In 1979, a workshop sponsored by NASA entitled “Resource Management on the Flightdeck,” served as the origin of Crew Resource Management (CRM) training in the United States. The workshop was a result of NASAs research into the cause of air transport accidents, with a particular emphasis on the human error aspects surrounding these disasters. At that time, it was estimated that 70 % of air crashed involved human error rather than mechanical or weather issues [19]. The major factors scrutinized, with regards to the interaction of the flightdeck crew, were interpersonal skills, decision making, and leadership. The development of Cockpit Resource Management, therefore, had the goal of reducing “pilot errors” by improving cockpit crew’s utilization of available human resources on the flightdeck. Specifically, Cockpit Resource Management was defined as a “management system that makes optimum use of all available resources, equipment, procedures, and people to promote safety and efficiency” [19]. Effectively, the program had the goals of teaching pilots to improve communication, prioritize tasks, delegate authority, and monitor automated equipment. At the end of the this meeting, several of the major air carriers participating in the program, with United Airlines leading the CRM movement, pledged to the create programs to improve the coordination and interpersonal aspects of flight operations amongst their flight crews. Understanding, however, the importance of non-pilot team members (flight attendants, dispatchers, maintenance crews, air traffic control, etc…) the terminology of Cockpit Resource Management evolved to Crew Resource Management. Since that time, numerous CRM programs have been developed in the United States and throughout the world. In the United States, the Federal Aviation Administration has mandated that all airlines implement a CRM program within the scope of their flight operations. Charter operations in the general aviation setting have begun to adopt similar principles in the scope of their flight operations as well [20]. Indeed, the aviation industry, as a high-reliability organization tasked with the risk-laden responsibility of transporting millions of passengers across the globe every day, has many similarities with medicine. The flightdeck has often been compared to the emergency room, operating room, or intensive care unit, where trained professionals must make sound decisions in a framework of potentially stressful situations, fatigue, and overwork, responsibility, and high technology. Particularly, both industries are focused on risk reduction and place heavy emphasis on appropriate interpersonal relationships and human resources for successful completion of tasks [19].

Not surprisingly, health care providers, administrators, and quality improvement staff have been quick to endorse Crew Resource Management as a potential mechanism by which to improve healthcare team functionality and to reduce medical errors.

Recently, in a large academic center with 27 operating rooms and approximately 19,000 procedures per year, mandatory CRM training for anesthesiologists, surgeons, nurses, technicians, and OR assistants was implemented. Additionally, several aviation-based safety techniques including pre-operative checklist and brief, post-operative debrief, and reading and initializing of files was mandated, with an emphasis at looking at compliance of briefings/debriefings and the number of wrong-site surgeries and retained foreign bodies. Wrong site surgeries and retained foreign bodies decreased from a high of seven in 2007 to none in 2008, but, after 14 months without additional recurrent training, these rose to five in 2009. Indeed, these findings attest to the benefits of CRM training programs, checklists, and briefings, while also stressing the need for recurrent training of staff to maintain a high level of reliability in the perioperative setting [21].

Several studies indicate that many organizations using the team structure to achieve organizational outcomes including safety and productivity are not always effective, and could benefit from high-reliability team training taken from aviation [22]. France and colleagues illustrate an example of the integration of a CRM program in a large academic medical center committed to training its entire workforce in CRM to improve team communication and patient safety. Much like other medical establishments, the hospital called in a commercial vendor to train its clinicians and administrators in an 8-h course which included lectures, case studies, and role playing. Given that a single day of training may not be effective enough to ensure system-wide change, senior administrators and clinical leaders devised a customized CRM program for perioperative services. Post training, and after observational analysis of 30 surgical teams, the authors found that teams were compliant with only 60 % of the safety and CRM practices taught during the course. Indeed, this finding has called for further development and testing of team training methods that are acceptable in the perioperative setting [23].

McCulloch and colleagues also examined the effect of CRM training on surgical staff in a single hospital with an initial 9-h CRM session followed by 3 months of twice-weekly CRM coaching. The results of the study indicated that the CRM training improved technical performance in the OR, but that the effects of improvement varied considerably between teams. Considerable cultural resistance was encountered during the implementation of debriefing and challenging higher authority, particularly from medical staff. The authors, therefore, recommended that more research be done in determining the optimal CRM training package and exploring further the cultural barriers to implementation [24].

