a nurse who commits an error that is a minor incident
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my name is Martin Bromley Im dad to two young children Victorian Adam and this is the story of the death of my wife Elaine who died in March 2005 as a result of an attempted routine operation that went wrong Im an airline pilot with the background in human factors I want to make a difference I want to be able to say to Victoria Adam in a few years time that although their mom died the lessons from that have been learned and that there is a change in practice in health care in the UK Alaine actually had very good health but she had suffered from some sinus problems and as a result consultant had recommended that she should have routine sinus surgery we left at 8:30 in the morning having kiss mommy goodbye and went off to do the weekly food shop I got a phone call at about 11 oclock that morning from the ENT consultants and they explained to me that when Elaine had been anesthetized her airway had collapsed that the oxygen levels in her body had fallen to very low levels and so they decided that the safer option was to let Elaine wake up naturally and unfortunately she hadnt done so I I went across to the intensive care unit and there I was met by two further consultants they explained to me very bluntly that Elaine had been without oxygen for a significant period of time and that I was looking at her having significant brain damage another brain scan was taken and even to me as a layman comparing the the new scan with the benchmark scan there was no doubt that by this stage there was virtually nothing that could be done for Elaine and I made the decision in consultation with the intensive care team to switch Elaines life-support off she died some, 13 days after the original attempted operation and really what I want to try and do is just share a bit of the story with you of what we know happened as best we can weve probably got 80% of the picture now I think Elaine was being cared for by an experienced Methodist and his experienced assistant the plan was that they would start with a laryngeal mask and they had done a very thorough pre-op assessment there were no unjú causes for concern at this stage and 8:35 in the morning Elaine was anesthetized after sleep the first mask wouldnt fit they try to second mask they then tried some extra drugs to try and would use some suspected tension in the muscles in the jaw so it was obvious almost straightaway that
things were going wrong we know that two minutes in Elaines oxygenation was 75 percent and falling and she was by this time already visibly blue within four minutes we know that her oxygenation had fallen to 40% or lower theres some confusion about the precise time but we know that six to eight minutes in a number of things were happening via netha test had already started to attempt to invade Elaine the oxygenation was still at 40 percent or lower the heart rate was falling the ENT surgeon waited formally op came into the theatre and an ethicist from an adjoining theatre became aware of a commotion and he walked in to see what could be done and at least three nurses answered a call for help and what happened is that the three consultants continued with the attempts to ensure Bay and they used a variety of different techniques and a variety of different pieces of equipment the nurses meanwhile performed some some tasks and of their own initiative but what we can say is that ten minutes in with hindsight this is a situation of cant intubate cant ventilate this is a recognized emergency in anesthesia for which guidelines exist were now ten minutes into this attempted procedure the patient my wife is blue her oxygenation is 40 percent or lower and it has been for six minutes the anitha test has 16 years experience and he is regarded as diligent by his colleagues the ENT surgeon has over 30 years experience the other an ethicist has additional skills pertaining to difficult Airways the three of the four nurses are all experienced in their job and its perhaps worth just wondering at this stage what was going through their mind the intubation attempts had failed the oxygenation was very low what we know actually happened is this point in ten minutes for a further 15 minutes the three consultants would appear to have continued with their attempts to intubate to the exclusion of any other option and at the end of that 15 minutes were now 25 minutes into the whole procedure they eventually get Elaines oxygenation to 90% but shes actually been at 40% or lower for a total now over 20 minutes the airway itself is not secure though and so they fiddle around a bit more and in fact her oxygenation falls again below 90% for a further 10 minutes and finally by the time with 35 minutes in they seem to make the decision that the best thing is just to let her wake up naturally thats we and they transfer to the recovery room and she lays there for an hour and
a half and of course she never wakes up based on the evidence from the inquest and from Professor harms report the leader Neath artist if I can call in that in his own words lost control there was a question mark in the inquest about who people felt was in charge at different points there was certainly a loss of awareness an awareness of time but also an awareness of the seriousness of the situation if you like the awareness of what was happening wasnt shared by each of the consultants there was certainly a breakdown in the decision-making processes and it would appear that the communication process is dried up amongst the consultants the story with the nurses is very different the nurses were generally aware of what was happening and what needed to happen when I said to you that six to eight minutes in those three nurses arrived one of them asked her colleagues go and fetch the truck he ostomy said there was already a quick tracking hit in theater she went out she collected the tracheostomy set she came back in she announced the consultants or the tracheostomy set was available and there was no response one of the other nurses who walked in immediately saw Elaines color immediately saw the vital signs and walked out again – phone intensive care she phoned to check that our baby immediately available she came back in and she announced the three consultants bed was available in intensive care and in her own words they looked at her as if to say whats wrong youre overreacting she actually walked out and cancelled that bed at the inquest two of the four nurses stated that they knew exactly what needed to happen but again to quote from the inquest didnt know how to broach the subject we have a breakdown of leadership of situational awareness of prioritization of decision-making of communication and an assertiveness and these same factors these same human factors are ironically are present in 75% of aviation accidents and really since then Ive been trying to understand why in aviation we we train and to understand about human factors and its an integral part of how we design equipment and how we manage procedures and how we work day to day its part of our everyday language but Im trying to understand why thats not part of clinical practice when we get out to the aircraft theres a lot of technical jobs that need to be performed theres the usual security checks of an empty air car theres the safety checks both of the outside we have to do a walk-around making sure the systems are
that everything we require for flight is switched on or or operating in the way it should having done all the preparation got everything ready for flight we then get together in a briefing and thats really to make sure that we both know what we expect to happen but more importantly that we think through all the possibilities Ive tried ranaut short consider stopping for any count warning on portion above 100 youll only consider stop we need that warning and sure failure something you thinks will stop us flying three things to reminds me of with a positive climb were gonna hear up if appropriate remind me to togas available Miami or Barcelona if its not performance limit inkling and proposed to follow the city the only other exceptions that is if we had someone control of the situation like the fires still burning when we get us speed in which case up all that and its suitable for a right-hand visual about four to seven right any questions on the Emergencies its an opening up of communication human factors tells us that actually were all wrong no matter how good we are and we need people around us to help us its creating that open environment within your colleagues being open to suggestions if they put their hand up and say excuse me Im not sure about this its not turning around and saying actually Im the boss here its turning around and saying tell me what your concern is its listening and before you ask by the way what happened to the people who are involved in my wifes incident you will be pleased to know that they all returned to work eventually after the incident and that is exactly what I wanted to happen by being back in the workplace they can spread those very personal lessons on to their colleagues and all of them will be much better clinicians as a result of what happened that theres no doubt the key message I would emphasize it is the in aviation we know 75% of accidents caused by human factors in healthcare whats the statistic is it 75% as well is it 85% is it 55% no one really knows my argument is though that the actual statistic is irrelevant if you accept common-sense and look around you that tells you a large proportion of accidents and instance will be caused by human factors the lessons from other industries are there and theyre equally applicable to health care and if it is only 45% that is an awful lot of lives that we could be saving lets wake up to human factors lets make a difference you
Just A Routine Operation, Martin Bromiley, Clinical Human Factors Group, human factors, improving patient safety
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