Dr. Adam Shehata (former professional pilot turned physician) and Dr. Amir Hamid (anesthetist and emergency medicine physician) discuss how to improve our healthcare system by integrating human factors into systems safety, including medical incident investigation and proactive safety measures.
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In this episode Amir and Adam discuss three aviation accidents that parallel the Elaine Bromiley case.
Human factors in medicine: As Captain Bromiley put it, this was not an individual failure. It was a system failure. It was a failure of human performance. In aviation, 75% of airline accidents are due to human factors rather than mechanical failure.
Eastern Airlines Flight 401 (1972)
Fixation-induced loss of situational awareness.
Troubleshooting a landing gear light indicator problem in the cockpit (one of the landing gear lights would not indicate the gear was down and locked).
The autopilot was engaged and the aircraft was flying over unlit terrain (the Florida everglades) at night.
One of the flight crew inadvertently bumped the control column which disengaged the autopilot.
Despite an altitude alert chime being audible on the Cockpit Voice Recorder (CVR), none of the crew responded to it.
The aircraft slowly descended and impacted terrain.
The landing gear was in fact down and locked and the failure of a single light bulb resulted in many fatalities.
United Airlines Flight 173 (1978)
Fixation-induced loss of situational awareness leading to fuel exhaustion and crashing in Portland
Troubleshooting a landing gear light indication problem, similar to Eastern Airlines Flight 401
Again the light failed to indicate, but the gear was later found to be in a safe position
This time the Captain continued to circle to try to troubleshoot the problem and optimize the conditions for the emergency landing with a potentially unsafe landing gear.
Despite the First Officer (FO) and Flight Engineer (FE) attempting to tell the Captain that the aircraft was dangerously low on fuel, the Captain continued to take time to work the landing gear problem.
When the engines began to fail, the Captain was surprised that it was because of a lack of fuel.
Air Florida Flight 90 (1982)
Poor crew coordination and lack of assertiveness / failure of leadership leading to a crash on departure in icing conditions.
The failure to engage the engine anti ice later led to a false indication in the cockpit instruments showing that the engines were developing sufficient thrust for takeoff when they weren’t.
The Captain ignored the First Officer’s repeated concerns about the amount of ice on the wings and whether the engines were developing sufficient power on takeoff.
Some of the links in these show notes are Amazon affiliate links. As an Amazon Associate, we may earn from qualifying purchases, at no additional cost to you. Currently, we receive no outside funding, so we thank you for supporting the podcast, again at no additional cost to you.
Welcome to the Medical Safety Podcast where we aim to improve the safety of our healthcare system through the integration of human factors into medical incident investigation and proactive safety measures. This podcast is hosted by two Canadian anesthetists, Drs. Adam Shehata and Amir Hamid. In the inaugural episode, we take a look at the 2005 death of Elaine Bromiley and the lessons learned from it.
Elaine Bromiley
Healthy 37 year old woman for elective sinus surgery in the UK in 2005
Can’t Intubate Can’t Oxygenate
Experienced surgical team
Elaine’s oxygenation fell and the team could not get oxygen to her through intubation, face mask ventilation, or by using a laryngeal mask airway (LMA)
Several minutes went by, meanwhile a nurse brought in a cricothyroidotomy kit for surgical Front of Neck Access (FONA). The nurse announced the kit’s presence to the operating theatre but received no response.
After 40 minutes (20 without sufficient oxygenation), an airway was established with an LMA.
A nurse had arranged for an ICU bed and returned to the OR to tell the team, but received a look from the physicians as if to say, “What’s wrong? You’re overreacting.”
Elaine was taken to the recovery room and the surgical team continued on with the rest of the patients on the list.
The nurses in the recovery room were concerned that Elaine may have been having seizures and called the anesthetist, but he was busy with a patient in the OR and could not attend.
Eventually, Elaine was transferred with an LMA (as opposed to a secured airway) to another hospital for ICU care.
Having confirmed an unrecoverable anoxic brain injury due to the lack of oxygen on induction of anesthesia, Elaine was removed from life-sustaining therapy and allowed to die naturally.
Martin Bromiley
Elaine’s husband, and father to their two young children, was also a UK airline pilot
He told the hospital that he would “wait for the report” which is what would have happened if Elaine had died on or near an airplane in the UK. The accident investigation board, an independent investigatory body, would have determined the causes and contributing factors and then published an anonymized report with recommendations on how to improve safety.
Making a welcoming environment, so that others feel they can speak up
CRM is not about being perfect. It’s about identifying and mitigating the times of increased risk of making mistakes and identifying why a particular mistake was made.
The perceived tension between performance and “soft skills” (CRM)
Some people view these non-technical skills as costing time and money and not contributing to patient safety or as detracting from efficiency. The reality is that good CRM skills make teams more efficient. Additionally, we are no longer in a stage in medicine where we can say that leadership or non-technical skills don’t matter. We have plenty of evidence that failures of leadership have directly resulted in bad outcomes (morbidity and mortality).
Additionally, CRM skills improve the working environment for all, which leads to the preservation of healthcare workers and mitigates burnout.
The origins of CRM
CRM developed in aviation because of a data-driven approach where successive accident investigations determined that the majority of aviation accidents were caused by human error (team performance) rather than mechanical failure, as had happened in the past.