On a positive note, Grogan and colleagues studied the impact of CRM on the attitudes of healthcare professionals, and studied the implementation of CRM among clinical trams for the trauma unit, emergency department, perioperative services, cardiac catheterization laboratory, and hospital administration. The 489 participants were then asked to complete a End-of-Course Critique and a Human Factors Attitude Survey to assess attitudinal changes on the usefulness of CRM training. The study demonstrated significant belief in the appropriateness of CRM implementation in improvement of fatigue management, team building, communication, adverse event recognition, team decision making, and performance feedback. Participants believed that CRM training has a positive impact on their outlook and practices to reduce medical errors and reduce patient safety [25]. Another study found that over the course of 7 years, training surgical staff in Crew Resource Management improved patient safety attitudes in the perioperative setting. In an observational study of 857 perioperative staff participants trained in one of ten CRM courses, there was a significant increase in perioperative checklist use, self-initiated reports of adverse events, perceived self-empowerment, and improved perceived culture of safety [26]. Additionally, CRM training has been demonstrated to improved nurse retention and changed nurse attitudes towards teamwork in the OR, thus improving the important safety climate and contributions from an important component of the surgical team [27].

However, while CRM training has been incorporated to some extent in the healthcare setting, the training is often piecemeal and voluntary, with few systematic approaches in linking training material with conventional practice. Further work is required to identify key non-technical skills (incl. cognitive and social) required in medicine, such that CRM can appropriately be applied in various healthcare settings, particularly perioperatively. Continuing to call upon the experiences of other high-reliability organizations is critical in development and integration of an effective curriculum [28]. Hugh and colleagues examined the use of CRM techniques, error analysis, and other strategies taken from high reliability organizations such as the nuclear power and maritime industry, as a means to reducing common laparoscopic bile duct injuries. A major cause of these injuries is spatial disorientation during the surgery, analogous to navigational errors while flying in either visual or instrument conditions. A customized set of CRM and other high reliability principles were put together as a training program for laparoscopic cholecystectomy and provided to one surgery unit, which later carried out 2,000 successive laparoscopic cholecystectomies. During this time, no bile duct injuries were reported, thus supporting the potential role of CRM and system-based risk management techniques perioperatively [29].

Indeed, communication, cooperation, and coordination are vital to effective perioperative care. As such, the principles of CRM have been integrated into a team training program developed by the Department of Defense and the Agency for Healthcare Research and Quality, known as the Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS). While the evidence for the continued use of team training programs perioperatively is still evolving, a multilevel evaluation of the TeamSTEPPS program in a single perioperative unit indicated that there was a significant increase in the quality and quantity of procedural briefings, the use of teamwork during cases, and an improvement in perceived safety climate and teamwork attitude [30]. A recent multicenter study looking at the effect of aviation team-style training on the incidence of time-outs, briefings, and debriefings did find significant increases in these safety strategies, noting, however, that continuing the benefits of aviation-based training would require collaboration of all OR staff [31].

In commercial aviation, recurrent simulator training and ground school are an important part of pilot training and competency assessment. Captains are required to undergo recurrent simulator checks every 6 months, and during that time, they are evaluated, provided information on new policies, and provided information on collective experience of other pilots. In the perioperative setting, this level of commitment to recurrent training and competency assessment is yet to reach the levels of that found in commercial aviation [13, 32].

With the increasing work hour restrictions, emphasis on competency-based curriculum, and the growing burden of patient safety failures, McGreevy examines the aviation paradigm and its applicability to surgical education, comparing and contrasting the training required to become a fighter pilot. He comes to the conclusion that aviators are often more carefully monitored and mentored than surgeons, and that acquisition of skills to become either a proficient pilot or perioperative team member requires an education that emphases systematic checklist use, particular learning objectives, briefings and debriefings, and assuring currency with performed tasks [33].

The rapid change in training methods for surgical staff has required a “team training” approach that integrates crises resource management and Crew Resource Management theory. These techniques include mock operating rooms and simulators including inanimate video trainers, human patient simulators, and virtual-reality computer-based trainers. The development of accredited skills-training centers, endorsed by the American College of Surgeons, appears to be a positive step towards catalyzing continued movement towards simulator-based training to improve perioperative safety [34, 35].

