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AEROMEDICAL CREW
RESSOURCE MANAGEMENT
Stefan Becker, EHAC Managing Director
Agenda
2
• To Err is Human
• Errors in Medicine
• Errors & Adverse Events
• CRM & CIRS in HEMS operations
• Responsibilities
• Leadership & Change of Leadership
• Development of ACRM
• Operational Goals
• Training Programme & Network
IHSS 2010 | Stefan Becker | Aeromedical Crew Ressource Management (ACRM) 4 October 2010 Estoril, Portugal
Human Factors in Medicine
3
6.6-13 % of adverse events
led to death
Over half of these adverse
events resulted from medical
errors and could have been
prevented
IHSS 2010 | Stefan Becker | Aeromedical Crew Ressource Management (ACRM) 4 October 2010 Estoril, Portugal
From Errors and Adverse Events
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An error is defined as An adverse event is an
the failure of a planned injury caused by
action to be completed medical management
as intended (i.e. error of rather than the
execution) or underlying condition of
the use of a wrong plan the patient.
to achieve an aim (i.e.
error of planning).
IHSS 2010 | Stefan Becker | Aeromedical Crew Ressource Management (ACRM) 4 October 2010 Estoril, Portugal
8th-Leading Cause of Death
5
More people die in a
given year as a result
of medical errors
than from
motor vehicle
accidents
breast cancer or
AIDS
IHSS 2010 | Stefan Becker | Aeromedical Crew Ressource Management (ACRM) 4 October 2010 Estoril, Portugal
Costs of Human Errors
6
$37.6 - $50 billion for
adverse events
$17 billion - $29 billion
for preventable
adverse events
IHSS 2010 | Stefan Becker | Aeromedical Crew Ressource Management (ACRM) 4 October 2010 Estoril, Portugal
Contributing Factors
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to Critical Incidents
Individual Factors Organisational Factors
Organisational
Situational Influence
Awareness
Unsafe
Supervision
Pressure Decision
Making
Preconditions
for Unsafe Acts
Emotional
Balance
Unsafe Acts
IHSS 2010 | Stefan Becker | Aeromedical Crew Ressource Management (ACRM) 4 October 2010 Estoril, Portugal
Human Factors in Aviation
8
In aviation human
factors lead to 70-90%
of all grave mistakes
(Kern T, 2001; Helmreich RL, 1993;
Wiegmann, 2003)
IHSS 2010 | Stefan Becker | Aeromedical Crew Ressource Management (ACRM) 4 October 2010 Estoril, Portugal
Fatal Accidents 2000-2009
9
(EASA Safety Report 2009)
IHSS 2010 | Stefan Becker | Aeromedical Crew Ressource Management (ACRM) 4 October 2010 Estoril, Portugal
Standard Problem Statements
10
acc. to EHSAT
Pilot judgement & actions 65%
Safety Culture/Management 51%
Ground Duties (Planning&Preparation) 38%
Pilot situation awareness 35%
Data issues 35%
Mission Risk 27%
Part/system failure 25%
Regulatory 25%
Maintenance 18%
Post-crash survival 17%
Aircraft Design 16%
Infrastructure 9%
European Helicopter
Communications 7%
Safety Team (2010)
Ground personnel 1%
0% 10% 20% 30% 40% 50% 60% 70%
IHSS 2010 | Stefan Becker | Aeromedical Crew Ressource Management (ACRM) 4 October 2010 Estoril, Portugal
Challenge „HEMS“
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Emergency
Aviation
Medicine
IHSS 2010 | Stefan Becker | Aeromedical Crew Ressource Management (ACRM) 4 October 2010 Estoril, Portugal
Interacting Responsibilities during
12
Missions
Aircraft control
Navigation Pilot
Flight Safety
Diagnosis & Indication
Initial medical treatment
Doctor /
Hospital selection for
Paramedic further med. treatment
Patient Safety
IHSS 2010 | Stefan Becker | Aeromedical Crew Ressource Management (ACRM) 4 October 2010 Estoril, Portugal
Interacting Responsibilities
13
Pilot
Doctor /
Paramedic
Flight Safety
Patient Safety
IHSS 2010 | Stefan Becker | Aeromedical Crew Ressource Management (ACRM) 4 October 2010 Estoril, Portugal
ACRM: Development
14
EU co-financed
“Leonardo da Vinci”
project
Building of a working
group
Implementation of the
training concept
3 hotrun trainings &
special evaluation
Enhancement of the
training concept
IHSS 2010 | Stefan Becker | Aeromedical Crew Ressource Management (ACRM) 4 October 2010 Estoril, Portugal
ACRM: Operational Goals
15
Improve Improve Enable Reduce Increase Protect
situation communic team- critical Reduce patient environ-
aware- ation work incidents accidents safety & ment
ness outcome
IHSS 2010 | Stefan Becker | Aeromedical Crew Ressource Management (ACRM) 4 October 2010 Estoril, Portugal
ACRM Training Programme
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Cross-professional teambuilding process
Development of a common goal and language
Sensitisation of individual expectations in the team
Changing perspective between self-perception and
external perception
Development of cross-professional competence
Improvement of non-technical-skills
IHSS 2010 | Stefan Becker | Aeromedical Crew Ressource Management (ACRM) 4 October 2010 Estoril, Portugal
ACRM Training Programme
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ACRM
Change of Leadership
Situation Awareness
Decision Making and
Stress management
Risk Management
Communication
Teamwork and
Human Error
Stress and
COMPANY SAFETY CULTURE
IHSS 2010 | Stefan Becker | Aeromedical Crew Ressource Management (ACRM) 4 October 2010 Estoril, Portugal
ACRM: Quality & Network
18
EHAC Working
Group
Regular meetings
Trainer qualification
Continuous improvement process
IHSS 2010 | Stefan Becker | Aeromedical Crew Ressource Management (ACRM) 4 October 2010 Estoril, Portugal
Train the Trainer Concept
19
IHSS 2010 | Stefan Becker | Aeromedical Crew Ressource Management (ACRM) 4 October 2010 Estoril, Portugal
EHAC
Country Helicopters Bases
Austria 28 24
Czech Republic 9 8
Finland 1 1
Germany 85 62
Great Britain 15 14
Hungary 8 6
Italy 11 10
Luxembourg 4 3
Netherlands 5 4
Norway 14 11
Poland 22 16
Slovakia 7 6
Spain 28 28
Switzerland 22 13
Total 259 206
Total HEMS AOC in EU: ???
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„Train those as a team,
which are expected
to work as a team.“
IHSS 2010 | Stefan Becker | Aeromedical Crew Ressource Management (ACRM) 4 October 2010 Estoril, Portugal
