Medical Safety Podcast

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Formula 1 Pit Stop Study

• Pit stops have evolved extensively over the years. See here
• Pit stops need to be done reliably and quickly
• Analyzed the F1 pit-stop process and applied to a patient handover process for moving pediatric cardiac surgery patients to the intensive care unit
• Emphasized clearly defined roles, sequencing, leadership and structuring communication.
• Recent work on radio-frequency identification (RFID) surgical sponges highlights the importance of research in patient safety interventions. His recent study found that RFID sponges had only a marginally acceptable benefit.

Current barriers to developing aviation-structured CRM in medicine: lack of training from healthcare workers, a focus on individuals versus teams, and cultural resistance to system change.

• Healthcare workers don’t have to demonstrate their ability to effectively communicate before being licensed
• Failure to properly train healthcare professionals on new protocols, checklists, procedures, etc.

Using of ideas from other industries takes research, adaptation, and training

CRM works to improve the performance of frontline workers. Moving beyond CRM focuses on human factors in the design of systems.

• Human factors in system design emphasizes how human behaviour and the limitations of human performance can be understood to enhance system performance.
• Human factors research initially started in the 1940’s in aviation, when focusing on pilot confusion between flaps and landing gear (two similar levers) in a basic airplane. The initial solution was to change the shape of the levers.

Employment of a human factors scientist in healthcare institutions may improve patient safety.

• Human factors scientists can improve healthcare design through:
  • Incident analysis
  • Developing standards of practice
  • Architecture and design of actual spaces
  • Observation and understanding of different clinical environments
  • Disseminating information to healthcare workers
• Dr. Catchpole’s current suggestions for improving safety in hospitals:
  • Procurement of devices (effort spent to determine functionality before it is purchased)
  • Clinical incident analysis (how harm comes from financial and staffing-related decisions, not just clinicians)
  • Human factors scientists spending time in clinical environments to find where the real pain points are.

Safety intervention worth mentioning

• Human factors or user-centred design, particularly when implementing new equipment or processes.
• A great example of a forcing function is to change epidural catheters to no longer accept Luer lock syringes.

Other resources

• The Design of Every Day Things by Don Norman
• The Field Guide Human Error by Sidney Dekker
• Still Not Safe by Robert Wears
• Institute for Healthcare Improvement: Certified Professional in Human Factors in Healthcare

Random recommendations

• Ken: Go and do some art. It doesn’t need to be good. Whether it’s sculpture, gardening, cooking etc.
• Amir: The Podcast Hard fork. The newest episode (their penultimate episode is very important: The AI mob that attacked hugging face
• Adam: The Rescue streaming on Disney+ in Canada, which is about the rescue of a Thai Boys Soccer Team that got trapped deep in a cave that flooded.

Thanks to Carter Ponce at VoV Media for his work in producing and promoting the show, and our intern, Dr. Sam Seshadri, a rural family medicine resident in Canada, for his research and help with post-production.

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7:20 Terminology

10:03 Timeline

12:00 Investigation

23:56 Analysis

31:36 Is the Swiss Cheese Model an answer?

35:45 Were these ‘bad apples’?

36:08 What if this was just isolated to one hospital?

38:44 How safety culture affects adherence to SOPs

43:16 The importance of vigilance and adherence to SOPs

45:33 Breach of the defences in depth

49:05 The near-miss that could have prevented this incident

51:30 Extended episodes available on Patreon

52:09 Mitigation strategies

59:54 Improving safety also improves efficiency and protects healthcare professionals

1:01:25 SOPs in drawing up and administering medication

1:04:53 CSF Lavage

1:09:44 James Reason’s Culpability Models

1:12:32 The importance of the non-punitive investigatory model

1:17:58 Criticism of the current level of investigation

1:25:33 Adam's near-miss in the OR

1:32:44 Other pharmacy-related medication deaths

1:36:13 Safety intervention worth mentioning

1:37:58 Who can do what tomorrow?

1:38:57 Random recommendations

1:41:32 Outro

On August 14, 2026, four patients scheduled for joint replacement in a Tennessee hospital received medication that the pharmacy labelled as a spinal anaesthetic but was in fact potassium phosphate. All four patients received their spinals within three hours of each other by the same anesthesiologist, who had no way of detecting the error made by the clinical pharmacy. This led to two people becoming paraplegic, one losing significant function in their legs, and one being placed on ECMO or a heart-lung bypass machine.