In medicine, we can safely assume the same trend, but as a profession that purports to follow the evidence, we should investigate and build a dataset on which to make these kinds of decisions. This could look like the aviation-style medicine incident investigation systems that exist in the UK and Norway and could use systems like audio and video recording of operating rooms, ICUs, and resuscitation bays. It would also likely require a change to legislation to protect that data from being used in litigation, as currently exists for aviation black boxes.
The evolution of CRM in aviation
from elective courses to mandatory SOPs to the point where even if a pilot completed the tasks technically correct, but exhibited poor CRM skills, they would fail their flight test.
“Anticipation builds vigilance; vigilance aids recognition; recognition leads to recovery.”
CRM & Error Management
In aviation, CRM treats errors as inevitable events to be managed, not moral failures.
Ep 4 - Escalating Language of Concern with Dr. Katie Lin
It is a set of skills that helps improve team performance through communication, leadership, and interpersonal skills.
It can help build a common language and shortcuts so that even people that have not worked together before can work well together. Used well, it can improve efficiency.
While it is more formalized in other industries (aviation, military), it exists in medicine and has existed for some time, but is more practitioner-dependent.
Order of priorities when leading a resuscitation
Establish communication, your role, and the role of others (“I’m Dr. [X], I will be leading this resuscitation. Who else do I have in the room with me?”)
Try to build some rapport, if time permits
Gather information, starting with threats to life
Prioritize treatment, diagnosis, and transportation
Maintain situational awareness by continually seeking new information and revaluate the diagnoses, need for more information and revaluate the decisions that have been made and need to be made
Prioritize the patient’s safety but also remember your colleagues’ including transportation team
How to manage your stress response to perform optimally
Take a breath
“Slow is smooth, smooth is fast”
Use a systematic approach
Maintain control of the room (ask for quiet when necessary, ask those not immediately involved in the resus to step out, )
Summarize the situation and seek the input of others
The foot of the bed is often a good place for the resuscitation leader. They can see the monitor and all of the work being done, as well as the patient and their colleagues. It also helps reduce the urge to physically do tasks that might in the leader’s skillset, but that would take them away from leading the team.
Practicing CRM
Visualize / walkthrough / tabletop common life threatening scenarios (head injury, multisystem trauma, obstetrical hemorrhage, etc). Do the routinely to maintain proficiency and re-evaluate as real-life scenarios occur.
Situational awareness
Ep 5 - Simulation in Medicine with Dr. Jesse Guscott
Although equipment is expensive and may seem like a barrier to establishing a simulation program, the emphasis of a simulation focused on CRM principles should be communication and having skilled debriefers who can facilitate skills development
Using simulation to have someone experience a crisis and reflecting on why things didn’t go well, with the help of a skilled debriefer/facilitator is key in identifying systems we can put in place to mitigate these issues when the occur in reality
“Simulation without goals is just playing”
When designing a good simulation experience, it is important to keep the learning goals at the forefront; this may mean that the simulation is not the highest fidelity, but sometimes they don’t need to be
When designing a simulation for learning, you have to make a safe environment and make it clear to the participants there is no evaluation component; learning is the single priority
It is hard to have the dual role of coach and assessor and may make the environment challenging for learning
Why simulation is important
As we have seen with the episodes focused on the airline industry, rarely are the catastrophic events due to a technical proficiency, catastrophic mechanical failure or knowledge issue; they are more often caused by failures in communication or decision making
When we analyze issues in medicine we can see similar trends
The evidence shows that simulation improves confidence of participants. It is very hard to measure competence; there is anecdotal support from bystanders, simulation facilitators, allied health that it makes people better, but there are no RCTs to demonstrate this as it is inherently a difficult thing to measure
For physicians who are at risk of leaving high acuity fields (IE: rural physicians working emergency medicine or hospitalist medicine), increasing their confidence may help with retention, which is pivotal in some of these communities. This may also encourage junior physicians to practice at full scope, especially in underserved communities where it is traditionally hard to hire physicians
Ep 7 - "A Life in Error" - Remembering Professor James Reason
Errors occur when a planned sequence of events fails to achieve its goal without an element of chance.
Slips and lapses are absentmindedness.
Trips and fumbles are maladroitness.
Mistakes involve higher order cognition
Main classification of errors:
Skill-based slips
Rule-based mistakes
Knowledge-based mistakes
Examples of skill-based slips: putting cat food in the teapot, getting into the bath with your socks on, trying to open a door with the wrong key.
Examples of rule-based mistakes: proceeding when it’s not your turn at the intersection (most driving errors are rule-based.
Examples of knowledge-based mistakes: devising an alternate route when there is a road-block, devising a differential-diagnosis and arriving at a working diagnosis.
In order to prevent, trap, and mitigate errors, we need a common language to discuss errors and how to manage them.
Violations are intentional deviations from norms and rules.
Corner-cutting or routine violations committed to avoid unnecessary effort or to circumvent inappropriate procedures (the written vs unwritten rules);
Thrill-seeking or optimizing violations (e.g. speeding);
Necessary violations that occur because the people making the rules are not the ones performing the actual work; and
Exceptional violations: one-off events that occur under exceptional circumstances.
The Swiss Cheese Model of defences in depth
Defences protect against hazards reaching losses, like barriers.
These barriers have holes in them, like swiss cheese
The holes are latent conditions and active failures
Latent conditions exist for years and are due to system factors (understaffing, policies etc)
Active failures are errors created by people at the front-end (doctors, nurses, pilots, technicians etc) that are closely connected in time to bad outcomes.
