OPENING CLINICAL LEARNING FEATURE ZONE KEYWORDS Human factors / Fixation errors / Airway management / Effective communication / Situational awareness / Leadership / Theatre culture Provenance and Peer review: Invited contribution; Peer reviewed; Accepted for publication December 2013.
The power of Elaine’s story: A personal reflection
by J Kamensky Correspondence address: Theatre Practitioner, Cardiac Theatres, University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton, SO16 6YD. Email: [email protected]
There will be few perioperative students (nursing, ODP) or surgical and anaesthetic trainees, who will not have heard of the tragic case of Mrs Elaine Bromiley. A 37 year old mother of two, admitted for an elective endoscopic sinus surgery and septoplasty, Elaine suffered major complications during the induction of general anaesthesia that resulted in her death due to hypoxic brain damage (Harmer 2005). As a student ODP, watching the DVD of the reconstruction of the events that contributed to Elaine’s death, I am conscious of the profound impact it had on me and the key learning points for practice. The importance of preoperative assessment Appropriate preoperative anaesthetic assessment is vital to ensure patient safety during general anaesthesia (AAGBI 2010) and sets the foundation for individualised anaesthetic care. Assessment highlights potential anaesthetic risks and enables optimisation of a patient’s preoperative condition because it includes physical examination of the airway, as well as careful assessment of the patient’s medical and family history, general health condition and life style. Physical examination of a patient’s airway prior to general anaesthesia helps to predict potential difficulties with airway management (Gupta et al 2005, Simpson & Popat 2002). Unanticipated difficult airway can cause delay or failure of intubation for general anaesthesia, which can result in hypoxaemia and ultimately lead to tissue hypoxia (Seo et al 2012). Prolonged tissue hypoxia can cause permanent hypoxic brain damage, which can result in disability or death of the patient (Gelenda 2001).
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While Elaine’s medical history didn’t suggest she had experienced difficulties with past anaesthetics, it should never be presumed that difficulty in airway management will not be encountered in future. Physical assessment described in the independent review of Elaine’s care (Harmer 2005) highlighted congenitally fused vertebra in her neck that could have inhibited neck movement, potentially causing difficulty in establishing a secure airway. Although a little restriction of Elaine’s neck movement was identified and the Mallampati score was two, normal mouth opening and thyro-mental distance did not suggest major difficult airway potential. This invites consideration that, despite the complex airway assessment, some patients with difficult airway will remain undetected. As much as 20% of difficult intubations are not predicted (Pinnock et al 2003), therefore the anaesthetic team must always be prepared for the unexpected and must plan the patient’s airway management before the induction of anaesthesia (DAS 2007).
Monitoring as essential Monitoring of vital signs during the induction of anaesthesia is important in early recognition of a patient’s deterioration and adverse events. However, monitors and alarms alert only to the existence of a problem; they do not offer a solution. Therefore, monitoring has to be used in conjunction with other clinical examinations and appropriate skills to interpret the patient’s vital signs (AAGBI 2007). Noninvasive monitoring of blood pressure, electrocardiograph and pulse oximetry were used to monitor Elaine’s vital signs during the induction of anaesthesia. These should have been accompanied by airway gases and airway pressure monitoring (AAGBI 2007). Although these are usually an integral feature of anaesthetic machines, Elaine’s status was unreported. Most adverse respiratory events can be readily diagnosed by pulse oximetry and capnography (Baraka 2010). Capnography is an established clinical tool, because it offers a good estimate of the partial pressure of carbon dioxide in arterial blood.
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OPENING LEARNING ZONE CLINICAL FEATURE
Monitoring of vital signs during the induction of anaesthesia is important in early recognition of a patient’s deterioration and adverse events
It reflects adequacy of ventilation, cardiac output and pulmonary blood flow, which are important variables in early recognition of respiratory or cardio-vascular compromise.
