Saturday, 23 March 2013

"How to avoid mistakes in surgery": a summary and commentary

I've just returned from the US, and my one "must see" catch-up TV programme was "How to avoid mistakes in surgery" (now available on youtube). It's great to see human error in healthcare getting such prominent billing, and being dealt with in such an informative way. This is a very quick synopsis (of the parts I particularly noted).

The programme uses the case of Elaine Bromiley as the starting point and motivation for being concerned about human error in healthcare. The narrator, Kevin Fong, draws on experience from other domains including aviation, firefighting and formula one pit-stops to propose ways to make surgery and anaesthesia safer. Themes that emerge include:
  • the importance of training, and the value of simulation suites (simlabs) for setting up challenging scenarios for practice. This is consistent with the literature on naturalistic decision making, though the programme focuses particularly on the importance of situational awareness (seeing the bigger picture).
  • the value of checklists for ensuring that basic safety checks have been completed. This is based on the work of Atul Gawande, and is gaining recognition in UK hospitals. It is claimed that checklists help to change power relationships, particularly in the operating theatre. I don't know whether there is evidence to support this claim, but it is intuitively appealing. Certainly, it is important in operating theatres, just as it has been recognised as being important in aviation
  • the criticality of handovers from the operating theatre to the intensive care unit. This is where the learning from F1 pitstops comes in. It's about having a system and clear roles and someone who's in charge. For me, the way that much of the essential technology gets piled on the bed around the patient raised a particular question: isn't there a better way to do this?
  • dealing with extreme situations that are outside anything that has been trained for or anticipated. The example that was used for this was the Hudson River plane incident; ironically, on Thursday afternoon, about the time this programme first broadcast, Pete Doyle and I were discussing this incident as an example that isn't really that extreme, because the pilot has been explicitly trained in all the elements of the situation, though not in the particular combination of them that occurred that day. There is a spectrum of resilient behaviour, and this is an example of well executed behaviour, but it's not clear to me that it is really "extreme". The programme refers to the need to build a robust, resilient safety system. Who can disagree with this? It advocates an approach of "standardise until you have to improvise". This is true, but this could miss an important element: standardisation, done badly, reduces the professional expertise and skill of the individual, and it is essential to enhance that expertise if the individual is to be able to improvise effectively. I suspect that clinicians resist checklists precisely because it seems to reduce their professional expertise, when in fact it should be liberating them to develop their expertise at the "edges", to deal better with the extreme situations. But of course that demands that clinical professional development includes opportunities and challenges to develop that expertise. That is a challenge!
The programme finishes with a call to learn from mistakes, to have a positive attitude to errors. Captain Chesley 'Sully' Sullenberger talks about "lessons bought with blood", and about the "moral failure of forgetting these mistakes and having to re-learn them". `On the basis of our research to date, and of discussions with others in the US and Canada studying incident reporting and learning from mistakes, this remains a challenge for healthcare.

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