The current medical model is not error tolerant. It expects practitioners to be perfect. If a pharmacist, nurse, physician etc makes a mistake, the safety margins are so razor-thin that it can easily result in a bad outcome for a patient.
Ep 6 - Patient Safety with Captain Martin Bromiley
Healthy 37 year old woman for elective sinus surgery in the UK in 2005
Can’t Intubate Can’t Oxygenate
Experienced anesthesiologist + another who joined when help was called for + a head and neck surgeon in the room + experienced OR nurses
Elaine’s oxygenation fell and the team could not get oxygen to her through intubation, face mask ventilation, or by using a laryngeal mask airway (LMA or rescue airway device)
Several minutes went by, meanwhile a nurse brought in a cricothyroidotomy kit for surgical Front of Neck Access (FONA). The nurse announced the kit’s presence to the operating theatre but received no response.
After 40 minutes (20 without sufficient oxygenation), an airway was established with an LMA.
A nurse had arranged for an ICU bed and returned to the OR to tell the team, but received a look from the physicians as if to say, “What’s wrong? You’re overreacting.”
Elaine was taken to the recovery room and the surgical team continued on with the rest of the patients on the list.
The nurses in the recovery room were concerned that Elaine may have been having seizures and called the anesthetist, but he was busy with a patient in the OR and could not attend.
Eventually, Elaine was transferred with an LMA (as opposed to a secured airway) to another hospital for ICU care.
Having confirmed an unrecoverable anoxic brain injury due to the lack of oxygen on induction of anesthesia, Elaine was removed from life-sustaining therapy and allowed to die naturally.
Martin Bromiley
Elaine’s husband, and father to their two young children, was also a UK airline pilot
He told the hospital that he would “wait for the report” which is what would have happened if Elaine had died on or near an airplane in the UK. The accident investigation board, an independent investigatory body, would have determined the causes and contributing factors and then published an anonymized report with recommendations on how to improve safety.
Mr. Bromiley was told that no such process existed in the UK and that “that would only happen if you sued us.”
Martin commissioned just such a report, anonymized it and published it “so others can learn”.
These are the things that could cause harm or problems
assessing the risk
The likelihood of a hazard causing harm
Putting in place controls or making a decision
Implementation of solutions that lead to risk reduction or prevention
Documenting the management decisions
A recording of the findings and outcomes of your intervention; if you don’t measure it, it doesn't matter
Allows you to keep track of efficacy of changes
Cyclical review
Check if old interventions are still valid or if there is a better way of risk management now
There is not the expectation that all risk will be eliminated but the goal is to reduce the risk to “as low as reasonably practicable” (ALARP)
The utility of this framing is that it helps set reasonable limits on the degree of intervention needed to address a problem. The example used in the report is “An extreme example is that spending £1m to prevent 5 staff suffering bruised knees would be considered grossly disproportionate”
This allows us to frame successes as reductions in adverse events rather than a total elimination of some events that are unavoidable
The UK’s Health and safety executive, their national regulator for workplace health and safety actually sets a guideline for acceptable risk: death of one in a million per year for both workers and the public
The utility of having this put out by a national board sets a benchmark for comparison
The HSSIB performed some back-of-the-napkin math and found that in 2013 there were approximately 4.7 million surgeries conducted in the NHS per year. Then using the data of reported unintentional retained sponges, they found that the average was one incident every 270,115 surgeries. Since it was not known whether anyone had ever died of a retained sponge, they used a conservative estimate of 1 in 10 retained sponges resulting in death.
Helen had heart surgery (CABG x3 “triple bypass open heart surgery”).
The day after the procedure, Helen had trouble breathing and a Chest X-Ray (CXR) taken for another reason, identified a retained sponge.
She was taken back to the OR and had the sponge removed. As she was quite unstable, the decision was made not to X-ray her in the OR and to close her chest and stabilize her. At 7:30 pm, a CXR identified a second sponge in the same location as the first. The following morning, she had another surgery to remove the swab from her chest. A CXR performed in the OR showed no foreign objects.
Helen was in the ICU for 7 days and was discharged 13 days after her final surgery to remove the second sponge. At home, Helen had ongoing health problems. Helen’s family referred the incident to the HSSIB.
When the investigators first met Helen six months after the incident, she was visibly upset by what had happened and she reported she had received limited mental health support. According to the report, Helen continues to have health and wellbeing issues.”
Background
Investigation began: Sep 28, 2022.
Interim report: Dec 7, 2023 (14 months later) highlighted common themes in 31 serious incident reports (investigations carried out by local healthcare trusts).
Final report: Apr 16, 2024.
Never Events
Defined as ‘patient safety incidents that are wholly preventable where guidance or safety recommendations that provide strong systemic protective barriers are available at national level and have been implemented by healthcare providers’ (NHS Improvement, 2018).” [emphasis added]
Multiple UK reports call for Never Events to be renamed because the events described are not entirely preventable, there are not strong barriers available to prevent them, and by calling them Never Events, it invites stigma and shame and discourages reporting and thorough investigation.
“The count” / reconciliation
Sponges are counted in a specific way, by two nurses, who must agree on the count before the sponges are used
Analysis and findings regarding the reference event (Helen’s CABG)
Mr. Bromiley was told that no such process existed in the UK
Martin commissioned just such a report “so others can learn”.