Timeline

1. Technician #1 initially selected the correct mepivacaine 2% vial and placed it on a work surface. 20 min later, the technician scanned and photographed that correct vial and then determined that another vial was needed. One vial would have enough volume for five syringes, but the order called for six syringes, and so another vial was required.
2. The technician retrieved potassium phosphate from a different bin that was stored close by the mepivacaine bin. Notably, the vials were lookalike drugs with extremely similar size, contents, and labelling down to the displayed names being similar. When the additional vial of potassium phosphate would not scan, the technician returned to the storage area, placed the two vials (including the correct mepivacaine 2% vial) into the potassium-phosphate bin, and retrieved two more potassium-phosphate vials.
3. Technician #1 bypassed the scanning of these two vials, photographed the two vials of potassium phosphate, and placed them along with five empty syringes, and six mepivacaine labels into a bin that was passed into the mixing room.
4. Technician #2, supervised by Technician #3, filled five syringes with 4 mL each and labelled them mepivacaine 2%. She also took photographs which included the potassium-phosphate vials. Technician #3 looked briefly into the medication bin that was passed into the mixing room and then sat down.
5. Pharmacist #1 approved the preparation electronically. Approximately 29 seconds elapsed during the computer review. The pharmacist did not detect that both photographs showed vials of potassium phosphate rather than mepivacaine.

James Reason’s Swiss Cheese Model is used to simplify a complex process where harms occur due to ‘holes’ in the barriers or defences in depth. We do this so that we can properly investigate and improve our safety systems, but it is not where the inquiry ends – it is the beginning of the investigation.

What if this was simply a ‘bad’ hospital, pharmacy, or ‘bad apples’?

Having four ‘bad apples’ is extremely unlikely. This is almost certainly not isolated to a single organization. Even the strongest, most safety-minded pharmacies and hospitals can find learning points here. It is that mindset – that systems can always be improved – that has permitted other safety-critical industries to make such significant safety improvements over the past several decades.

Lessons to learn

• Latent conditions must be continually rooted out.
• Segregation of high alert medications is paramount.
• Leadership walkthroughs are an important way to ensure that written policies are actually implemented.
• Human factors should be taught to all front-line medical workers, including models and policies that consider how stress and fatigue increase the likelihood of errors being made and not being trapped.
• There are tools to examine and strengthen the workplace culture.
• The use of technology (scanning the medication vials) is only one barrier. In this case, the barrier can be strengthened (likely by requiring a pharmacist-controlled resolution or some other check such as entering the drug ID number), but we also see what the investigators in this incident call an overreliance on technology.
• In upcoming episodes, Dr. Ken Catchpole talks about the use of icons (such as the biohazard symbol + colour coding), so that medication types can be easily identified from a distance.
• Medications could be colour coded with dye, as aviation fuel is.
• People-focused solutions (training, adherence to SOPs such as telling workers to ‘read the label’ or ‘look at the pictures’) are the least effective. However, to the degree that this barrier can be improved, consideration should be given to examining the SOPs: what procedures are trained, are they actually used in practice, and are frontline workers regularly monitored for adherence to SOPs.
• Additionally barriers for error-critical medications such as intrathecal medications. In this case, the hospital introduced an additional crosschecking of work for all intrathecal medications.
• Reconciliation of the amount of medication orders vs filled by the pharmacy.
• Revision of the regulatory oversight of clinical pharmacies to help prevent recurrence should be considered.

Other pharmacy medication errors that have resulted in death:

1. In 2006, 1.5 year old Emily Jerry in the US died due to a pharmacy technician inappropriately preparing her chemotherapy. The pharmacist in that case was held criminally responsible for the death.
2. In 2011 in the US, an infant died from an incorrectly compounded parenteral nutrition.
3. Andrew Sheldrick, age 8, died in Ontario, Canada in March 2016. Andrew’s medication was incorrectly compounded.

Other resources

• APSF YouTube Video (10 min) on this incident
• News release update from the subject hospital
• Practice Patient Safety
• James Reason’s Culpability Models (see our website for diagrams)
• The Hierarchy of Intervention Effectiveness Diagram

Safety intervention worth mentioning: Tennessee Health Facilities Report

Who can do what tomorrow?

