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Coda Change


Jun 25, 2021

How a Crisis Resource Management failure led to a full-blown medical emergency.  

It is estimated that 70% of avoidable deaths in healthcare involve a breakdown of the principles of CRM.

Crisis resource management, involves seven crucial steps:

  1. Know your environment
  2. Anticipate and plan
  3. Take a leadership role
  4. Communicate effectively
  5. Call for help early enough
  6. Allocate attention wisely, use all information
  7. Distribute workload, use all available resources

Unfortunately, a failure in adhering to the 7 principles of CRM lead to serious complications for the birth of Tamara & Garry Hills’s son.

We hear from Tamara and Garry as they explain the human and systemic factors that ultimately led to a full-blown medical emergency.

A lack of situation awareness, combined with poor communication, unfortunately led to Christopher Hills suffering a severe brain injury. This likely occurred during the 17 minutes of terminal Bradycardia.

Tamara, Garry and Christopher bravely share their story to inspire healthcare workers to embrace crisis resource management.

For more head to: codachange.org/podcasts