Safety at the Sharp End

Safety at the Sharp End

Authors: Rhona Flin, Paul O’Connor, Margaret Chrichton


This book addresses the non-technical skills that maintain safety in high-risk industries. The authors define these as the ‘cognitive, social and personal resource skills that complement technical skills, and contribute to safe and efficient task performance’ (page 1). The book explores skills such as situation awareness, decision-making, communication, teamwork, and leadership. It also discusses how to manage stress and cope with fatigue (page 1). The authors, experienced crew resource management (CRM) teachers, gave clear definitions of the concepts they discuss.



Situation awareness is the core skill the book discusses; it encompasses ‘the cognitive processes for building and maintaining awareness of a workplace situation or event‘ (page 17). The loss of situation awareness, or being out of the loop, is a leading cause of aviation accidents (page 18). The book evaluates the important psychological mechanisms relevant to this skill such as memory, perception and attention. The authors offer many practical tips to guide against loss of situational awareness; an example is their advice to workers in risky environments to ‘have some spare capacity in case the information load they have to cope with suddenly rises’ (page 31). They also list the important indicators that suggest impending loss of situational awareness.



The book’s discussion of communication skills was laced with fitting anecdotes such as the alpha piper oil platform disaster (page 70) and a hospital scenario of medication error (page 76). The authors explored the one and two way models of communication, types of feedback, and the significance of non-verbal communication. They explained the importance of assertiveness in communication and emphasised the importance of briefing in creating a shared mental mode (page 83). There is a helpful analysis of debriefing and the eight essential team behaviours which foster learning (page 85-86).



The discussion of teamwork was detailed and covered important topics such as conflict resolution. The book illustrated the consequences of poor teamwork with several examples such as the bay of pigs invasion of Cuba by CIA-backed exiles. The authors discussed team identity, team training and shared mental models. They gave many helpful guidelines for example how to exert assertiveness within the team (page 97).



The authors reviewed decision-making and explored its types, models and strategies. They addressed the factors that influence the decision-making process and discussed the techniques of teaching this key skill. There was an exploration of leadership which included a review of the types and range of leadership styles (page 133). Allied to leadership is the discussion of expertise and its relationship to mental models and mental simulation.



The exploration of stress and fatigue on performance was very enlightening. The authors discussed the classification and indicators of fatigue and listed fatigue prevention and management tips such as cognitive control techniques (page 181). The authors illustrated the consequences of fatigue on performance with the example of the Columbia space shuttle disaster (page 167). The book ends with chapters addressing the identification, training and assessments of non-technical skills.

Beate W.
Beate W.


This is a detailed text, well-written and with several important references. Concepts are well described and there are many clear tables and boxes that summarised or listed key points. The bulleted key points at the end of each chapter greatly enhanced recall and learning. The book’s illustrative examples of high profile accidents and disasters, including the Tenerife airport KLM and Pan Am plane crash, graphically illustrated the importance of non-technical skills. Some of the latter chapters were slightly too academic for the general medical practitioner but are invaluable for those engaged in safety management and education.


There are very few books that address non-technical skills in this depth. The relatively small size of the book belies the extensive range of subjects it discusses. The topic, frequently overlooked, is critical to patient safety and the authors have reviewed it in sufficient depth. I highly recommend it to every doctor.


  • Publisher, place, date: Ashgate, Surrey, 2008
  • Edition: 1st
  • Chapters: 11
  • Pages: 317
  • ISBN: 978-0-7546-4600-6
  • Price: £23.75
  • Star rating: 5



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