• Policymaker / government: Advocate for an aviation-style national medical investigatory body like England’s HSSIB and Norway’s UKOM, with independence from the regulator so that the entire system can be strengthened where necessary.
• Hospital CEO / Department Head: Assess the organization’s safety culture using the available tools and monitor for adherence to SOPs. Investigate near misses to remove latent conditions and prevent sentinel events.
• Practitioner: CRM and remaining vigilant with good practices.

Random recommendations

• Amir: Properly ground coffee beans. Amir's coffee grinder.
• Adam: Scrubs Season 2 (or 11?) is out on Disney+ in Canada.

Go to our website for the full show notes.

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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
• See Episode 3 Show Notes

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.
  
  

Other Resources

• TC Approved Check Pilot Manual.
• 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.

Safety Intervention Worth Mentioning:

• University of Texas Human Factors Research Project: Threat and Error Management. Published December 2006.

Who can do what tomorrow?

• Policy Level: Read the TEM paper linked above to see what can be done to improve training and evaluation of non-technical skills in medicine.
• Hospital CEO/Department Level: Consider how improving non-technical skills can improve working conditions and team satisfaction.
• Practitioner Level: Read the TEM paper.

Random Recommendations

• Mike: Enjoy a nice walk outside.
• Adam: EPIC (Full Official Concept Album on YouTube Music) by Jorge Rivera-Herrans. See also these “animatics” (YouTube fan-based sketch animations)
• Amir: Promethea Unbound by Mike Mariani

Thanks to Carter Ponce at VoV Media and our intern, Dr. Sam Seshadri for help with post-production.

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Watch the full video podcast on YouTube here:

https://youtu.be/wDgv5gnRDX8?si=T6jKII0V5-QI9cTs

Show Notes

• The National Confidential Enquiry into Patient Outcome and Death (NCEPOD) is an independent UK charity and company that started in 1988 that reviews medical and surgical care in the UK to improve care for patients
  • 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
  • An open call for topics,
  • An audit of potential projects,
  • Discussion with relevant professional bodies,
  • A final discussion with the Healthcare Quality Improvement Partnership for funding of a topic
• Following this, the NCEPOD—advised by the Royal Colleges, professional organizations, patients, caregivers, and charities
  • Creates surveys to go out to clinicians and patients for case series
  • Clinicians then independently, voluntarily, and confidentially review cases
  • 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

Safety Intervention Worth Mentioning:

• NCEPOD Reports – see below.
• NCEPOD Audit Tools for various hospital departments.

Random Recommendations

• Dr. Mason: “Try to find the lightheartedness where you can.”
• Adam: Watch the World Cup. Look for something to bring us all together.
• Amir: Podcast Search Engine.

Other Resources

Trauma: Who Cares? (2007) (NCEPOD)

• Testicular Torsion (NCEPOD)
• Transition from Child into Adult Healthcare (NCEPOD)
• Common Themes (NCEPOD)
• Emergency surgery in children and young people (2025) (NCEPOD)
• Getting it Right First Time Programme

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Show Notes

• 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.

Safety Intervention Worth Mentioning: NCEPOD reports

1. The National Confidential Enquiry into Patient Outcomes and Death (NCEPOD) - Common Themes 2024 Report

Random recommendations

1. Adam: CBC’s The Expert Witness from Uncover and watch out for CBC’s See You in Court (Season 2) podcast.
2. Amir: Journal for both positive and negative emotions in your life

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Show notes

• Colon Cancer Screening
  • 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.
  • The SGFP Advocacy Campaign
    • 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.
  • We saw an example of this kind of analysis conducted by the HSSIB in Ep 9 - Unintentionally Retained Surgical Sponges - Part II.
• 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
  1. Chair’s Letters (how Adam and Amir first discovered this issue)
  2. Policy content
  3. Advocacy tools
• Who can do what tomorrow?
  • 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.
• Other resources
  1. Ontario Medical Association (OMA) - Advocacy group for Ontario physicians (The SGFP is a section of the OMA)
• Random recommendations
  1. Dave:
     1. Wheat Kings bakery in Kingston, Ontario.
     2. The Tragically Hip’s Wheat Kings song about the wrongful conviction of David Milgaard, whose story was recently showcased on CBC’s See You in Court podcast.
     3. TV show Lioness, which follows a team of female CIA operatives.
  2. Kevin: Dungeon Crawler Carl book series by Matt Dinniman.
  3. Adam: Neil Pasricha’s 45 Things I (Almost) Learned as I Turn 45
  4. Amir: TV show Abbott Elementary