Importantly, Martin did not seek punishment. He specifically stated that the physicians and nurses that were in that room were intelligent, hard working, caring professionals. He did not blame them. He blamed the system. The system can be changed but first we need to know what happened and why.
The report
A failure of leadership and communication which led to a fixation-induced loss of situational awareness
The physicians became fixated on intubating to the exclusion of other possibilities of providing oxygen (such as FONA).
They became so fixated that they did not respond to the nurses who later reported knowing what needed to happen but being unable to communicate it effectively.
YouTube videos Martin Bromiley produced to improve patient safety:
Some of the links in these show notes are Amazon affiliate links. As an Amazon Associate, we may earn from qualifying purchases, at no additional cost to you. Currently, we receive no outside funding, so we thank you for supporting the podcast, again at no additional cost to you.
Error prevention: reduces the chance of making an error in the first place. Usually through human factors engineering and improving working conditions. The focus is here, which involves planning, discipline, and preparation. (e.g. aircraft design, fatigue risk management, rules around how much additional fuel must be onboard, use of checklists to avoid memory errors).
Error trapping: catching the error before there is any effect. This is often about vigilance and teamwork. (e.g. crosschecking, callouts, assertiveness to encourage speaking up)
Error mitigation: to limit the severity of outcomes. This is about resilience and recovery. (e.g. unstable approach leads to missed approach. Short on fuel > divert to alternate.)
Error chains: a single error rarely, if ever, causes a major accident. It is untrapped, unmitigated error chains that result in accidents.
In clinical medicine we see this often: errors are inevitable (ask any clinician), harm is not.
Medical examples of error management:
Error prevention: pre-printed order sets, standardize drug trays, avoiding look-alike drugs.
Error trapping: Surgical “time-out” checklists before skin incision, closed-loop communication during resuscitation.
Error mitigation: iatrogenic opioid overdose that was recognized and naloxone is given.
Acceptable delays to ensure appropriate margins of safety
There are occasions in medicine and aviation where one group of professionals needs to push back on the production pressure to perform tasks appropriately in order to ensure safety. Both professions must understand that certain delays are required, however, the degree to which this happens is not consistent around the world. Mike gave the example of arriving early to train a new pilot and occasionally needing to close the cockpit door after saying the flight crew needed ten minutes. Amir and Adam gave anesthesia examples where they had to delay the OR in order to prevent or trap errors (additional airway equipment, provide preoperative medications).
CRM is alive and well in medicine, but we must meeting people where they are at
In this episode, there were many examples where medical teams are performing good CRM, particularly Threat and Error Management through the use of briefings. Mike mentioned the public health example of meeting people where they are. We should acknowledge that a lot of CRM strategies and skills exist in modern medicine, but much of it is not formalized.
CRM as an inclusive tool to improve team performance
CRM by its nature of improving team performance has its foundation on clear communication from all team members. While it used to be called Cockpit Resource Management, it changed to become Crew Resource Management to emphasize the inclusion of flight attendants, ground personnel, air traffic controllers, etc. Many errors have been prevented or trapped by ancillary personnel speaking up.
Escalation of Language of Concern
In order to encourage everyone to speak up, formalized escalation of language models exist. In aviation this is the PACE model:
Probing: “I’ve never seen [x] done before. Can you tell me why you’re doing it this way?”
Alert: “The oxygen saturation is 90%.”
Challenge: “The oxygen saturation is critically low, we need to move to BiPAP.”
Emergency: “This is an emergency. Dr. [x] will perform a cricothyroidotomy.”
In an emergency, you can start ‘higher up’ on the PACE ladder, as appropriate, but starting lower is less aggressive and can prevent conflict.
Instrumentation to avoid fixation-induced loss of situational awareness
Cockpit instrumentation is being redesign to account for the fact that hearing is one of the first things to go in a high cognitive load. Rather than just the aural announcements of “terrain, terrain”, the words are being displayed in red letter on the displays in front of the pilots.
Cognitive load in training: much of what we can process related to cognitive load. As novice become experts, they can deal with greater and greater cognitive loads before becoming task saturated. This is well-recognized in pilot training.
Line Oriented Safety Audits (LOSA)
Trained observers in the cockpit observe and report on real-world operations. In this way, an accurate analysis of company-specific operations can occur. These observe comment on both salutary solutions and errors which can then be fed-back to trainers and risk management.
Theoretically, there is no reason such a system could not exist in medicine. In such a system, trained people would observe physicians and provide information solely for the purpose of improving safety, rather than any punitive action.
Use people’s first names as opposed to their title, when it is critical to get their attention.
Who can do what tomorrow
Policy / government / regulator: Canada could have an aviation-style investigation board for medical incidents, as the UK and Norway currently have. This would be a non-punitive investigation conducted by a knowledgeable independent board to determine the causes and contributing factors of specific medical incidents. The report would be anonymized and publicly available and would include recommendations for practitioners, training institutions, medical device manufacturers, and regulators.
