> At 09:14 2/05/98 EDT, you wrote:
> >
> >Hi gang, I'm back.
> > I spent last week in a TDY location presenting a Facilitator training
> >class. It was quite interesting in that the facilities were less than ideal,
> >but the lessons of overcoming barriers demonstrated that CRM can be discussed
> >in a variety of locations and settings, to include the parking lot while the
> >fire department checked out the building.
> > I also experimented with the theme of the session, to provide repeated
> >discussion of "error vs. violation", and some of our thoughts on error
> >managenment, as we explored aviation events. Mixed in with this was a lot of
> >"risk management", since that is the latest "buzz-word" in this culture. The
> >discussions seemed to have been quite effective.
> > Some of this class had been to several CRM classes before, and thought they
> >knew the meaning and purpose of the training. As we finished off the week,
> >many reported that they felt they had a much better understanding of what they
> >had been exposed to in the past.
> > The audience included some from the medical community, and one particular
> >nurse enlightened us with the following story, which I think you'll find
> >interesting:
> >
> > Once upon a time, in a hospital, a doctor told a nurse to administer some
> >insulin to a diabetic patient. He told the nurse to give the patient "10 cc".
> >The nurse thought that to be an unusually large amount, but did not question
> >the order. She then went to the cabinet and noticed that the syringe she
> >normally used for injections was too small, and hunted for a larger one. She
> >then picked up a bottle of insulin from the cooler. These bottles only
> >contain 5 cc, and usually last about a month. She, of course, had to use two
> >complete bottles to collect the assigned amount. While she was injecting the
> >patient, she even thought to herself, " . this is a lot for one dose." As
> >you might imagine, shortly after the injection the patient went into shock.
> > The investigation revealed that the doctor had indeed said "cc", and had
> >even written "cc" on the records, thereby constituting a written order. The
> >unfortunate truth is, however, the normal dosage is "units" which is not the
> >same as "cc".
> > To this day, the nurses of the organization often discuss this mishap,
> >and wonder, how could this have happened? There were so many "flags" to catch
> >the error, but the error slipped right through.
> >
> >Thought you might enjoy the analogy.
> >
> >And, oh by the way: interesting round on psycho-babble. I agree with the
> >conclusions. The research and theories may be OK to guide the development of
> >courses, but don't belong in the aviator's class room. I've often asked the
> >CRM class students to start the morning with a group hug, and a song, but
> >they refuse.
> >
> >Greg Deen
> >Raytheon
> >
> >
> >Hi Greg
>
> Looking at your last paragraph. It seems that there is still confusion in
> some areas of CRM around psychology theory/practice issues. I have never
> heard of a CRM class starting with a group hug/song. Im not sure how it
> illustrates your point.
>
> Psychological theory and research whether to do with groups or whatever
> originates in the real world of practice - its not the other way around.
>
> Cheers Kerry
Hi Kerry, I suspect a little smiley was missing! :-)
Steve Smith