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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4:11 Multi-Crew License & Pilot Proficiency Checks
16:32 Crew Resource Management definitions
32:11 Situational Awareness
41:43 Cooperation
48:36 Decision Making
1:02:51 Safety Intervention Worth Mentioning
1:06:51 Who can do what tomorrow?
1:11:08 Random recommendations & conclusion
Show Notes
CRM definitions (From TC Approved Check Pilot Manual):
Situational Awareness: an ability to accurately perceive what is taking place inside and outside the aircraft
System Awareness
Environmental Awareness
Awareness of time and anticipation of future events
Cooperation
Team building and maintaining
Consideration of others
Support of others
Resolving conflicts
Decision Making
Problem diagnosis
Option generation
Risk assessment
Option selection
Outcome review
Leadership and Managerial Skills
Use of authority and assertiveness
Providing and maintaining standards
Planning and coordination
Workload management
CRM has evolved in aviation
CRM started as a pilot-led and evidence-driven response to aviation accidents in the 1970s and 80s where team performance led to accidents, rather than mechanical failure
Evaluating pilots-in-training in both their technical and CRM skills is structured and formalized.
In every pilot license, there is a ground school, a written exam, flying lessons, and a flight test as well as minimum flight hours and experience. They are evaluated on their technical and non-technical skills.
Flight tests include scenario-based oral exams similar to physician board exams.
Currently pilot training programs in Canada are starting to shift from modular or block-style training (private license, adding night and instrument ratings, etc.) to a more integrated philosophy to train multi-crew airline pilots from day one.
A Pilot Proficiency Check (PPC) acts as a type rating that is added onto an existing pilot license for a specific type of airplane. This happens roughly every six months and reviews both normal procedures and emergency procedures.
Given the basics of CRM described above, pilots are marked based on four global points (effective, acceptable, poor, unacceptable) while examiners think about possible CRM elements including:
Did they anticipate the threat?
Do they make inquiries for more information?
Do they consider downstream consequences
How was the situational awareness?
Did they communicate appropriately?
How did they manage their workload?
How did they get rid of distractions?
Was the aim achieved?
Errors are deemed as “critical," "major," or "minor," each with their own repercussions on the outcome of the flight test.
The CRM framework allows us to trace back errors observed and trace back why they might have occurred.
In aviation the Pilot Proficiency Check is a check on a specific aircraft where a line check is run by the airline to determine the safety and effectiveness of company-specific policies and procedures.
Situational Awareness
“We all have our own mental models about a certain situation, and if it is accurate, this means that we have good situational awareness."
We may have fixation-induced loss of situational awareness through task saturation (e.g. intubation, troubleshooting landing gear)
Captain Schuster imagines workload management in three buckets: information can be perceived, processed, and then acted upon. Each must be balanced to function well.
Cooperation
Cooperation: the ability to work effectively as a team.
Cooperation begins in the formation of the team and considers the skills and attitudes of individual members.
Basic conflict resolution techniques can aid in examining the root cause of errors.
A debrief of the exercise is just as important as completing the full exercise in examining the components of CRM that failed and that were successful.
Decision-making
Decision-making includes identifying the problem, generating options for action, assessment of the risk, willingness to reassess the plan, and analysis of the outcome.
Decision-making in aviation is most often evaluated in the debrief, where the examiner and the trainee discuss the thought processes of the trainee and hypothetical cases.
“The event in the simulator is the practice, the learning takes place in the debrief.”
Leadership, Managerial Skills (and followship)
Designated leadership (e.g. Captain) versus functional leadership (context-specific, depending on who has the most relevant experience)
Followership: giving appropriate feedback at the appropriate time, asking questions if unsure, suggesting alternate courses of action (which requires good situational awareness).
Authority gradient: if too steep, people will not speak up when necessary. If too flat or out of balance, there is a risk of failure of leadership.
Good leaders use functional leadership to achieve goals. (e.g., the First Officer has more experience at a particular airport).
Good followers will use graduated assertiveness when necessary (e.g., the Probing, Alerting, Challenge, Emergency (PACE) model described in Episodes 3 & 4).
Leadership on the flight deck incorporates planning and coordination.
For example, in November, Captain Schuster will ask his First Officer, “Have you needed to de-ice yet this season? Have you had a chance to look over the checklist in advance so there aren’t any surprises?”
Workload management is also a part of leadership, where the leader assesses the situation and then delegates appropriate tasks with clear communication while ensuring they are not task saturated.
