Friday the 8th June, South Kensington Campus
Friday the 22nd June, St Mary’s Campus

Places are limited so register now at www.cpssq.org

View this pdf for full details of the programme.

1. Development of a How To Guide on Implementing Human Factors in Healthcare – Part 2
The How To Guide: Part 2 will follow on from the guide that was developed as part of the National Patient Safety First Campaign. Whereas the first ‘How To Guide’ largely focused on giving a broad brush overview of human factors, we would like Part 2 to include more examples and case studies demonstrating the implementation of human factors in healthcare . We also recognise that there is a need to convey the breadth of human factors, in terms of the implications for the design of healthcare systems and equipment etc.

This project is being led by Dr Jane Carthey, Human Factors and Patient Safety Specialist and Nicola Davey, Senior Associate, NHS Institute for Innovation and Improvement.

2. Creating a human factors resource for Boards
The aim is to develop a learning resource for Boards, which is available to be freely downloaded from websites including CHFG and national organisations such as The Health Foundation, NHS Institute for Improvement and Innovation, NHS Confederation etc.

This project is being led by Stephen Ramsden, Independent Consultant, Transforming Health Ltd; previously Chief Executive at Luton and Dunstable Hospital NHS Foundation Trust and Chris Frerk, Consultant Anaesthetist, Northampton General Hospital.

How you can help
Both projects aim to include practical case studies from within and outside the NHS, as well as signposting healthcare professionals to human factors guidance.

Stephen and Jane would welcome your input and ideas into shaping the content and focus of each of the above products. Do you have:

• a case study you think is suitable for inclusion in the guide?
• any tips on engaging Boards and clinical teams?
• suggestions for guidance and good practice from other industries which healthcare could learn from?

If so, please email your thoughts, suggestions, materials and case studies to Jane, as soon as possible please.

Many thanks for your help.

Jane, Stephen, Nicola and Chris

Authors: Lamb, Bryony; Clutton, Nick
Source: The Journal of Practice Teaching and Learning (The Journal of Practice Teaching  in Health and Social Work), Volume 10, Number 2, 2010 , pp. 4-27(24)

Access the article here.

Follow this link to watch an excellent film of Brian Goldman talking about doctors talking about making mistakes.

Brian Goldman: Doctors make mistakes. Can we talk about that?

Human Factors – My Story

 I was the duty Paediatric Intensive Care Unit consultant one weekend.  A teenage boy had been admitted to the PICU having suffered major trauma. He had been hit by a car at high speed whilst running across a road.  His injuries included a right pneumothorax for which an intercostal drain had been placed and extensive lacerations to his right side.  He was ventilated and receiving full intensive care support.  It was noted that the intercostal drain was very low on x-ray and appeared to be abutting the diaphragm, although this had not had any discernible clinical effect.  All parameters and vital signs were quite stable.

On Saturday morning it was decided that he should undergo elective debridement and cleaning of his abdominal and limb abrasions.  He was taken to theatre by the paediatric anaesthetist and was to be operated on by the orthopaedic surgeons.

A short time after he had left PICU, I received a call from the anaesthetist to say that the patient was hypoxic and that he was having trouble improving his oxygenation.  He asked me to go to theatre and assist him.  This was an unusual request as we work in a large teaching hospital with specialist paediatric anaesthesia and indeed my colleague was a very experienced and reliable practitioner (I am not an anaesthetist).

When I arrived in theatre I saw that the patient’s oxygen saturation was 86% despite being intubated and receiving 100% oxygen by hand ventilation.  The anaesthetist told me that the situation had deteriorated a few minutes earlier, after the endotracheal tube had been re-taped.  He said that the right side of the chest was hyperexpanded, hyperresonant to percussion and that the trachea was deviated to the left.  He had surmised that, given this constellation of signs, the right pneumothorax had re-accumulated and was tensioning.  We had earlier discussed the fact that the intercostal drain was oddly positioned.  While this was happening, the consultant orthopaedic surgeon was standing, knife in hand, prepared (and quite keen) to insert a new intercostal drain on the right.

I was initially sceptical because there had previously been no problem with the drain or indeed expansion of the right lung.  However the right chest was clearly hyperexpanded and hyperresonant to percussion.  There was little movement of the left side.  I asked for a stethoscope and auscultated the chest.  There was air entry on the right but no air entry at all on the left side.  At this point I asked the anaesthetist whether the endotracheal tube could be in the right main bronchus (a well-known complication of intubation that only requires a few centimetres movement of the tube further into the patient).  This would have resulted in exclusive ventilation of the right lung and would account for all the clinical signs.  He thought not, but unsecured and gradually withdrew the endotracheal tube.  There was an immediate improvement in oxygen saturation and chest wall excursion, with both sides moving equally.  The patient was fully saturated within a minute of this manoeuvre and the intended procedure went ahead uneventfully.

Human Factors:

Experienced anaesthetist unable to contemplate the most obvious cause of the problem due to influential ‘noise’: history of pneumothorax, oddly-positioned drain, and unintended collusion with surgical team regarding the nature of the problem.

Senior surgical colleague poised with knife, ready to ‘solve’ the perceived problem (which would have resulted in unnecessary harm to the patient).

On a positive note, the anaesthetist was sufficiently concerned to call in a third party (me) before the wrong action was taken.  This was a very sensible thing to do, and quite courageous given the urgency of the situation and the potential threat to ego.  In this case my objective appraisal of the situation averted an adverse event.

 Outcome

The patient was fine.

The anaesthetist was relieved, embarrassed, enlightened and grateful.

The surgeon was disappointed (!) that they didn’t get to perform a heroic intervention, but acknowledged all the issues.

I was impressed that my anaesthetic colleague would have the strength to ask for help in a fraught situation, even if it meant finding out they were wrong.  This attitude ought to be encouraged.

Consultant paediatric Intensivist
April 2012

Follow this link for more on the conference and how to register.

Bringing together the very latest Patient Safety and Improvement Initiatives from some of the world’s leading children’s hospitals. A candid record of lessons learnt and practical success from your peers in paediatrics, interspersed with some truly inspirational talks from people outside the medical profession.  For more information and how to book a place, see this flyer.

Risky Business London 2012: Tough Times Needs Creative Minds
24-25 May 2012 King’s Place, 90 York Way, London N1 9AG

Hosted by Great Ormond Street Children’s Hospital in partnership with the BMJ & ADCH

Sharing new ideas on managing risk, patient safety, leadership and teamwork from some of the highest achievers in other high-risk businesses, industries, sport, exploration, media, military, and the arts.

For more information and how to book a place, see this flyer.

Systems human factors: how far have we come? BMJ Qual Saf bmjqs-2011-000476 Published Online First: 7 November 2011 [available to subscribers]