Published 7/1/2011
Dirk H. Alander, MD; Robert Brooks, MD, PhD, MBA; David B. Carmack, MD; Col. Joseph Legan, MD

Improve surgical safety by using CRM

Crew (team) resource management and the orthopaedic surgeon

Safety in the medical field has been a much debated topic since the late 1990s, due to a continuing and unacceptably large number of preventable medical errors. The traditional drivers for improving outcomes—retrospective analyses of morbidity and mortality—were insufficient to address the impact of technology and the explosion of diagnostic and treatment options. The publication of “Error in Medicine” by Lucien Leape in 1995 and the 1999 Institute of Medicine report To Err is Human: Building a safer health system triggered the modern patient safety movement.

Orthopaedics and patient safety
The AAOS promotes patient safety through ongoing patient safety alerts, robust public relations campaigns, and safety advocacy projects. One of the Academy’s most notable safety campaigns was the “Sign Your Site” program to reduce wrong-site surgeries.

In orthopaedics, technology—in particular, advances that support treatment for musculoskeletal injuries and that enable surgeons to perform complex surgeries using a variety of implants—has strained operating room personnel and hospital systems. As general awareness of preventable errors increases, and as the federal government focuses on the costs of these errors, physicians will have to respond by driving improvements in patient safety.

Strategies to improve patient safety have included standardization of medical equipment; the establishment of protocols and checklists; and, recently, attempts to use crew resource management in the operating room. The goal of these diverse approaches to safety is to optimize patient care while minimizing preventable error. Ultimately, surgeons must create and sustain a culture of safety that puts all available resources to work in preventing and mitigating errors.

Applying lessons from aviation
Many similarities between the aviation industry in the late 1970s and early 1980s and medicine over the past decade can be found. In both professions, the number of complex systems that needed to be used correctly and efficiently to complete the job without problems increased rapidly. In aviation, the interdependence of crew members and the communication between them are critical for a successful flight, just as interdependence and communication among surgical staff are critical for a successful outcome.

The impact of aviation accidents resulting from crew error not only commanded media attention but also prompted steps to minimize preventable errors. A crash between two jumbo jets that resulted in the deaths of 583 people in 1977 brought the issue to a head. The post-crash investigation highlighted the lack of effective communication among the crew, captain, and air traffic control. The authoritarian and hierarchical culture in the cockpit was seen as significantly impeding effective communication, resulting in poor decision-making and the subsequent tragedy.

As a result, the aviation industry developed a strategy known as crew resource management (CRM). A critical aspect of CRM is the ability to maximize the available resources, facilitating communication among crew members and leading to improved decision-making in the cockpit. This change in aviation culture required the flattening of the social hierarchy and a shift in the authoritarian nature of captains and pilots.

Initially, airline pilots resisted this “new” culture of communication and crew interaction, not because they opposed the goal of safety, but because they didn’t want to give up the authoritarian and hierarchical nature of their position. It took a decade before CRM was fully integrated into airline training programs.

In medicine today, surgeons—like the airline pilots decades ago—have a strong authoritarian and hierarchical structure with a centralized and often isolated command. Such a structure does not create an appropriate environment for reliably managing complex systems.

CRM in the operating room
A major cause of adverse events in medicine is a failure of communication. In the operating room, various professions (surgeons, anesthesiologists, nurses, technicians) must interact closely and constantly across multiple levels of social and economic strata. This requires clear, concise communication. CRM provides a series of tools to improve that communication, enabling the operating surgeon and the surgical team to make well-informed decisions.

A fundamental aspect of CRM is empowering team members to cross check each other’s actions and to seek clarity when a potential problem emerges. Everyone on the team needs to understand the intentions and actions of the others and the necessary procedures for reaching a good outcome. The surgeon may know what he or she wants, but the outcome depends to a significant extent on everyone else’s knowing and understanding what is being done, what their responsibilities are, and how to facilitate the team’s actions.

The core structural phases of CRM in the surgical setting include a pre-operating room review, preoperative briefing/time out in the operating room, and debriefing after the surgery is completed. Each category includes must-do action items (tailored to the needs of the local medical system) that are necessary to complete. The overriding principle in all phases of surgical care is the need to freely communicate important information among team members for the patient’s ultimate benefit.

Standardized procedures
Consistent use of standardized procedures allow for cross checking and verification of intentions. Checklists reinforce that standardization and provide a method of confirming vital information. The Joint Commission’s Universal Protocol should be an integral part of these lists.

Checklists demand engagement and focus by the operating room personnel. Other activities in the operating room should be suspended or minimized while the checklist reviewer moves through the list.

A “white board” (Fig. 1) with checklist information is useful to cue and direct focused conversation among the members of the surgical team. The goal is to actively engage all those involved in the procedure and ensure open lines of communication.

Standard language and checklist items promote understanding by avoiding vague or confused information. Communication can be as simple as a quick reminder or question; regardless of the form used, a confirmation should be expected, indicating that the information has been received. If the intended recipient does not appear to clearly understand the message, a “read back” request can help provide assurance that the communication was received. Unfortunately, information received may not mean it is understood.