Hospitals / heads of department: We saw in aviation how CRM was a data-driven response in the 1970’s and onward to team performance becoming the predominant reason for aviation accidents. We don’t have the same quality of evidence in medicine, however, we need not wait for the government or regulator to mandate the technology that would lead to this data becoming available. The technology exists for audio and video recording (“black boxes”) of the OR, ICU, and resuscitation bays of emergency departments. Individual hospitals or departments could run a pilot program (ensuring that such information is prevented from being used in litigation by invoking current quality of care investigation legislation). Much like Tommy Douglas’s creation of publicly-funded healthcare in Saskatchewan, which was later expended to cover all of Canada, any hospital that begins such an endeavour may be credited with pushing the entire profession in this direction.
Residency program directors: while modules on human factors are a good start, we can look to the evolution of CRM in aviation and see that formalized CRM training with high-fidelity simulation is the gold standard. For those that are already doing this, Mike’s comments about the field of aviation ideally incorporating CRM into earlier stages of pilot training can be instructive for the medical field.
Next episode: Escalating Language of Concern with Dr
Some of the links in these show notes are Amazon affiliate links. As an Amazon Associate, we may earn from qualifying purchases, at no additional cost to you. Currently, we receive no outside funding, so we thank you for supporting the podcast, again at no additional cost to you.
“The continuous extraction of environmental information. The integration of this information with previous knowledge to form a coherent mental picture and the use of that picture in directing future perception and anticipating future events.”
In essence: noticing what is going on, processing it, and understanding its significance (what will likely happen in the future).
Avoiding fixation-induced loss of situational awareness
Continually scan the environment for cues (vital signs, patient picture, staff, look at the floor for blood, fluids etc)
Recognize that any complex or lengthy procedure will lead to task saturation and a loss of situational awareness (e.g. intubation, chest tube / central line insertion, vascular access etc)
Avoid doing those tasks or delegate the running of the resuscitation to someone else if you are the only provider that can complete that task
Continually seek input, challenge/prove assumptions, and summarize the situation to allow others’ to improve your situational awareness
Use closed-loop communication: expect it, and ask it of others
Buy time: summarize, have standard phrases (e.g. “IV, O2, monitors, I want a full set of vitals including glucose and temp”)
If you’ve lost SA, say so. “I’ve lost situational awareness due to the intubation. Who knows what’s going with X, Y, and Z?”
Summarizing for the team (shared mental model)
Where we’ve been
Where we are currently
Where we need to be
Priorities for making that happen
Telling the team the working diagnosis (e.g. respiratory failure, PE, etc) can help them access their own mental schema for that and they can watch for your blind spots and anticipate things that may be otherwise forgotten. It also makes explicit the idea that what is going on is a life threatening emergency and reduces confusion.
Say “critical finding” to alert the team to issues
When to summarize:
At handover (establishes roles and sets priorities)
Before and after a critical procedure (e.g. intubation, chest tube insertion)
A critical change in the patient’s condition
Tips for leading resuscitations with fewer resources
Fewer hands increases the importance of prioritizing and not overloading your colleagues
‘Chunking’: Make a list of medications and batch them in three’s (these 3 first, then these 3, etc.)
Use whiteboards / paper to hold the big picture, as things may not move as fast
Manage your workload: Give the list and say “please let me know as these medications are given” (then you can focus elsewhere)
Optimizing Crisis Resource Management to Improve Patient Safety and Team Performance: A handbook for all acute care health professionals. Edited by Peter G. Brindley and Pierre Cardinal
Dr. Lin’s tips on building rapport and interpersonal dynamics: (51 mins)
Start from a place of mutual respect and professionalism
Who is in the room / on the call? What is their role?
Disagreements happen, but we must be able to disagree in a professional manner
Stay grounded and help others to stay grounded. (e.g. Pause, take a breath, remind everyone “this is a recorded call”)
Validate feelings of frustration: “This is a challenging situation”
Hit the reset button: “I think we’ve gotten off to the wrong start. Can we pause and reset? Can we start again?”
Acknowledge the person’s expertise and find common ground: “I’m asking for your help right now because I’m really worried about this patient. I would really appreciate your help because I don’t know what to do next. I think we can agree on X, Y, and Z.”
Announce: “Critical finding [x]”
Assertiveness models
The ‘I notice’ model
I notice [x finding] “I notice that the oxygen saturation is starting to drop. Do you want to do anything about that?”
I wonder [why the provider is doing something]. “I wonder if we should apply a non-rebreather mask at 15L/min?”
I worry [express specific concern] “I’m worried about the hypoxia.”
This is an emergency (I’m taking over)
The PACE model
Probe: “Why is [x] being done?”
Alert: [X finding]
Challenge: “We need to do [Y[“
Emergency: “This is an emergency” (I’m taking over)
Other resources
Optimizing Crisis Resource Management to Improve Patient Safety and Team Performance: A handbook for all acute care health professionals. Edited by Peter G. Brindley and Pierre Cardinal
Some of the links in these show notes are Amazon affiliate links. As an Amazon Associate, we may earn from qualifying purchases, at no additional cost to you. Currently, we receive no outside funding, so we thank you for supporting the podcast, again at no additional cost to you.
Simulation directly works on team dynamics; improving team dynamics may improve the work environment and improve retention
Different kinds of simulation
There is a specific kind of simulation focused on logistics and ergonomics
Although some Simulation focused on CRM principles may bring this out, there is a dedicated form of simulation meant to test this
This can be implemented locally without a lot of equipment or cost by a hospital “code committee” to solely look at implementation in a site or system
Rapid cycle deliberate practice is a tool you can use to work on specific technical skills in a short time frame without needing a full theatre simulation experience
Can we use simulation as an evaluation tool for competency?