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Show notes

• The Health Services Safety Investigations Body (HSSIB) investigates patient safety concerns in the UK. They are an independent body with the aim of making healthcare safer.
• 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.
• The Stafford Hospital deaths was an inciting event for the creation of the HSSIB.
• 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).
• The National Confidential Enquiry into Patient Outcomes and Deaths (NCEPOD) is an audit-based body that also helps improve patient safety.
• 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
    1. Medical culture (are we ready for them?);
    2. Patient privacy;
    3. Misuse of the data (i.e. for discipline); and
    4. Cost of installation and maintenance.
  • Adam’s rebuttal of these:
    1. 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).
    2. Patient privacy: gain consent (as is currently done by the few organizations that currently use OR recorders) or anonymize.
    3. 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
    4. 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

1. The Health Services Safety Investigations Body (HSSIB) (where you can subscribe to their mailing list)
2. HSSIB Report: Retained swabs after invasive procedures (April 16, 2024)
3. HSIB Report: Severe brain injury, early neonatal death and intrapartum stillbirth associated with larger babies and shoulder dystocia (April 19, 2021)

Other resources

1. The Stafford Hospital deaths was an inciting event for the creation of the HSSIB.
2. The National Confidential Enquiry into Patient Outcomes and Deaths (NCEPOD) is an audit-based body that also helps improve patient safety.

Random recommendations

1. Rosie: Disney+ Suspect: The Shooting of Jean Charles De Menezes
2. 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.
3. Amir: Awakening from the Meaning Crisis by John Vervaeke (50-part lecture series, YouTube, free)

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Show notes

Risk management principles:

• Key elements of risk management
  • Identifying hazards, or risk identification
    • 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.
• 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

1. “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.”
2. “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.”
3. “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

1. “Manufacturers of swabs can improve patient safety by facilitating better detection of retained swabs through user-centred design.”
2. “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.”
3. “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.”
4. “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

1. HSSIB Report: Retained swabs after invasive procedures (April 16, 2024)
2. HSSIB Interim Report - Retained swabs following invasive procedures: themes identified from a review of NHS serious incident reports (December 7, 2023)
3. HSIB Legacy Report: Detection of retained vaginal swabs and tampons following childbirth (June 7, 2021)

Random recommendations :

1. Amir: Gardening
   1. 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
2. Adam: Marty: Life is Short
   1. Documentary about Canadian Comedian, actor and writer Martin Short. Features many comedians and hilarious stories

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Show notes

• The reference event: Helen’s CABG
  • 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)
  • 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
    1. responsibility for swab counts (surgeon vs scrub nurse)
    2. communication of information about swabs
       • Surgeons not informing scrub nurse when a sponge was inserted
    3. visibility of swabs
       1. Not in direct line of sight
       2. Soaked with blood and therefore lacking contrast with surrounding tissue
       3. 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.
    4. 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)

1. 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.
2. 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.
3. “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.”
4. The solution is to change the working conditions

Health Services Safety Investigations Body (HSSIB) reports

1. HSSIB Report: Retained swabs after invasive procedures (April 16, 2024)
2. HSSIB Interim Report - Retained swabs following invasive procedures: themes identified from a review of NHS serious incident reports (December 7, 2023)
3. HSIB Legacy Report: Detection of retained vaginal swabs and tampons following childbirth (June 7, 2021)

Other resources

1. Willful Blindness by Margaret Heffernan
2. Selective Attention Test (Simons & Chabris, 1999, YouTube) (1 min)
3. Cognitive bias in diagnostic radiology (radiopaedia.org)

Random recommendations

1. Adam: Go see the RCAF Snowbirds! 2026 Schedule
   1. Snowbirds to be grounded after the 2026 season until 2030 when they acquire new aircraft (CBC: May 19, 2026)
2. Amir: Be a tourist in your own city

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Show notes

• 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.
• 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.