The value of pre-oxygenation There was no record that pre-oxygenation was provided for Elaine (Harmer 2005). Routine pre-oxygenation before the induction of general anaesthesia is not mandatory, however it is an additional safety precaution. Replacing alveolar gas with 100% oxygen allows for a longer period of apnoea as the airway is secured, without a drop in oxygen saturation. This ‘extra time’ can be lifesaving in cases of unanticipated difficult airway situations. Despite the
Reflect
Watch the video: ‘Just a routine operation’ available from the Clinical Human Factors Group website www. testing.chfg.org Reflect on the role of theatre practitioners in this procedure. a. Identify what the practitioners did right and what they did wrong. b. What should they have done? c. Think of the reasons why they did not do so and how could these communication barriers be overcome. Now think of your clinical environment. d. Are there similar communication barriers present? e. What can be done and what can you do to promote an open culture and fearless communication across the hierarchies in your clinical environment? f. Bring any areas for development to the attention of your line manager.
Notional Learning Hours 1 Hour for reading and reflection
Knowledge and skills dimension ✔ Personal and people development ✔ Make changes in own practice and encourage others to do so
recommendations of several studies in favour of routine pre-oxygenation prior to administration of general anaesthesia, there are currently no national guidelines or mandatory requirements, for this practice in elective patients. It is highly likely that if Elaine had been pre-oxygenated, the oxygen reserves in her lungs would have delayed the occurrence of hypoxaemia. Although an alternative outcome to this case will never be known, pre-oxygenation would undoubtedly have shortened the total period of hypoxaemia and allowed for a lower degree of hypoxic brain damage (Gelenda 2001). On the balance of probabilities, it is beneficial to establish compulsory routine pre-oxygenation prior to the induction of general anaesthesia.
The principles of airway management Evidence has suggested (Chrimes & Fritz 2013, DAS 2004) that the decision to intubate after an unsuccessful attempt to secure the airway with a laryngeral mask airway (LMA), and inadequate ventilation via a face mask and oro-pharyngeal airway (OPA), was justifiable. The laryngoscopic view – classified on the Cormack-Lehane scale as grade IV – indicated great difficulty in tracheal intubation. Consequently, multiple attempts of laryngoscopy caused bleeding and swelling of the larynx, which further compromised the visualisation of vocal cords. Three attempts of direct laryngoscopy using different size and shape of blades should be followed by fibre optic intubation and, if unsuccessful, by surgical airway by tracheotomy or cricothyroidotomy, if ventilation via a facemask is not sufficient (Takrouri et al 2003). However, fibre optic intubation should not be performed if the airway is occluded by blood. In the case of an unsuccessful intubation attempt and possible ventilation via a face mask, the difficult airway algorithm requires using alternative approaches in intubation (ASA 2003). To prevent trauma to the larynx, the maximum number of laryngoscope insertions should be limited to four because multiple and prolonged attempts at tracheal intubation are associated with
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morbidity and mortality (Henderson et al 2004). To minimise the damage of laryngeal tissues, indirect laryngoscopy is preferred rather than attempting a blind intubation. However, further attempts of laryngoscopy should not be performed in cases where there is great difficulty in ventilation via a face mask, an oropharyngeal airway (OPA) or four-handed technique (DAS 2004). The situation Elaine experienced is classified as ‘can’t intubate, can’t ventilate’ (CICV) (DAS 2004) which is a well-recognised clinical emergency with a clear algorithm of management (Reid & Bromiley 2012). In case of failed intubation and insufficient ventilation of a patient’s lungs, immediate surgical access to the trachea for adequate oxygenation is required (DAS 2004, ASA 2003). This is particularly indicated if the rapid development of hypoxaemia is associated with bradycardia (Henderson et al 2004). Failure to oxygenate leads to hypoxia, followed by brain damage, cardiovascular collapse and death. The DAS guideline (2004) for CICV states that cannula cricothyroidotomy or surgical cricothyroidotomy should be performed at this stage. Although this procedure can have serious complications, the presence of an ear-nose-throat consultant and senior theatre practitioners in the anaesthetic room, as well as immediate availability of tracheotomy equipment, should have provided extra reassurance and skills to establish a definitive airway solution. Moreover, acknowledgment of availability of the tracheotomy set made by one of the practitioners was ignored (Harmer 2005). Unfortunately, the failure to secure a definitive airway in this situation contributed to Elaine’s death.