In medicine, we are rarely given the opportunities to practice what we learn in simulation, or real life scenarios reflective of what we see in simulation, so there are not many opportunities to practice these events prior to being evaluated on them
If we build a training system that the skillsets of CRM are taught well, and people have the opportunity to practice those skills, in training and in independent practice, with a very low barrier to entry, we may have the foundations for using simulation as a competency assessment tool, like they have in aviation
There are some residency programs that make simulation a mandatory part of their program and use it as a formal assessment tool during their licensing
Some key CRM themes
Fixation vs focus:
Fixation is when you devote your attention and mental resources to the wrong thing in a crisis situation
Focus when you devote your attention and mental resources to the correct thing in a crisis
If you are maintaining your situational awareness (an accurate mental model of what is occurring and what the priorities are) then you are not fixated.
The issue is that our attention narrows when performing complex tasks and we lose our situational awareness (e.g. when intubating, we momentarily lose sight of the bigger picture).
Either delegate such tasks (IV access, intubation, chest tube insertion, etc) or have someone else run the rest of the resuscitation and then inform you of what occurred while you were performing that task.
If our system is built around the infallibility of a single person, or a few key people, our system will inevitably fail because no one can be perfect 100% of the time
Crisis resource management is fundamentally moving from a theoretical solution to a problem in crisis, to a practical solution to this problem
Ways to improve your performance in crisis
Think about the resources you have available that can help you; sometimes this is a colleague, or a more experienced member of the team. You may also lean on support outside of your immediate institution
Use a whiteboard or other visible task board to help maintain situational awareness in crisis and manage priorities
Develop and practice communication, situational awareness, leadership and communication, even if it is in a low fidelity sessions like table rounds, similar to journal clubs you may already have
Some of the links in these show notes are Amazon affiliate links. As an Amazon Associate, we may earn from qualifying purchases, at no additional cost to you. Currently, we receive no outside funding, so we thank you for supporting the podcast, again at no additional cost to you.
Conversely, the response in most medical safety protocols is to warn practitioners of the dangerous conditions and then blame them when the bad outcome occurs, because this time they knew about the dangers. We should instead insist on changing the working environment, which produces the errors.
Medicine being one of the oldest professions in the world and certainly one of the most complex, contributes to the difficulty in changing its culture.
In changing the culture of medicine to improve the overall system, we also need to consider how the training of healthcare professionals entrenches the stigma of reporting errors.
There is no true tension between training excellent physicians and reporting systemic deficiencies, because “stress testing” of physicians can happen in simulations and true-emergencies, while we also work to improve day to day conditions for everyone.
We are moving towards a model of care where we speak of Centres of Excellence, rather than “who is the orthopaedic surgeon?” Medicine is team-based and even, or perhaps especially, community hospitals whose teams are well-known to each other can deliver excellent and safe care.
R v Omstead, [1999] OJ No. 570
1999 in Leamington, Ontario Nurse Omstead was charged with manslaughter (criminal negligence causing death) after she gave potassium chloride thinking it was furosemide because they were lookalike drugs stored close together.
The judge acquitted Omstead because the Crown failed to prove beyond a reasonable doubt that her actions were a marked departure from a reasonable nurse in her situation. The judge noted that latent conditions such as the drugs looking alike and being placed together were significant factors in the error.
The judge also noted that the error had been reported by Omstead herself and a conviction could have a chilling effect on future reporting of errors.
Criminal trials are held to determine criminal blameworthiness and judges in such cases cannot make recommendations to hospitals or policymakers.
Investigating errors as being produced by the working conditions and being related to systemic deficiencies does not mean that individuals cannot be held accountable for gross negligence (e.g. intoxication). It does mean that if, for example, training deficiencies are found, the training system can be corrected and everyone who was similarly situated can benefit.
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Importantly, Martin did not seek punishment. He specifically stated that the physicians and nurses that were in that room were intelligent, hard working, caring professionals. He did not blame them. He blamed the system, but the inquiry did not end there. The system can be changed but first we need to know what happened and why.
The report (see MSP Ep 1 - Elaine Bromiley)
Professional, third-party investigation may help
Avoid the fundamental attribution error in medicine, which suggests that when we see another’s actions, particularly errors, we attribute them to individual failings, but when we see our own, we see them as products of the environment or context.
By running similar can’t intubate, can’t oxygenate scenarios, it was seen that many anesthetists at the time, fell into the same patterns of behaviour that led to Elaine Bromiley’s death, so arguments that “I wouldn’t have done that” are not credible when put to the test.
Provide a “win-win-win”
Patients and loved ones win as they generally want to know what happened and how the system can learn to prevent it in the future;
Hospitals and healthcare systems win because safety is tangibly improved; and
Practitioners win by also becoming better, but also knowing that it wasn’t all on them. That the system failed and it was not a moral or individual failure on their part. This reduces moral injury and distress for the practitioner. In this way, we preserve a much needed resource in the healthcare professional, but also in the person who is less likely to self-harm.
Provide commentary about how the system as a whole, which includes the regulator, operates, as opposed to looking at one hospital or one profession.
Blame-culture in medicine
The blame-culture in medicine is so ingrained that some view physicians as more culpable than pilots given a similar set of circumstances (physicians taking care of Elaine Bromiley vs pilots in United Flight 173).