Appropriate feedback to trainees and to their training unit allows both individual and system-wide deficits to be studied and improved on.
CRM in medicine
The concept of a Pilot/Physician Proficiency Check (PPC) where a physician must recertify their proficiency at normal and emergency procedures, exists in certification courses such as ACLS, ATLS, and NRP. We do not have specialty or institution-wide proficiency checks after the specialty exams.
Medicine remains very individual-focused as opposed to team-focused (e.g. one doctor runs the code and must think of the next steps of action, whereas in a flight emergency the captain often gives control of the aircraft to the first officer, leaving them free to think about next steps).
Medicine has started to recognize the importance of debriefing after resuscitation or critical events.
Re-enactment of a check flight and assessment of CRM (YouTube 19 mins). The issue starts in the briefing where the First Officer lacks trust due to the Captain’s apparent lack of knowledge. This leads to an in-flight emergency that results from a poorly managed abnormal event: an electrical problem. During the running of the checklist, no one is flying the airplane (monitoring the airspeed, which was previously too fast and the thrust levers retarded), the stick shaker activates, indicating an aerodynamic stall is imminent and the crew recovers from the Undesired Aircraft State (UAS). During the debrief, we see the learning take place.
Started with anesthetists focused on post-operative outcomes, in response to post operative deaths eventually adopted by surgeons, and finally into all medical practices
Periodically release reports on key topics related to quality of care
Consists of a small team of non-clinical staff, clinicians, and a board of trustees
Funding comes from the NHS England directed through departments of Health and Social Care.
According to Dr. Mason, the mandate of the NCEPOD is to “use clinicians to highlight where they think they can improve care."
NCEPOD reports, while not being formal academic research, can act as the initial bridge to new safety interventions; the NCEPOD process attempts to identify common issues in different care environments and works on reports to provide recommendations; it exists somewhere between an audit and a Quality improvement body
The process of the NCEPOD (roughly two years) includes
The National Confidential Enquiry into Patient Outcomes and Death (NCEPOD) - Common Themes 2024 Report
The NCEPOD Common Themes Report was first published in 2018 as a “living report” of key topics to be discussed in the care of hospital patients. It was subsequently updated in 2024 to the current edition with a stronger focus on communication, transition planning, and follow-up.
Common Thread: health care often does not fail due to technical proficiency, rather, it fails due to lack of teamwork, weak communication, poor documentation, and delayed recognition of deterioration.
The NCEPOD may serve as a useful guide for healthcare workers and policymakers looking for ways to optimize patient safety and flow through the institution.
Colon cancer screening is conducted in Ontario with the Fecal Immunochemical Test (FIT). The test detects microscopic blood in the stool.
An abnormal FIT leads to a colonoscopy which can detect colon cancer or polyps before they turn into cancer.
Screening tests
A screening test is used to test populations that are at average risk for a disease. It is difficult to design a screening test, because they have criteria.
A good screening test targets an important condition with a detectable preclinical phase, accurately identifies disease, is safe and acceptable, leads to an effective intervention, and (most importantly) improves meaningful patient outcomes while minimizing harms such as false positives, overdiagnosis, and unnecessary treatment.
Changes to the FIT
On July 1, 2026, the Ontario government lowered the eligibility age for people to access publicly funded colorectal cancer screening from 50 to 45.
At the same time, they change labs from LifeLabs to In-Common Laboratories (ICL), which did not have the same ability to communicate the results digitally, as was previously done.
The lack of digital communication was replaced with faxed results. This means that:
Results do not integrate with family physicians’ digital inboxes;
Electronics flags and red highlighting of abnormal results are not available;
Front-office staff, which are typically not involved in digital communications, must manually review the results;
Digital reminders in physicians’ Electronic Medical Records (EMRs) are not updates - a considerable issue since many family physicians have over 2000 patients each. This increases the risk of missed future screening;
Increased risk of delayed or missed diagnosis of colon cancer, which ultimately increases the risk of morbidity and mortality (disease and death) from colon cancer in Ontario;
Batch faxes: faxes with multiple patients on the same page, which increases the risk of communication errors; and
Patients being informed by letter of possible colon cancer before their physicians have been informed.
Excellent care is one goal, but well-connected and easy to navigate care is an entirely different matter.
In the current healthcare system, it is practitioners that are keeping people safe by filling in the cracks in the system, rather than the system helping to make it easy for practitioners to get it right, and harder for them to get it wrong.
