25 May 2011

Human factors and patient safety

Every doctor or healthcare provider should watch this video. 


Just A Routine Operation from thinkpublic on Vimeo.

It could never happen to me, right? Wrong. I'm as human and as fallible as those doctors who killed that poor lady, and as those pilots who flew perfectly good aircraft into smoking craters.

Take home points for me?

Situational awareness: never get so focused in on a single thing (like getting the intubation) that you lose sight of the big picture.

Teamwork: know who's in command, know your team, brief the team, and make sure that all team members feel comfortable speaking up if they see a problem.

Which goes back to what I've been saying for years about ER nurses. If you shit on them, if you belittle them or fail to respect them, they won't speak up and you will miss critical opportunities to prevent a mistake. Respect them and keep open channels of communication, and they will save your ass time and again.


  1. What's absolutely frightening about this story is that every day most of us are able to observe the interpersonal relations between dr.s and with their staff that led to this situation. How many of us have seen anesthesiologists, let alone the nurses treated as second class professionals in the OR?? Truly frightening. I hope everyone who sees this can make a commitment to being that one who will risk taking a chew-out later in order to ensure they were never afraid to speak up on behalf of a patient who can't.

    What a brave and good man her husband is to tell this story in hope that it can save other lives.

  2. I think we've all seen lives lost and lives saved based on the presence or lack of communication between team members. It's important to always have someone in charge, and it's important for the whole team be able to talk and to listen.

    One of the main things I love about the ER is the team work we usually have. I have seen doctors that would ignore nurses that were pointing out problems, but that's rare. I have seen nurses that were afraid to speak up, it's not quite so rare, but it is uncommon.

    Everyone should have a job and know what there job is, and know everyone else's job as well as possible. When the SHTF, as it often does, this is what saves lives.

    Shadowfax is right, doctors shouldn't shit on nurses, and perhaps even more important, nurses should not be afraid of doctors, even the ones that do shit on them. Even if a doc is a jerk and doesn't like or respect you, if you speak up when he's missing something important, he's thank you in the end, and you'll probably gain his respect. If it turns out you were wrong, it'll be a chance for you to learn something.

    I've spoken up or asked questions about things lots of times, it's pissed of a few doctors, it's gotten me chewed out a couple times, but it's also saved a few lives. I've found that even the docs that don;t like it would usually prefer you speak up rather than stay quite, because even if you were wrong that time they pretty much all know they'll be wrong or miss something occasionally.

    So yeah, docs don't be jerks to the nurses you work with, but nurses don't be afraid of docs, even the few that are jerks.

    Rambled a bit there, but hopefully made my point.

  3. The most striking thing about this story was that the woman experienced her callamity at the beginning of an ENT surgery. Anesthesiologists and ENT's know more about airways, mechanical and surgical than any other specialties out there. The fact that the ENT was there for so long, struggling for the intubation, with a tracheostomy tray at his side and NEVER performed one literally blows my mindl

  4. Wowsers. Luckily, I've problem-solved my way around this type of stuff and not had any outcomes like this. One time, my problem solving was saying in all-caps to an anesthesiologist...


    Like 10 people turned to look at me and a couple of med students were like "whew, thanks for saying that", and the anesthesiologist listened to me after a couple of snotty comments. Holla. Not a single one of the 10 people mentioned the really profound gag reflex that I could hear all the way down the hall. I was just strolling by and stopped in to see what that awful sound was and saw a tube being stabbed into someone's gaggy throat.

    Best part of the video was the way he said "anesthetist", though I must admit.

    Word Verification now: "Prerant".

  5. I feel very strongly about this, considering a few things.

    First of all, there are no respiratory therapists in the UK.

    Second of all, I remember being very clearly taught during my training as a respiratory therapist, the imperative nature of avoiding tunnel vision, in a policing standpoint. I take this very seriously, as my husband is a police officer. Primarily, because it's supremely important in these situations, as that poor husband has pointed out, that the human factors are an important part of clinical practice.

    There's an entire book written on this with regards to the medical context. It's called the Checklist Manifesto, and it's all about bringing the pre-flight checklist to the medical situation. It's an amazing piece of literature and this is a situation where it could have been well applied. I plan to buy it for my manager of ICU as a gift, because she is such an amazing advocate of such evidence based practices.

  6. "Which goes back to what I've been saying for years about ER nurses. If you shit on them, if you belittle them or fail to respect them, they won't speak up and you will miss critical opportunities to prevent a mistake."

    One of the point of this video and the story of Elaine is that the doctors work on their own belittling the nurses who are there to help them. Teamwork is the issue here. Indeed, humans are a great factor on patient's safety. This is a tragic story but serves as a hope for others, eh. :)

  7. I am having another surgery in a little over 2 weeks and I should probably not have watched that. It was terrifying! I'm glad you posted it, it has important lessons, but the timing for me reading it was kind of awful.

  8. 'there are no respiratory therapists in the UK.'

    This is not true. They are called respiratory care practitioners, respiratory nurse specialists etc here.

    Before anyone chips in with a 'failure of socialised medicine' comment, I would point out that the US has a surgical error rate about twice that of the UK.

  9. This is why nursing is something no doc could ever do. We do have a huge responsibility to watch that we don't make mistakes as well as that we don't inadvertantly harm someone because following your orders will harm them, and to actually stop you from harming the patient yourself. Always remember docs, that I stay with that obnoxious patient and you get to (most of the time) walk out.


  10. Doesn't everyone remember their BASIC training in medicine? ABC !!
    A = Airway. And if the SAO2's drop toward 80, then TRACH if you're battling laryngospasm or something else. A trach would have saved this woman's life. PERIOD.

  11. Aviation really is good at human factors. They invented the checklist, they were controlling foreign-object debris long before the medical community formalized sponge counts, and of course they recognized Murphy's law, which is actually about human factors: if there is a wrong way to do something, someone will do it that way, so make it impossible (by design or procedure) to do it that way, rather than relying on a person to avoid making any mistakes. I hope Mr Bromley's work is well-received and fruitful.


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