The idea that the physician has all the answers and can save the day all on their own is an outdated concept that has no place in modern team-based medicine.
Human factors are so called because they are a part of the human condition and they exist amongst all high-risk industries.
There are many ways of getting human factors training and investigation into medicine, but perhaps the most likely to be permanent is when the front-line professionals demand it.
In medicine, we need senior clinicians to describe times when they’ve made mistakes. Not things that were mostly someone else’s fault, but time when they made a serious error. This will allow more junior members to talk about these issues and that is the starting point for fixing these issues. Those clinicians that do this, will be remembered as it is rare these days.
Audio-Video Recordings (“Black Boxes”) in Healthcare
With much of society being recorded, patients are often surprised that we don’t audio and video record in resuscitation areas (ORs, ICUs, ED’s). One reason for this is the lack of specific legislation that exists for other industries (such as protects the black box recordings from being used in court). It is possible that current quality of care legislation can be invoked to protect such records should anyone want to start a pilot project, but certainly this is an area that needs to be explored before full implementation of nation-wide recorders would be likely. In the UK, the HSSIB has specific legislation protecting such recordings.
Making it easier to get it right and harder to get it wrong
In general, we need more interventions in healthcare that make it easier to get things right and harder to get things wrong. As Professor James Reason’s work shows, errors are a part of the human condition and while we cannot change the human condition, we can change our work environment.
The Health Services Safety Investigations Body
The HSSIB works a bit differently from the AAIB (the UK’s air accident investigatory body). While aviation investigations and reports focus on specific accidents, the HSSIB may start by looking at one incident, but generally looks at a number of similar incidents and publishes a report where all the incidents have a specific theme.
Independence of investigatory bodies from the regulator is of prime importance otherwise credibility is in question.
Learning from excellence
Medicine can export good ideas to other industries, such as “learning from excellence”. This means that we should be investigating notable times when things went right, so that we can improve our chances of success.
Justifying the costs of safety endeavours
It is impossible to measure harm that is prevented (because it is a non-event);
Society spends millions of dollars investigating aviation accidents where only a few people died. Why should it matter that someone died on an airplane vs in a hospital, if there is the potential to prevent their death?
We spend billions of dollars helping heal people after the healthcare system has harmed them and there can be considerable cost savings associated with improved systems safety.
Safety intervention worth mentioning
The YouTube videos Martin Bromiley produced to improve patient safety
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This resulted in a “risk to life” (RtL) of < 1 in 1 million, which indicated that based on the HSE”s tolerability framework, the risk of harm may be deemed to be at an acceptable level for healthcare organizations.
The use of tools and technology for reconciliation
The report provides some recommendations and comments regarding the way the count is currently conducted and they break it down into technical and non-technical tools
Non technical tools
The manner in which each scrub nurse laid out their scrub table allowed many of them to immediately identify a missing sponge; “Swabsafe” trays with specific placeholders for used swabs, but these were not favoured by everyone; other tools.
Technical tools
Radiofrequency identification (RFID) tags (preferred by HSSIB who noted that this measure has been adopted in the US for this purpose)
Read multiple tags simultaneously
Can be read when out of sight (e..g in the human body) at > 10m
Many studies in the US showing they can reduce the number of retained sponges and improve the efficiency and effectiveness of the count, as well as reduce costs.
Barcoding - swabs in and out, but must be scanned
The findings of the report
A range of interrelated system factors (tools, technology, organisation, task, environment, and people) influence the reliability of the sponge count.
The reconciliation process has not been formally analysed or designed using human factors expertise (where the interactions between people and other elements of the system in which they work are explored) or any other process design expertise.
Other safety-critical industries assess and control risks to be ‘as low as reasonably practicable’ (ALARP), where there is not an expectation to eliminate all risk. These risk management principles have not been applied to the risk of swabs being unintentionally retained.
There is no accountability framework, and it is unclear who owns the risk for retained swabs and reducing the risk for retained swab events to as low as reasonably practicable.
Blame can be inappropriately placed on scrub nurses or surgeons when an item goes missing, rather than the reconciliation process being seen as a team activity and one that can be influenced by a wide range of interrelating factors.
Staff and national organisations had varying views on the roles and responsibilities for swab reconciliation; limitations in training were identified.
The investigation was told by various national organisations that there is a concern about removing Never Events from the NHS’s framework and how determining risk appetite (where it is accepted a level of harm will occur) will be perceived by the wider public.
The design of swabs does not help staff to locate, identify, or track swabs during the reconciliation process.
There are technologies and tools that could be used to improve the accuracy of the swab count; however, these have not been embedded into UK healthcare.
The technology and tools have not been formally considered using risk management principles in terms of reducing the risk to as low as reasonably practicable, or how the technology could reduce other patient safety concerns while also supporting productivity and efficiency in healthcare.
The Recommendations
“HSSIB recommends that the Centre for Perioperative Care (CPOC) and Association for Perioperative Practice (AfPP) continue to work together with other key stakeholders to review, amend and embed the process and standards for the reconciliation of swabs ensuring it is robust. This review should utilise human factors expertise and user-centred design principles, to reduce the risk of retained swabs to as low as reasonably practicable. Any changes to either organisation’s processes should consider potential unintended consequences and the influence on other safety-critical tasks and include consideration of professional roles and responsibilities in relation to swab reconciliation.”
