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Martin Bromley set up the Clinical Human Factors Group and applauded the return to work of the clinical team that were involved in the events surrounding his wife’s death…
In March 2005 Elaine Bromley died during a routine operation. After his wife’s death, Martin Bromley, an airline pilot with a background in Human Factors, was emphatic that he wanted the Health Service to learn and implement the learning from this tragic event and most importantly to ensure that there were changes of practice across the UK to ensure that this never happened again.
In good health, Elaine had undergone minor surgery for a sinus condition. During the anaesthetisation Elaine’s airway collapsed. Elaine remained deprived of oxygen for a prolonged period of time and consequently some 13 days after the original operation, in the face of irreparable brain damage and in consultation with the doctors, Martin made the heart-wrenching decision to turn off Elaine’s life support.
During the event three very experienced consultants worked on Elaine as the situation escalated and four highly skilled nurses were in attendance.
After a detailed deconstruction of the incident it was found that:
*Can’t intubate and can’t ventilate is a recognised condition in anaesthesia and guidelines exist for managing this situation.
*The lead anaesthetist, in his own words, ‘lost control’ of the situation.
*There was an evident loss of awareness of time by the clinicians.
*There was a breakdown in the decision making processes.
*There was a lack of recognition of the seriousness of the situation – certainly the awareness of what was happening was not shared by or between the consultants working on Elaine. The communication between the consultants ‘dried up’.
*There was no clear leadership of the team resulting in, those giving evidence in the inquest said, that they felt there was a question mark over who was in charge.
*Elaine was taken to the recovery room rather than a intensive car unit, for an hour and a half after the critical event and left to wake up naturally – which, in fact, she did not…
Interestingly the story with the nurses was very different – the nurses were summoned 6-8 minutes into event. They were generally aware of what was happening and the seriousness of the situation, as well as what needed to happen:
*One of the nurses asked another to go and get the tracheotomy set – when she announced to the consultants that the tracheotomy set was now available and there was no response.
*Another, who walked in and saw Elaine’s colour and vital signs, immediately walked out again and called ICU for a bed, walked back in announced that the bed was available and in her own words the consultants looked at her as if to say ‘why are you over-reacting?’. She cancelled the bed.
*Two of the nurses stated at the inquest that they knew what needed to happen but did not know how to broach the subject.
Martin draws a comparison with the fact that these same factors, a lack of leadership, lack of situational awareness, breakdown in communication and a breakdown in decision making combined with a lack of assertiveness are the same factors that are present in 75% of aviation accidents
Martin’s quest has been to question why this understanding of Root Cause Analysis and Human Factors that dominates the aviation’s industries procedures and the review and design of its systems and equipment, is not more widely accepted into healthcare. He is determined to change this and to influence clinical practice.
As a pilot he illustrates the point by highlighting that not only is there a comprehensive physical and systematic check of all equipment before any flight– but also the crew convene for a briefing. This briefing is to discuss what they expect to happen but more importantly to think through all the possibilities of what might happen. They determine what they can and must expect from one another including that they may need to be reminded to take certain actions.
This briefing plays a vital role … it is an opening up of communication. Human factors tells us that we are all wrong no matter how good we are and that we need people around us to help us. This initial briefing helps to creates a dynamic environment with colleagues being open to suggestions, so that people feel free to express concern and to know that others, including those more senior, will listen.
Martin concludes in his powerful video – Just A Routine Operation – by telling us what finally happened to those people who were in the room when his wife experienced this fatal incident…They returned to work. He tells us that this is exactly what he wanted to happen. That by being back in the workplace they can spread these very personal messages to their colleagues and how he believes all of them will be much better clinicians as a result of this tragic event, their involvement in the analysis of what happened and the implementation of changes.
Martin re-iterates that the lessons of effective Root Cause Analysis and Human Factors from other industries are there, learnt the hard way, for the health care sector to learn from. He, as I am, is convinced that they are equally applicable to health care and that these lessons can save lives in the health service.
Learn more about Sologic RCA
RCA & FMEA TRAINING
Root Cause Analysis and Failure Modes & Effects Analysis training by Sologic provides the tools, skills, and knowledge necessary to solve complex problems and manage risk in any sector, within any discipline, and of any scale.Learn More
SOFTWARE
Sologic’s cloud-based Causelink has the right software product for you and your organization. Choose from Individual, Team, or Enterprise.Learn More