Dr. Benneyworth on behalf of the HSSIB notes the importance of meeting people who have been harmed by the system. Listening to patients is important, including if not especially after a bad outcome.
A significant benefit of the HSSIB is that it has healthcare, human factors, and other industry expertise that is ready to investigate immediately, rather than waiting for a commission of inquiry to be stood up.
Canada does not have a national healthcare system. What started as a social experiment in Saskatchewan with Tommy Douglas, became what we now know as the Canadian healthcare system because of a cost-sharing legislation (The Canada Health Act).
As healthcare is mostly administered under the provinces, there is nothing stopping a province from creating a body like the HSSIB.
Despite the HSSIB being a relatively new body, there is already evidence of its efficacy. For example, after the aortic dissection report, evidence suggests that approximately 300 more people a year are being identified as having an aortic dissection and are getting life-saving surgery.
Just as some issues require a national response, there are likely issues that require a multinational response (e.g. medical devices, similar to how airplanes are subject to Airworthiness Directives / grounded for mandatory maintenance).
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
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.”
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
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The data is pooled, and narrative recommendations are created
The recommendations are reviewed by all stakeholders prior to publishing
In England, every hospital has internal designated NCEPOD “local reporters” who serve as intermediaries and repositories of adverse events/NCEPOD relevant issues and liaise with the NCEPOD
The NCEPOD looks at a large number of incidents and institutions to assess quality of care, and shortcomings broadly, whereas the Health Services Safety Investigations Body (HSSIB) investigates individual cases to identify broader issues related to patient safety.
The NCEPOD is similar to a deductive approach
HSSIB uses an inductive approach
Both branches may use multiple cases to draw a conclusion about patient care but have different starting points and philosophies and may refer to each other as appropriate
Examples of NCEPOD work include the introduction of NCEPOD “Theatres,”dedicated emergency operative rooms as opposed to emergency procedures bumping elective operating room slates into the evening or night.
Dr. Mason is particularly proud of the NCEPOD for its part in
Providing clinical voice for clinicians who want to make a difference
Having a formal process for reviewing individual cases that occasionally lead to specific patients having an improved outcome
Changes to trauma care in the UK to an organized service centred around major trauma centres. Trauma: Who Cares? (2007)
Similar to the Transportation Safety Board (for aviation) watchlist, the NCEPOD has a list of “Common Themes” which highlight key themes in quality of patient care
Dr. Mason’s key suggestions in advocating for the creation of something similar to NCEPOD in Canada:
Highlight how the work is directly relevant to patients while engaging clinicians as opposed to punishing them.
Acts as a protective mechanism for the healthcare institution.
Emphasizes clinicians volunteering their time to reflect on cases of other clinicians and generate insights into how care could have been improved
In addition to the above, the timeline was extremely short: primary care partners were not informed until 70 days before the go-live date.
That digital integration was not made a condition of the lab contract and how this is a structural gap in program design as well as the lack of primary care input at the design level.
That this is at odds with Ontario Health’s own Patients Before Paperwork commitment. In that Ontario Health initiative, Ontario, in 2023 made a major commitment to “axe the fax,” including eReferral and centralized intake / care coordination.
Ontario has said that to mitigate this risk, front-line office staff should be vigilant in looking for the faxes.
This is another example of the medical system relying on front-line practitioners plugging the gaps in the system and how this contributes to physician burnout, which can deprive communities of an important resource.
If Ontario’s healthcare system had a Safety Management System (SMS), a risk analysis would have been conducted
At a minimum a proper SMS that included proactive safety measures would have identified the risk that the transition created.
In this case, the FIT test has not changed but more people are being screened, so an analysis of whether the increased risks of delayed and missed diagnosis were counterbalanced by overall less morbidity and mortality for screening more people a few months earlier, would have been conducted.
This is a balancing of the risk of early implementation with poorer communication standards compared to the risks for those aged 45 to 49 who wouldn’t be screened until the proper communication standards had been achieved. The analysis would have to show that more lives / harm would be saved with early implementation compared to the number of lives lost.