When action is expected or required, using a standardized sequence of information such as SBAR (Situation, Background, Assessment, and Recommendation) is appropriate. Making this a habit results in organized and succinct communication, especially under potentially stressful conditions.

One more strategy may be useful, especially when it becomes clear that the patient is at risk because of something being overlooked, misapplied, or forgotten. This is the time for “CUSsing.” No, not profanity, just CUS: first, express CONCERN, then show or tell why you are UNCOMFORTABLE, and finish by emphasizing the SAFETY of the patient. It should get everyone’s attention and a complaint about that sort of CUSsing is unlikely.

A culture shift occurs in the traditional operating room when CRM is employed and the team as a whole becomes accountable for the successful outcome of the surgery. Individual team members are responsible for their own job AND for the outcome of the surgical procedure as a whole. The entire team shares the responsibility for outcomes, providing an impetus for the vigilance needed to see and avoid errors. The knowledge gained by knowing the patient, the plan, and the expectations can drive an increased situational awareness, making it easier to break a potential chain of errors that could otherwise lead to a harmful event.

Dirk H. Alander, MD; Robert Brooks, MD, PhD, MBA; David B. Carmack, MD; and Col. Joseph Legan, MD, have served on the AAOS Patient Safety Committee and presented a symposium on “Crew Resource Management (CRM): The Orthopaedic Surgery Perspective. “Where are we and how did we get here?” during the 2008 AAOS Annual Meeting.

Editor’s Note: This is the first of two articles focusing on crew resource management (CRM). Next month, the authors will discuss the implementation of CRM in both military and civilian settings.


  1. Wachter RM: Understanding Patient Safety. New York, McGraw-Hill, 2008.
  2. Moser RH: Diseases of Medical Progress: A Contemporary Analysis of Illnesses Produced by Drugs and Other Therapeutic Procedures. Springfield, IL, Charles C. Thomas, 1959.
  3. Womack JP, Jones DT, Roos D: The Machine That Changed the World, 1st HarperPerennial ed., HarperCollins Publishers, 1991.
  4. Leape LL: Error in Medicine. JAMA 1994;272(23):1851-1857.
  5. Kohn LT, Corrigan JM, Donaldson MS, Committee on Quality of Health Care in America (eds): To Err is Human: Building a Safer Health System. Institute of Medicine, Washington, DC, National Academies Press, 2000.
  6. Reason J: Human Error. Cambridge, UK, Cambridge University Press, 1990, p173.
  7. Reason J: Human error: Models and management. BMJ 2000;320(7237):768-770.
  8. Sutcliffe KM, Lewton E, Rosenthal MM: Communication failures: An insidious contributor to medical mishaps, Acad Med 2004;79(2):186-194.
  9. Gawande AA, Zinner MJ, Studdert DM, Brennan TA: Analysis of errors reported by surgeons at three teaching hospitals, Surgery 2003;133(6):614-621.
  10. Wong DA, Herndon JH, Castillo-Watkins S, et al: Medical errors in orthopaedics: Results of an AAOS member survey. Paper #84, American Academy of Orthopaedic Surgeons 78th Annual Meeting, Feb 25-27,2009.
  11. Guerlain S, Turrentine FE, Bauer D, Calland J, Adams R: Crew resource management training for surgeons: Feasibility and impact. Cogn Tech Work 2008;10;255-264.
  12. Karl RC: Staying safe: Simple tools for safe surgery. Bull Am Coll Surg 2007;92(4):16-22.
  13. Haynes AB, Weiser TG, Berry WR, et al: A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 2009:360(5):491-499.
  14. Lingard L, Regehr G, Orser B, et al: Evaluation of a preoperative checklist and team briefing among surgeons, nurses, and anesthesiologists to reduce failures in communication. Arch Surg 2008;143(1):12-17.
  15. Pratt SD, Mann S, Salisbury M, et al: John M. Eisenberg Patient Safety and Quality Awards: Impact of CRM-based training on obstetric outcomes and clinicians’ patient safety attitudes. Jt Comm J Qual Patient Saf 2007;33(12):720-725.
  16. Dunn EJ, Mills PD, Neily J, Crittenden MD, Carmack AL, Bagian JP: Medical team training: Applying crew resource management in the Veterans Health Administration. Jt Comm J Qual Patient Saf 2007;33(6):317-325.
  17. Paige JT, Aaron DL, Yang T, et al: Implementation of a preoperative briefing protocol improves accuracy of teamwork assessment in the operating room. Am Surg 2008;74:817-823.
  18. Nundy S, Mukherjee J, Sexton JB, et al: Impact of preoperative briefings on operating room delays: A preliminary report. Arch Surg 2008;143(11):1068-1072.
  19. Neily J, Mills PD, Young-Xu Y, et al: Association between implementation of a medical team training program and surgical mortality. JAMA 2010;304(15):1693-1700.