I am a lecturer at Malmoe School of Nursing in Sweden and use this video clip in my lectures to pre-graduate nurse students concerning safety in healthcare. It’s a valued contribution to the lecture as it helps the students understand patient safety and the importance of learning from mistakes to develop rather than blaming others.

thank you Katherine

I see Elaine Bromiley’s family give full permission for the use of the investigation report for educational purposes so I will add it to the Human Factors Error Management page. http://theatreteam.co.uk/best-practice/human-error-management/

Please email me at admin@theatreteam.co.uk if there is anything else that you think would be of benefit to include there.

Liv

The issue is not to get into a technical discussion of CICV. Also, don’t forget that the incident occurrred several years ago now. If you want a full account of the investigation into the precise events you can find it here: http://www.chfg.org/resources.htm

However, the point is that the anaesthetic staff were under extreme stress and completely lost situational awareness. Under stress the first sense to be lost is hearing (unlike induction of anaesthesia). Which is why the nurses were not heard. Also they became fixated on the solution.

Martin’s message is that we are all human and we can create a more resilient system if we acknowledge that fact and learn non-technical skills to improve team-working and communication. One of the keys to this is a flatter hierarchy in which all can speak up.

You might be pleased to know that Martin has remarried, but he is still very active in running the clinical human factors group in the UK (see link above). He also works full time as a pilot and as a trainer in human factors for bmi.

We get tunnel vision, we get arrogant we get side tracked! What we need to do is learn from other professions that the only way to reduce those human factors influencing events is by accepting they are there and putting mechanisms in place to prevent them causing tragedies like this!

The much derided(admit it we all sighed not ANOTHER piece of paperwork to fill in when it arrived!!) WHO surgical safety checklist is one small step towards this and I am absolutely positive that it will have the effect of advancing safety that is it’s aim…. but much more needs to be done!

Well done Martin Bromiley, your attitude and courageous behaviour after an event that would have moved most people to blind rage is absolutely going to help save the lives of others!!!