Safety intervention worth mentioning: leadership walkthroughs

• Dr. John Dornan, New Brunswick’s Health Minister, spends 24 hours in Moncton Hospital’s ED
• Dr. Warren Thirsk challenges Alberta Premiere Danielle Smith to come on shift

Other resources

1. Martin Bromiley: A patient’s perspective (March 16, 2018 - YouTube 23 min)
2. A Life In Error: From Little Slips to Big Disasters by James Reason

Random recommendations

1. Adam: Politics Without Politicians by Helen Landemore
2. Amir: The Black Swan by Nassim Taleb

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Show notes

• Elaine 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”.
  • 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”
    1. 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;
    2. Hospitals and healthcare systems win because safety is tangibly improved; and
    3. 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
  1. Just a Routine Operation (YouTube - 6 min)
  2. Just a Routine Operation (YouTube - 14 min)
  3. Martin Bromiley: A patient’s perspective (March 16, 2018 - YouTube 23 min)

Other resources

1. A Life In Error: From Little Slips to Big Disasters by James Reason
2. Royal College of Anesthetists (RoCA) NovPod - S2E11: Prevention and management of pain during caesarean section (with Susanna Stratford)

Random recommendations

1. Martin: Confessions of a Hornet Pilot by Tug Wilson
2. Adam: Project Hail Mary audiobook, movie or Artemis II lore
3. Amir: The Drama movie

Please consider donating at medicalsafetypodcast.com or becoming a patron of the show at Patreon.com/medicalsafetypodcast where you find full episodes

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Show notes

• How to make simulation effective
  • 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
  • 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

Safety intervention worth mentioning

• Cognitive aids, such as the Stanford Emergency Manual (there is also a phone app)
• Buy a whiteboard and put it in the resuscitation area

Resources mentioned in the episode

• Jesse Guscott’s SCORE course

Random recommendations

• Fackham Hall
• The Shadow of the Sun by Ryszard Kapuściński
• Take more photos of the people you love

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• What is Crisis Resource Management (CRM)?
  • 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
  • “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:
    1. At handover (establishes roles and sets priorities)
    2. Before and after a critical procedure (e.g. intubation, chest tube insertion)
    3. 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
    1. I notice [x finding] “I notice that the oxygen saturation is starting to drop. Do you want to do anything about that?”
    2. I wonder [why the provider is doing something]. “I wonder if we should apply a non-rebreather mask at 15L/min?”
    3. I worry [express specific concern] “I’m worried about the hypoxia.”
    4. This is an emergency (I’m taking over)
  • The PACE model
    1. Probe: “Why is [x] being done?”
    2. Alert: [X finding]
    3. Challenge: “We need to do [Y[“
    4. Emergency: “This is an emergency” (I’m taking over)

Other resources

1. 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
2. EMsimCases.com

Random recommendations

1. Katie: The Anthropocene Review by John Green for “a moment of thought-provoking calm”
2. Adam: Exit the Game
3. Amir: 99% Invisible podcast

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• Aspects of CRM
  • 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.
  • 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

1. 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.
2. 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.
3. 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.

Other Resources: United Flight 232 - Captain Al Haynes (YouTube)

Next episode: Escalating Language of Concern with Dr. Katie Lin

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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.
• Just a Routine Operation (YouTube - 6 min)
• Just a Routine Operation (YouTube - 14 min)
• Martin Bromiley: A patient’s perspective (March 16, 2018 - YouTube - 23 min)
• Eastern Airline Flight 401 Mayday Fatal Distraction - S05E09 (YouTube)
• United Airlines Flight 173 - Mayday Focused on Failure S12E08 (YouTube)
• Air Florida Flight 90 - Mayday Disaster on the Potomac - S13E04 (YouTube)
• ACCRAC Ep 325: The WISH Inventory and Well-Being in Anesthesiology with Drs. Higgins and Vinson (anesthesiologists take an outsized sense of responsibility for outcomes - at 5 min

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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.
  • 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:
  • Just a Routine Operation (6 min)
  • Just a Routine Operation (14 min)
  • Martin Bromiley: A patient’s perspective (March 16, 2018 - 23 min)

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