Indeed, financial and time constraints have made teaching outside of the operating room, using a variety of simulator platforms, an attractive option. With the establishment of simulator standards, an unprecedented endorsement of simulation as an education tool, and expansion of CRM training, surgical simulation seems to play a key role in training and multidimensional competency verification [36]. In addition to training for surgeons, there has been increasing emphasis on assuring that anesthesia personnel are trained in human factors and Crew Resource Management, given their important in assuring patient safety during the operation [37].

Incident reporting systems are frequently used in aviation, and one particularly successful program is the Aviation Safety Action Program administered by the National Aeronautics and Space Administration (NASA). Under this program, NASA, and not the Federal Aviation Administration (FAA) collects data reported anonymously by flight operators. Certain hospitals have incident reporting systems, though these are used infrequently and many clinicians are unaware that they exist [13]. The United States, Britain, and other countries also have non-punitive incident reporting systems in aviation which are shared between aviation bodies. These systems are important in allowing organizations to learn from failures in the delivery of care [11].

Choy notes the importance of critical incident monitoring in anesthesia as a means for quality improvement and maintenance of high safety standards. Noting the importance of human error in contribution to mortality and morbidity perioperatively, he also points out that that growing acceptance that human error perioperatively is often due to a failure of systems rather than an individual fault. As such, critical incident monitoring in healthcare allows more lessons to be learnt on a system-wide level, and the growth of information systems technology allows for wider implementation of monitoring systems. However, further research is necessary to ensure the benefits of critical incident monitoring in healthcare, particularly with devising a system that meets the needs of the organization [38]. Additionally, whether or not the reporting system for critical incident monitoring should be anonymous is a matter of much debate, given that an anonymous system may not allow for further information gathering from the reporter.

A recent incident reporting system developed in a department of neurosurgery involved asking all neurosurgery staff members to report near misses on a voluntary, confidential, and protected form. These reports were then entered into an online database and reviewed by facilitators who performed an aviation-derived root cause analysis. The results revealed predominantly human factors as the causal factors for surgical errors, with technological, organization, and procedural factors being far less likely to be causal. Indeed, this is consistent with aviation accidents, where human factors are identified and targeted as the most likely to contribute to unsafe flight [39].

Other studies have investigated appropriate modalities of feedback from incident reporting systems as a means to improving patient safety. Through a mixed methods review to study established incident review programs in a variety of high-reliability industries, one study identified the essential components of a critical incident feedback reporting system in the healthcare setting. These included the role of leadership, credibility and content of information, the timely dissemination of feedback throughout the organization, the capacity for rapid action, and the establishment of feedback mechanisms at all levels of the organization. Most importantly, the study noted that the safety-feedback mechanism must be closed by assuring that corrective action be taken based upon addressing the feedback provided [40].

Dr. Richard Karl, founder of the Surgical Safety Institute, aptly notes that “the fact that an elementary checklist’s efficacy would warrant publication in one of our most prestigious journals signals how far we have to go to match the kinds of safety techniques viewed as commonplace and unremarkable…” [13]. Indeed, checklists have been routinely used by airline personnel over the past 70 years, while they have been sporadically used by perioperative personnel. Checklists serve as methodical reminders to ensure that that critical tasks have been completed successfully, and in aviation, are actively used during pre-flight, pre-start, taxi, takeoff, cruise, approach, landing, and post-flight phases. Indeed, structured checklists in the perioperative session can achieve great success as they have the potential to standardize human performance and ensure that procedures are followed correctly without overt dependence on memory [41].

Two predominant methods on checklist use have been developed by the aviation industry, namely the “do-list” and the “challenge-response” method. These methods have been developed based on different operational philosophies. In the “do-list,” the checklist is used as a method by which the pilot goes through the checklist and configures the aircraft after reading each item. In the challenge-response method, the more common method used by commercial operators, the checklist is a backup tool to verify all items have been accomplished after the pilot configures the aircraft for memory. The latter method, argued by some, reduces the possibility of missing an item during a single review of all the critical items [42].

David Gaba, a noted patient safety advocate and private pilot, notes that “simulation in healthcare can be categorized by 11 dimensions: aims and purposes of the simulation activity; unit of participation; experience level of participants; healthcare domain; professional discipline of participants; type of knowledge, skill, attitudes, or behaviors addressed; the simulated patient’s age; technology applicable or required; site of simulation; extent of direct participation; and method of feedback used.” While noting that the global costs and benefits of simulation are difficult to ascertain, he points out the various driving forces behind integration of simulation to improve patient safety: Surgical/medical professional societies, insurers, health financiers/payers, and the public at large [43].