Re: Experiment

Kerry Douglas (kerry_at_cairns.net.au)
Tue, 5 May 1998 16:22:39 +1000

At 10:28 5/05/98 +1200, you wrote:
>
>Kerry Douglas wrote:
>
>> 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
>
>
Hi Greg and Steve,

Here's a big Hug, Hug, Hug to start your week. Now a song....(thinking)...

..`Fly the ocean in your silver plane...

See the jungle when it's wet with rain,

..Just remember `til you're home again,

..You belong right here'.

Cheers, Kerry. :-)