CRMDEEN 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