Fixation and fallibility: being human The team failed to manage the CICV situation by not following the DAS (2004) guideline. Instead, due to pressure of the situation, clinicians developed ‘cognitive tunnel vision’ (Ortega 2011), and became fixated on intubation, failing to consider any other means of oxygenation. ‘This and only this!’ fixation type errors occur where clinicians concentrate solely on a single aspect of a case and overlook 51
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The power of Elaine’s story: A personal reflection Continued
other important features (Fioratou et al 2010a). Fixation errors are a natural human vulnerability that we all need to be aware of. Fixation errors in anaesthesia can contribute to significant morbidity and mortality and anaesthetic practitioners should be sensitive to the circumstances that increase the likelihood of them happening (HCPC 2012, NMC 2008). Examples of such circumstances are: high stress cases, confidence wobbles, poor teamwork, absence of a designated team lead, lack of assertiveness, fear of speaking up and communicating across the hierarchies, as well as in the case of a sudden emergency standing back from direct intervention. Although it is impossible to prevent all human errors, strategies need to be implemented to minimise their occurrence and the degree of harm they cause. A useful strategy in ameliorating fixation errors is actively to seek a second opinion (Ortega 2011). In Elaine’s case, although a second and third opinion was invited, given the intensity of the situation, all three clinicians became fixated on intubation as the only option.
their potential impact for the immediate and near future (Endsley 1995 cited by Fioratou et al 2010b). It is one of the most essential skills for effective and safe perioperative practice. Lack of situation awareness was exacerbated by poor communication between clinicians. As much as 70% of harm associated with perioperative care arises from poor communication (Vats et al 2009). Moreover, humans are more prone to error in stressful situations (Woodhead 2009). The human potential to error can be mitigated by checks and stop/pause moments at different stages of the perioperative pathway, performed by different professionals (Vats et al 2009). Catching medical errors can be lifesaving if they are identified early and managed appropriately.
The positive influence of effective communication
To mitigate biasing individuals, from whom we may seek a second or third opinion, it is important to avoid subjective interpretation of the situation. If the second opinion is not available, it is worth considering a change in point of view and seeking alternative explanations (Ortega 2011). To handle the emergency situation as experienced by Elaine, anaesthetists have to be able to recognise the need for an alternative approach to the problem and produce a different solution (Fioratou et al 2010a). Equally, theatre practitioners have to be able to modify and adapt their practice to emergency situations (HCPC 2012, NMC 2008).
Effective communication within the perioperative team is especially important in successful management of medical emergencies (Reid & Clarke 2009). A common challenge is that some members of staff find it difficult to communicate across the hierarchies. In Elaine’s case, all the necessary equipment to perform surgical airway was available in the anaesthetic room, theatre practitioners were aware of the need and suggested it. Despite the fact that the anaesthetic practitioner made the tracheotomy set visible to the team of clinicians and stated that it was available, this did not prove to be sufficient external artefact to break their fixation on intubation. Regrettably the anaesthetic practitioner’s voice was not loud or assertive enough, to register with his colleagues, as is encouraged in such situations (HCPC 2012, NMC 2008).
In Elaine’s case it was evident that the clinicians were not aware of the rapid passage of time or that there was a problem with ventilation. This is indicative of a lack of situation awareness among the anaesthetic team and a failure to communicate the seriousness of the situation appropriately. Situation awareness concerns the perception of elements in the environment, the volume of time and space, and the capacity to assess and comprehend
Lack of assertiveness, can often be attributed to strict hierarchal cultures between professions in operating theatres, impacting psychological safety and the degree to which all staff are encouraged to speak out (Harmer 2005, Reid & Bromiley 2012). A telling sign of a poor safety culture is the failure of clinicians to pay due regard to and actively encourage safety suggestions offered by theatre practitioners. In the absence of psychological safety,
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health professionals are unable to perform to the best of their capabilities, despite their high level of technical skills (Reid & Bromiley 2012). The negative effect of hierarchies can be reduced by promoting communication within the perioperative team and creating an environment in which clinicians actively encourage suggestions from theatre practitioners and theatre support staff (Reid & Clarke 2009). Speaking up is integral to the professional accountability of each health practitioner (Reid & Bromiley 2012). The recent report of the Mid Staffordshire NHS Foundation Trust Public Inquiry (Francis 2013) highlighted that not being able to speak up can result in neglect and cause unnecessary deaths. To enhance the quality of patient experience and outcome in the National Health Service, we need to learn from errors, and the operating theatre is an excellent place to start. All members of the multidisciplinary team should feel able and encouraged to stand up and point out if they see that something is not right for the patient. Health professionals have to act as patients’ advocates, by promoting their rights and interests (HCPC 2012, NMC 2008). The lack of leadership during the management of this crisis was evident (Reid & Bromiley 2012). This was also one of the reasons behind the neglect, highlighted in report of the Mid Staffordshire
Review
Locate your local policy on difficult airway. Locate and review the difficult airway trolley to make sure that it is in agreement with the policy and fit for its purpose. Report any discrepancies to your line manager.
