3.2 Structures and Processes . . . . . . . . . . . . . . . . . . . . . . . . . . 29114.3.3 Medical Equipment-Related Incidents . . . . . . . . . . . . . . . . 29214.3.4 Human Resource Management . . . . . . . . . . . . . . . . . . . . . 294

14.4 “Organizations and Accidents”: In a Nutshell . . . . . . . . . . . . . . . . 296References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 296

15 Reliable Acute Care Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29915.1 Organizations Devoted to Safety . . . . . . . . . . . . . . . . . . . . . . . . . . 30115.2 Safety Culture: The DNA for Safety . . . . . . . . . . . . . . . . . . . . . . . 302

15.2.1 What Is Safety Culture? . . . . . . . . . . . . . . . . . . . . . . . . . . . 30215.2.2 Safety Culture and Safety Climate . . . . . . . . . . . . . . . . . . . 30315.2.3 The Development of Safety Culture. . . . . . . . . . . . . . . . . . 30415.2.4 Safety Culture Is an Informed Culture . . . . . . . . . . . . . . . . 30815.2.5 Organizational Theories and Safety Culture . . . . . . . . . . . 308

15.3 Paths Leading to Safety Error Avoidance, Error Management, and Learning . . . . . . . . . . . . . . . . . . . . . . . . . 309

15.4 Proactive Clinical Risk Management: Use Your Imagination . . . . 31015.5 Optimizing Skills: Training and Qualification. . . . . . . . . . . . . . . . 311

15.5.1 Simulation-Based Education and Crisis Resource Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . 311

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15.5.2 Formal Teamwork Training Interventions. . . . . . . . . . . . . 31415.5.3 Quality Assurance and Continuous

Quality Improvement . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31515.6 Error Avoidance: Standards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 317

15.6.1 Standard Operating Procedure . . . . . . . . . . . . . . . . . . . . . 31715.6.2 Standardization of Communication. . . . . . . . . . . . . . . . . . 31815.6.3 Tool with Untapped Potential: Checklists. . . . . . . . . . . . . 318

15.7 Learning (in) Organizations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32115.7.1 More Than Learning Individuals:

Organizational Learning . . . . . . . . . . . . . . . . . . . . . . . . . . 32115.7.2 Single-Loop, Double-Loop, and Deutero Learning . . . . . 32315.7.3 The Importance of Teamwork

in Organizational Learning . . . . . . . . . . . . . . . . . . . . . . . . 32415.7.4 A Learning Tool: Debriefing. . . . . . . . . . . . . . . . . . . . . . . 325

15.8 Learning from Incidents: Critical Incident Reporting and Accidents Analysis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32615.8.1 Incident Reporting System:

How to Make It Work . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32715.8.2 Characteristics of an Incident

Reporting System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32815.8.3 System Analysis of Accidents. . . . . . . . . . . . . . . . . . . . . . 331

15.9 Sharing Knowledge for Safety: Approaches to Knowledge Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 331

15.10 “Reliable Acute Care Medicine”: In a Nutshell . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 334

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 335

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 341