Published 9/1/2007
Stephen A. Albanese, MD

From the cockpit to the OR

Crew resource management: A model for orthopaedics?

Human beings make mistakes, but systems play a role as well. Poorly designed systems frequently lead people to make errors or—at minimum—fail to prevent them.

That was one of the conclusions of the 1999 Institute of Medicine report, To Err is Human: Building a Safer Health System, which raised awareness of the significant consequences of medical errors.

As in medicine, errors in the high-stress aviation environment can result in serious harm to the public. For this reason, successful error-prevention strategies implemented in the aviation industry are increasingly used as models in developing patient safety strategies in medicine.

Crew resource management
“Crew resource management” (CRM) training evolved out of a 1979 NASA workshop convened to evaluate the causes of aviation mishaps.1 Human error was found to be the primary cause of most aviation accidents. Failures of interpersonal communication, leadership, and decision making in the cockpit were identified as significant contributing factors.2

CRM training, therefore, emphasizes the role of human factors in high-stress, high-risk environments. The training encompasses a wide range of knowledge, skills, and attitudes including communications, situational awareness, problem solving, decision making, and teamwork.

Various CRM models—all based on the same basic concepts and principles identified in the NASA workshop—have since been successfully adapted to different industries and organizations. Over the past 20 years, these principles have gradually been incorporated into various components of the healthcare system.

Striking parallels
So how do aviation-based safety practices apply to the healthcare setting? Many striking parallels exist between the cockpit and the operating room (OR) or emergency department (ED). For example, flight crews and physicians and other healthcare providers are highly trained professionals working in complex and technically demanding situations. In both settings, routine decisions have life-and-death consequences, and team members are sometimes strangers. In both the cockpit and the OR, a lead professional sets the tone of the team’s work. And in both places, fatigue and routine are the enemies of precision.

Teaming up for safety
In orthopaedics, the composition of the “team” may vary, depending on the specific environment and needs. In the OR environment, team members frequently include surgical technicians, nurses, anesthesiologists, and surgeons.

To be effective, the CRM model relies on a system of cross-monitoring by members of the healthcare team. Effective communication is essential if CMR is to improve patient safety. Any member of the team—regardless of his or her level in the organization—must feel comfortable raising questions or concerns without hesitation.3

When a team member’s question or concern is obviously valid—as in the situation described in the accompanying sidebar—solutions can be implemented to address the identified concerns. When the best course of action remains in question, however, a mechanism for rapid conflict resolution is imperative, particularly in fast-paced, stressful environments such as ORs and EDs.

AAOS: A leader in patient safety
Over the past decade, CRM has been implemented in high-risk healthcare disciplines such as obstetrics, intensive care, and emergency medicine. The Joint Commission also recommends implementation of team training as part of patient safety education.

During this time, the AAOS has emerged as a nationally recognized leader in the advancement of patient safety. The “Sign Your Site” campaign led by former AAOS president S. Terry Canale, MD, has been embraced by the Joint Commission, which identified signing the site as one of its quality goals beginning in 2003.

The Academy also played a significant role in the Joint Commission’s May 2003 summit to develop a “Universal Protocol” to avoid wrong-site, wrong-procedure, and wrong-patient surgery.4 Throughout his 2003-2004 term as Academy president, James H. Herndon, MD, promoted AAOS patient safety efforts and participated in the press conference announcing the endorsement of the Universal Protocol by more than 40 professional medical organizations.

Communication is key to patient safety
When addressing patient safety issues, the importance of effective communication cannot be underestimated. “Active involvement and effective communication among all members of the surgical team is important for success” is one of the principles endorsed by the Joint Commission in developing the Universal Protocol. In addition, the “time-out” that is required immediately before starting a procedure is completely dependent on effective communication among all members of the operating team. A breakdown in this system—including the reluctance of a team member to voice a concern—can result in significant negative consequences for the patient.

Although technologic advances such as computerized order entry systems have been effective in reducing errors, they tend to deemphasize the important personal communication aspects of healthcare delivery.

The principles of CRM are sound, but the extent to which the model should be formally implemented in a healthcare system remains open to debate. The impact of process changes is difficult to measure. For example, the literature shows that formal training results in consistent improvements in communication, but the actual impact on patient outcomes is not as apparent. Any decisions regarding implementation of CRM concepts and training must be made collaboratively, involving the administrative lines of each environment.

The methods used to implement and evaluate workshops or training on CRM fundamentals must be tailored to the specific organization. In settings where formal training is not feasible, the basic concepts of CRM can easily be implemented to positive effect. Facilitating open communication among the team, for instance, creates a more pleasant work environment, encourages team members to be more invested in the outcome, and improves the organization’s effectiveness.

Surgeons must take the lead
The CRM model does not in any way diminish the leadership role of the orthopaedic surgeon. In fact, it underscores the importance of that role. As in aviation, in which there is one responsible commanding officer, the physician is the ultimate decision maker in most clinical environments. This does not preclude increased involvement of other team members or the creation of a positive work environment that encourages the free exchange of concerns in a nonthreatening manner.

Crew resource management should help our profession achieve what is now being called “the high-reliability OR,” in which the frequency of all types of adverse events is markedly reduced. The evaluation and, when appropriate, adoption of strategies to promote patient safety must remain a priority in the constantly evolving practice of orthopaedic surgery.

Dr. Albanese is the Council on Education representative to the AAOS Patient Safety Committee. He may be reached at albaness@upstate.edu.

Talking “up the chain”
Effective communication requires that any team member must feel comfortable in raising questions or concerns. Because a junior or subordinate team member may be hesitant to speak up, crew resource management expert Todd Bishop of the Error Prevention Institute developed the following five-step assertive statement process to help junior team members feel confident talking “up the chain of command.”

  • Get the person’s attention: “Dr. Smith.”
  • State your concern: “I’m very concerned that we’re preparing the wrong leg for surgery.”
  • State the problem as you see it: “The X-rays and your initials indicate the right knee, but the left knee is being scrubbed.”
  • Propose a solution: “I think we should call a time-out and verify the site.”
  • Obtain agreement (or buy-in): “Do you agree, doctor?”


  1. Cooper GE, White MD, Lauber JK (eds): Resource management on the flight deck: Proceedings of a NASA/Industry workshop held at San Francisco, California, June 26-28, 1979. NASA Conference Publication 2120, March 1980.
  2. Helmreich RL, Merritt AC, Wilhelm JA: The evolution of Crew Resource Management training in commercial aviation. Int J Aviat Psychol 1999;9:19-32.
  3. Oriol MD: Crew resource management: Applications in healthcare organizations. J Nurs Adm 2006;36:402-406.
  4. Joint Commission Web site (http://www.jointcommission.org). Accessed September 7, 2007.