Notional Learning Hours 2 hours
Knowledge and skills dimension ✔ Personal and people development ✔ Health safety and security
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OPENING LEARNING ZONE CLINICAL FEATURE
Effective communication within the perioperative team is especially important in successful management of medical emergencies
NHS Foundation Trust Public Inquiry. Forty percent of human errors can be ameliorated through effective leadership and the standardisation of procedures and processes supported by checklists, stop/pause moments and clear allocation of roles (Catchpole et al 2007 cited by Hellaby 2013). In Elaine’s case it is possible that the reluctance to perform a surgical airway was due to a confusion of each team member’s role and the absence of a clearly defined leader. Too much time was wasted trying to intubate Elaine; the outcome was compounded due the exclusion of any other intervention.
It could be any one of us Anaesthetists must act promptly and appropriately when anaesthetic complications arise (The Royal College of Anaesthetists & AAGBI 2010). Effective management of medical emergency requires the clear definition of a leader and clear delegation of tasks to the members of the team (Healey et al 2006). Wellcoordinated, effective team-work increases the potential of successful management of emergency scenarios such as Elaine’s. Once airway is achieved via intubating laryngeal mask airway (ILMA) and the ventilation and oxygenation appear sufficient, further attempts in intubating the trachea should not be performed (Harmer 2005). Although, ILMA has been shown to reduce the number of intubation attempts, in case of unanticipated difficult airway in elective surgery, the patient should be woken immediately once the ventilation and oxygenation is achieved (DAS 2004, Henderson et al 2004). In Elaine’s case, there were clear indications that she had suffered some degree of hypoxic brain damage as a result of the prolonged period of hypoxaemia. This required controlled ventilation with 100% oxygen (White & Morris 2010). Without doubt, surgical airway should have been performed, to ensure adequate ventilation and oxygenation (DAS 2004).
Post-anaesthetic care Patients with a high possibility of brain damage should always be transferred to the intensive care unit (ICU) rather than to recovery (Smith & Nielsen 1999, White & Morris 2010). Although a successful outcome could not have been guaranteed in Elaine’s case, there are suggestions that early ICU admission would have allowed for a lower degree of hypoxic brain damage (Cooper et al 2006). Elaine’s care could have been further enhanced had she been transferred ventilated and with invasive monitoring in situ. As Elaine’s emergency unfolded, an ICU bed was ordered by one of the nurses, but was subsequently cancelled; the nurse doubted her initial judgment because the clinicians weren’t behaving in a way that indicated that the situation was as serious as she had perceived it to be (Reid & Bromiley 2012). This raises the issue of confirmation bias, which dissuades us from responsive action, because those around us are carrying on as normal (Reason 1995). Before the anaesthetist leaves the recovery room, the patient’s vital signs should be stable and the recovery practitioner should formally agree to take over the care for the patient. Instead, Elaine was transferred to the recovery unit self-ventilated but unconscious; she was haemodynamically unstable and recovery practitioners were reportedly very unsatisfied with her condition. They were particularly concerned about her seizures, which are common after hypoxic brain injury (White & Morris 2010). Seizures can be signs of cerebral irritation, indicating the potential of further brain damage (Hatfield & Tronson 2009). Elaine’s condition indicated that the recovery area was not the right place for her immediate management. Recovery practitioners should not accept such cases, unless they are confident that they can deliver the same level of the care that is provided in ICU. Such situations require staff to exercise their professional judgment and insist on transfer to ICU (HCPC 2012, NMC 2008). Accepting patients inappropriately to a recovery area can occur in the absence of a formal handover of care that qualifies the level of patient dependency and required intervention (Harmer 2005). Such situations
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are unsatisfactory; there is often confusion about who is in charge of the patient and patients fall between the potential of someone, everyone and then no-one. Failing to share vital information about Elaine’s condition with her designated postoperative practitioner, via formal handover, further compromised her care and safety. In addition to a verbal handover, anaesthetists should provide detailed written postoperative instructions to support immediate and continuing care (AAGBI 2002). Recovery practitioners are encouraged to advocate for their patient and should refuse to accept them without a formal handover of care and clear postoperative instructions (Hatfield & Tronson 2009). The fact that Elaine’s transition of care took place without a formal handover, suggests poor communication between the anaesthetist and post-anaesthetic practitioners, as well as lax procedures. The independent review of Elaine’s case reported that the anaesthetist was not always available when called for by recovery practitioners (Harmer 2005). Anaesthetists have a continuous duty of care for the patient in the recovery room and should be readily available if needed (AAGBI 2010). In case of crisis or deterioration, anaesthetists should take an interest in their patient’s progress, by visiting the recovery area or ICU (AAGBI 2005). Anaesthetic and recovery practitioners should always feel empowered to raise concerns, even when presented
Project
Locate your local policy on management of ‘can’t intubate, can’t ventilate’ situation and discus with your colleagues how you would implement the policy in your clinical environment.