“HSSIB recommends that NHS England develops a framework to assess whether risks, such as retained swabs, are reduced to an acceptable level. This will allow organisations to develop their risk strategies and document their risk acceptance criteria and tolerance.”
“HSSIB recommends that the National Institute for Health and Care Research assesses the priority and feasibility of commissioning research to review the viability of implementing technology that could support reducing the risk of retained swabs. The review should balance patient safety, costs, benefits, design, implementation, and the various ways in which the technology could be used to reduce other patient safety concerns to as low as reasonably practicable.”
HSSIB Safety Observations
“Manufacturers of swabs can improve patient safety by facilitating better detection of retained swabs through user-centred design.”
“The NHS can improve patient safety by ensuring procurement decisions about swabs are made on a risk-informed basis that incorporates evaluation trials and user-centred design processes in the design, manufacture and testing of products.”
“Multidisciplinary team training can improve patient safety by increasing the understanding of team roles, responsibilities, teamwork, the interrelationships between the work system and people and ultimately improve the care of patients undergoing an invasive procedure.”
“A user-centred evaluation of non-technical tools to aid the swab count can improve patient safety by helping national organisations and trusts assess whether their risk of retained swabs is as low as reasonably practicable.”
Health Services Safety Investigations Body (HSSIB) reports
It doesn’t have to be gardening but have a small plant or flower that you can take care of. It is helpful to watch something grow and develop. As a resident can be very low stakes
Documentary about Canadian Comedian, actor and writer Martin Short. Features many comedians and hilarious stories
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The HSSIB: “Limitations in the evidence meant it was not possible to identify precisely what happened during Helen’s surgery to result in two swabs being retained."
It is curious that the first finding of this report is that the available evidence made it impossible to determine precisely what happened during Helen’s surgery, yet there is no mention of recording devices in the report. In aviation, they had to invent a robust means of recording what occurred in order to determine what happened and how to prevent future accidents. In this case, OR Black Boxes would almost certainly have provided the evidence needed. Patients continue to be placed at risk by the unavailability of this information.
Factors affecting the sponge count
responsibility for swab counts (surgeon vs scrub nurse)
communication of information about swabs
Surgeons not informing scrub nurse when a sponge was inserted
visibility of swabs
Not in direct line of sight
Soaked with blood and therefore lacking contrast with surrounding tissue
Radiopaque stripes appear similar to other lines on XR and when an XR is performed for another reason, no one is looking for a sponge.
the make-up of the operating theatre team
When there is a change of nurses, the count wasn’t always being conducted between the outgoing and incoming nurses
the timing of the count and its confirmation at Sign Out
the type and duration of the surgical procedure
professional culture and practice
Surgeons taking swabs directly from the nurse’s table without informing the nurse.
distractions and interruptions
competing tasks (counting while doing other tasks)
time pressure
time of day
More common in surgeries between 2 pm and 7 pm, raising concerns of fatigue (HSSIB noted further data are required here)
clarity of policies and procedures - lack of clarity on specific times counts are to be performed
The report again identifies weaknesses in the level and quality of the evidence available in the investigation and finds that there may be other factors that affect the reliability of the count that could not be identified because of that.
Factors affecting the detectability of the sponges in Helen’s chest
Sponges come with tails, but these were cut off before the sponges were used.
Sponges absorb blood and then look like tissue.
Sponges can be very deep in a cavity and be obscured from view by organs.
Factors affecting the detectability of the sponges on x-ray
There were many other items visible on the CXR (tube, lines etc) making the sponges more difficult to detect.
The clinicians were focused on other theories for Helen’s deterioration.
Factors affecting detection of the second retained sponge
Staff thought there was only one sponge.
Helen was unstable and it was deemed unsafe to conduct an extensive search of the chest cavity or an X-ray.
Analysis and findings of the wider investigation
The low frequency of retained foreign objects following invasive procedures indicates that the counting system is largely successful, however, counting items is not a strong systemic barrier.
There is a tension between spending more time on something that seems to be largely working well (the count) and the need to be efficient with operating room time (or else harm comes to patients).
HSSIB explicitly identifies the conflict that is present in frontline healthcare workers’ minds: ‘every minute that is spent attempting to improve a process that works most of the time is a minute of OR time that another patient cannot receive’
The HSSIB resolves this tension by pointing out that while ‘Frontline workers generally operate under rules and procedures which provide a normative standard against which their behaviour can be judged. In contrast, designers, managers, and such generally operate with more degrees of freedom.” Meaning we may be able to design better sponges and use system measures rather than people-focused measures to reduce this risk without a tradeoff.
OR Black Boxes & Medical Culture (Patreon-only)
Safety intervention worth mentioning: The Hierarchy of Intervention Effectiveness (see diagram)
In North America, medical culture places the emphasis on the frontline staff to get it right and when incidents are made known to staff, there is an expectation that that awareness should be sufficient to prevent it from recurring. This is as opposed to changing the working conditions, which is Professor James Reason’s main conclusions in his life’s work.
In the interim report, the HSSIB refers to “The Hierarchy of Intervention Effectiveness” from Cefazzo and St-Cyr, 2012, which shows various interventions and their relative effectiveness.
“The hierarchy is a tool for ranking the effectiveness of measures used to reduce the risk of a safety event. Measures that rely on people are considered to be less effective.”
The solution is to change the working conditions
Health Services Safety Investigations Body (HSSIB) reports
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