Risk management in mature safety management systems
Key elements of risk management:
identifying hazards (things that could cause harm) (e.g. poorer communication standards leading to increased risk of delayed or missed colon cancer diagnoses)
assessing the risks (the likelihood of a hazard causing harm and how much harm may be caused) (e.g. estimate the number of delayed and missed diagnoses of colon cancer)
putting in place risk controls as appropriate (e.g. delaying the transition until the same communication standards are in place)
documenting the management decisions
reviewing the risk controls (an iterative process)
Within risk management there is not an expectation to eliminate all risk, but to reduce risks to ‘as low as reasonably practicable’ (ALARP). This requires risk to be balanced with efficiency.
“The decision process begins with a presumption that the risk reduction measure should be implemented. It would only be deemed reasonable not to implement the risk reduction measure if it would be ‘grossly disproportionate’ to the benefits that would be achieved. An extreme example is that spending £1m to prevent 5 staff suffering bruised knees would be considered grossly disproportionate”
Meaning the government-of-the-day bears the onus to show that the risks and the costs were considered.
Safety management systems improve efficiency and safety
A safety management system and risk analysis is not a hoop to jump through or a bureaucratic process: it is a process that guides decisions to make them not only safer, but more efficient, ultimately leading to cost savings.
In this case, considerable time and expense has been required to mitigate the risks caused by the reversion to faxes. Many meetings, use of front-office staff, etc.
For those unfortunate Ontarians that have delayed or missed colon cancers, the healthcare system will spend enormous sums of money caring for them. The costs of one colon cancer surgery on the system alone would likely pay for the time it would have taken to conduct a proper risk analysis, not to mention the agony and hardship for the family of that person.
Dr. Barber wonders whether the current system of issuing FITs to patients, rather than, for example, having them available at the pharmacy, would improve uptake of colon cancer screening.
Safety Intervention Worth Mentioning: Section on General and Family Practice (SGFP) Advocacy Campaigns
Section on General and Family Medicine website: SGFP.ca
Chair’s Letters (how Adam and Amir first discovered this issue)
Policymaker / government / regulator: Take heed of the issues presented here and work quickly to at least restore the level of communication of FIT tests in Ontario to what it was previously. In the future, perform a risk analysis.
Primary Care Offices and Practitioners: Tell your Member of Provincial Parliament (MPP) of the difficulties and risks to the patients you’re treating. Advocate for system change. In the meantime, ensure office staff know what to look for.
The HSSIB does a lot of work in observing how work is actually performed in healthcare (work as done, as opposed to work as imagined).
Providing empathetic care can protect against burnout.
As the HSSIB retained sponges report shows, by redesigning the system (e.g. RFID tagged sponges) we can improve patient safety, increase efficiency, and reduce costs all at the same time. Improved safety does not necessarily mean increased costs, in fact, in the HSSIB’s experience, the opposite is true - that the safest organizations are often the most efficient.
OR / Resuscitation Recorders
In the sponges report, the HSSIB was not able to determine what happened in the reference event where sponges were left inside a patient. This is because the only evidence available was from the people’s memories of those events.
The HSSIB did not turn their mind to recommending OR recorders.
In aviation, the black boxes (Cockpit Voice Recorder and Flight Data Recorder) were invested to gather such evidence.
Concerns raised regarding the potential use of OR recorders
Medical culture (are we ready for them?);
Patient privacy;
Misuse of the data (i.e. for discipline); and
Cost of installation and maintenance.
Adam’s rebuttal of these:
Medical culture is informed by the use of technology and as the HSSIB gains a reputation for safety, a just culture emerges. Rather than wait for medical culture to change, we can change medical culture through the appropriate use of this technology (just as we did in aviation).
Patient privacy: gain consent (as is currently done by the few organizations that currently use OR recorders) or anonymize.
Misuse of the data (i.e. for discipline) - legislation and policies similar to what currently exists in aviation. Also, only the safety investigator and no one else can access the data; and
Cost of installation and maintenance: in terms of cost-benefit analysis, this is a low-cost for significant benefit.
Safety Intervention Worth Mentioning: Health Services Safety Investigations Body (HSSIB) reports
Adam: Be inspired by the expertise and passion people have in a field other than your own. I was reminded of this by famed US author, lawyer, and happiness guru Gretchen Rubin. She recently told the story of a colleague of hers and linked to a CSPAN panel that she was on about former US Supreme Court clerks.
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
Analysis and findings regarding the reference event (Helen’s CABG)
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
Snowbirds to be grounded after the 2026 season until 2030 when they acquire new aircraft (CBC: May 19, 2026)
Amir: Be a tourist in your own city
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.
Martin commissioned just such a report, anonymized it and published it “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, 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
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
