Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

What Does it Take to NOT Kill a Patient – Part II


The use of simulation is a valuable tool because it allows us an insight into ourselves when the odds are stacked against us. Every pilot has screwed up in the simulator, and those events allow us to develop more resilient and reliable ways of thinking and working so when things really do turn bad we have a much greater chance of success. But this is an insight that many of you won’t have experienced. Sitting around a coffee table anaesthetists will tell me how they wouldn’t have behaved in the way the anaesthetists did on my late wife’s case. It’s incomprehensible. But place those same anaesthetists and colleagues into the simulator a week later; you’d be surprised how many do follow the same path when presented with the same stressors and human factors.[1]

This is not about checklists.

This is about creating an environment that makes harm to our patients much less likely.

Do any of us want aviation to regress to the safety level of 40 years ago?

The IOM (Institute Of Medicine) report on deaths due to medical error estimated that there are between 44,000 and 98,000 patients killed by all of us in medicine in an average year.

Even if the numbers are wildly inaccurate, the aviation fatality numbers from decades ago have nothing on medicine.

Are we adding to the deaths due to medical error?

or

Are we working to prevent deaths due to medical error?

Modern medicine is becoming too complex and too fast paced to ignore the human factors that can turn a disaster into an heroic save, or vice versa.[1]

We didn’t need waveform capnography back in the old days, and we don’t need it now!

This attitude kills.

The truth is that waveform capnography improves our ability to assess placement of the endotracheal tube (and it has plenty of other uses).

We don’t need simulations. Are you trying to suggest that we don’t know what we’re doing?

The truth is that in well done simulations, we can learn the mistakes that we are likely to make during even routing cases, when something happens a little bit differently from the way we expect it to.

Give us the tools that make it easy to get it right, give us the processes that give safety a better chance, and give us the training so that we can use these and behave in a way to make a quantum leap in safe practice.

NAP4 gives us good data on the scale and nature of the problem,[1]

Why are so many of us so opposed to making mistakes less likely to happen?

The simple answer is that we think that we are too good to make these mistakes. That is the blame it on the hubris answer, but it is also an overly simplified answer.

We just need to improve safety and get rid of the obstacles to improved safety, even if these obstacles are the people who believe they are perfect. Remediation is nice, but patients’ lives are more important than the feelings of dangerous medics.

See also:

What Does it Take to NOT Kill a Patient – Part I – 4/03/2011

What Does it Take to NOT Kill a Patient – Part II – 4/04/2011

What Does it Take to NOT Kill a Patient – Part III – 5/20/2011

What Does it Take to NOT Kill a Patient – Part IV – 5/23/2011

What Does it Take to NOT Kill a Patient – Part V – 5/30/2011

Footnotes:

[1] Major complications of airway management in the UK – 2011 NAP4
Royal College of Anaesthetists
Mr Martin Bromiley, founder Clinical human factors group
Forward (page 7/54 Section 1)
Page with link to various full text pdf versions of report, press release, executive summary, and full report.

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