Fragmented handover, fixation error and the debrief — CRM in the resuscitation

Structured handover — ISBAR. The ambulance-to-ED handover should be led by the receiving team leader using the ISBAR structure. Identify the patient (name, age, location) and the clinicians on each side. Situation — the witnessed VF arrest, the downtime, the rhythm on arrival, the number of shocks, the drugs given and the times. Background — the past history, the medications, the allergies, the premorbid state, the events preceding the collapse. Assessment — the current vital signs, the examination findings, the working diagnosis, the investigations done in the field (blood glucose, the ECG). Recommendation — the receiving team states what it needs from the paramedics (stay, transfer the patient, retrieve the next of kin) and what the plan is. The structured handover gives the team a shared mental model and prevents the silent assumption that critical information was conveyed.^[2]

Crisis resource management principles violated. First, the team leader did not stand back: by failing to direct the handover and by not summarising the situation aloud, the leader ceded the overview and the team did not share a mental model of the downtime and the drugs. Second, role allocation was unclear — the registrar performing the resuscitation without an explicit hand-back to the standing-back leader dissolves the leader-operator distinction that CRM requires. Third, closed-loop communication broke down: the potassium was returned but not explicitly called out and acknowledged. Fourth, situation awareness was degraded at all three levels (perception of the gas result, comprehension of its significance, projection of the imminent rearrest). The CRM framework — leadership, communication, situation awareness, decision-making and resource management — is the set of non-technical skills the team must apply deliberately, not assume will happen.^[1]

Fixation error and its defence. The registrar anchored on a primary cardiac cause and dismissed the hyperkalaemia — the classic this-and-nothing-else fixation error, in which the working diagnosis is held and the contradictory evidence is filtered out. The defences are deliberate and structured. The team leader performs a structured ABCDE reassessment at every cycle and explicitly names at least three alternative diagnoses aloud, forcing the question "what else could this be?". The team leader invites dissent — "tell me if I am missing something" — and flattens the authority gradient so that the nurse or the registrar who notices the potassium feels able to speak. Cognitive biases are universal, they are amplified by stress and fatigue, and they are mitigated by structured process, not by exhortation.^[4]

The debrief — plus-delta. After the resuscitation, lead a hot debrief with the whole team present in the bay, lasting five to 10 minutes. Use the plus-delta format: invite each team member in turn to name one thing that went well (the plus) and one thing to change next time (the delta). Keep it non-judgemental and focused on team performance and system factors rather than individual blame. The plus-delta captures both the learning and the immediate psychological support that protects the team from the second-victim effect. Document the deltas and feed them into the formal incident review or cold debrief if the event is serious. The meta-analytic evidence (46 samples, N = 2136) found debriefs improve effectiveness over control by approximately 25%, with similar effects for teams and individuals and a bolstering effect of alignment with potential impact of facilitation and structure.^[3]