J R Army Med Corps 157(3 Suppl 1): S299-S304 S299 Introduction In 2000, the National Academy of Sciences published To Err Is Human, the result of a comprehensive investigation into the quality of health care in America. Conducted under the auspices of the Institute of Medicine, the researchers noted that between 44,000 and 98,000 people died from medical errors each year in the US alone. More people die every year due to medical errors than from motor vehicle accidents, breast cancer or AIDS [1]. Moreover, these errors were not necessarily the result of inadequate medical knowledge by practitioners but partly a function of imperfect feedback mechanisms (e.g. in patient handover) and the inability to transform new knowledge into meaningful clinical actions. he study’s recommendations for patient safety took their cue from aviation. Like surgical teams, light crews operate in environments where small errors can have grave consequences. Like surgical teams, airlines have come to recognize the relevance of non-technical skills even in technically sophisticated environments. By the late 1960s, it was becoming apparent that although airline pilots were technically competent, their ‘people skills’ might be a problem. A series of accidents prompted a number of research programmes, including one on human factors in aviation safety conducted by the National Aeronautics Space Administration (NASA), which identiied resource management on the light deck as an important issue [2]. his, and subsequent work, led to the introduction of the irst training courses in what was initially called Cockpit Resource Management, intended to address and improve pilot’s understanding of, and skills in, decision-making and team working. On the understanding that the team (and the aircraft) extended beyond the light deck, this was subsequently reformulated as Crew Resource Management (CRM). Since 1992, training in CRM has been mandatory for all pilots and non-technical skills are assessed using a series of behavioural markers known as the NOTECHS framework. he concept and application of CRM has extended both into military aviation and beyond aviation into many other industries, including healthcare, frequently and necessarily being adapted to suit the needs of each. In anaesthesia, for example, Gaba et al have adapted CRM to create a simulation-based curriculum known as Anaesthesia Crisis Resource Management (ACRM) [3] – the change from ‘Crew’ to ‘Crisis’ being made because, although not viewing themselves as crew, ‘all intuitively knew what crises were’. CRM issues amongst medical staf who deploy on military operations with the Defence Medical Services (DMS) arise as they predominately work day to day in the National Health Service (NHS) and their typical trauma patients are civilians with blunt injuries. he trauma injury patterns previously experienced in Iraq and now in Afghanistan are far more severe that that seen in an average UK hospital. Casualties sustain injuries mainly from blast and ballistics as compared with the blunt trauma that is common in the NHS [4]. here are speciic standard operating procedures that have been devised for these conditions such as damage control resuscitation (DCR) that will be unfamiliar to those who have not previously deployed [5]. he equipment used in the ield hospital is also unfamiliar and it is important that pre-deployment training allows individuals the opportunity to familiarize themselves. One such course is the Military Operational Surgical Training Course (MOST) where the entire trauma team practices in a high idelity simulation environment. Scenarios are speciically designed with key technical and non-technical learning objectives all aiming to allow familiarization with the case mix, standard operating procedures (SOPs) and equipment. Simulation allows facilitated learning to be delivered with an immediate human factors focused debrief in a safe environment [6]. Typical deployments are for 8-12 weeks at a frequency of 6-18 months, depending on the individual’s role. he deployed ield hospital is a unique environment where the efective use of CRM is vital to the success of the operation. Medical units rotate every three to six months, but there are individual replacements that arrive on a regular basis, the result of which can lead to a constantly changing team. Individuals therefore need to be able to Corresponding Author: Mr MJ de Rond, Reader in Strategy & Organization, Judge Business School, Trumpington Street, Cambridge CB2 1AG Tel: 01223 764135 Email: mejd3@hermes.cam.ac.uk Making Diicult Decisions in Major Military Trauma: A Crew Resource Management Perspective MJ Midwinter 1 , S Mercer 2 , AW Lambert 3 , M de Rond 4 1 Defence Professor of Surgery, Academic Department of Military Surgery & Trauma, RCDM, Birmingham; 2 Consultant in Anaesthesia, University Hospital Aintree, Liverpool; 3 Consultant Surgeon, Ministry of Defence Hospital Unit, Derriford & Academic Department of Military Surgery & Trauma, RCDM, Birmingham; 4 Reader in Strategy & Organization, Judge Business School, Cambridge University Abstract he purpose of this article is to consider three underappreciated but important features of high performance teams: the trade-of relation between social and technical competence, the relevance of team size on productivity, and the inevitability of tensions that, while often experienced as dysfunctional, are in fact quite useful. It does so by reviewing a series of related studies in aviation and the organisation sciences, and by extrapolating insights for crew resource management in major military trauma along two generic themes: team context and team process.