Notional Learning Hours 1 hour
Knowledge and skills dimension ✔ Personal and people development ✔ Health safety and security
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The power of Elaine’s story: A personal reflection Continued
with an unapproachable anaesthetist, for the safety and quality of patient care depends on it.
Caring for staff: the second victims of any adverse event Reflecting on the independent review of the case (Harmer 2005) it was surprising that, despite the tragedy and trauma of Elaine’s experience, staff were encouraged and expected to remain on duty and to continue working. After the critical incident, and certainly one of such magnitude, a time should be allowed for debrief and reflection (Critical Incidence Stress Debriefing Service 1997). Debriefs provide an opportunity to analyse an incident and to learn from it. It is vital that the extenuating circumstances and contextual factors that contributed to an incident are acknowledged; it is also very important to give staff time to express their distress at what happened. In situations of patient harm, if the situation is not managed compassionately and effectively through a model of commitment to learn versus blame, some staff never recover and never return to work (Berland et al 2008). The thorough analysis of the error, slip or lapse is essential in identifying and implementing countermeasures that can prevent or decrease the likelihood of the same error occurring in future (Cant & Cooper 2011).
Reflect
Think about the article you have just read and tasks you have completed. Did you learn anything new? If yes, how is this knowledge going to influence your practice? Reflect on your learning experience using a model of reflection of your preference.
Notional Learning Hours 1 hour
Knowledge and skills dimension ✔ Personal and people development
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Full and proper understanding of the incident can positively reduce the stress among team members, enabling them fully to focus on their work, to rehabilitate and grow on from the trauma, and to become more situational and self-aware practitioners (Cant & Cooper 2011). Conversely, the failure to address psychological distress caused by containment, repression and lack of understanding of the incident, can have a negative effect on performance. Practitioners with impaired performance or judgement through psychological distress may never regain their capacity to practice (Berland et al 2008)
References
Conclusion
Baraka A 2010 ‘Routine’ preoxygenation before induction of and recovery from anesthesia Middle East Journal of Anesthesiology 20 (6) 769-71
Review of Elaine’s story and the independent inquiry conducted by Professor Harmer (2005) provide a powerful lesson for every practitioner. Careful reading of the independent review and viewing of the film that recreates the events of the fateful day of 25/03/2005 should feature in the continuing development program of every perioperative professional, for we can never be complacent about the trust that patients and their families put in us. We work in a very risky environment. As we become more familiar we can become blind to, or accepting of the associated risks, with potentially serious consequences. We also are human and prone to lapses, slips and distraction. The case of Mrs Elaine Bromiley is the story of human error that was detected by theatre practitioners but not effectively communicated back to clinicians. It is also a reminder that everyone is capable of making mistakes, therefore everyone should be open to suggestions from others. Of my studies to date, Elaine’s story is probably the most powerful learning experience. I value the courage of Martin Bromiley in sharing it with us, in the spirit of learning versus blame. Finally, I would like to highlight the valuable work of The Clinical Human Factors Group in their open discussion of how understanding of human factors can improve patient safety.
American Society of Anesthesiologists 2003 Difficult airway algorithm Available from: http:// airwayeducation.homestead.com/ASA.html [Accessed December 2013] Association of Anaesthetists of Great Britain and Ireland 2002 Immediate postanaesthetic recovery London, AAGBI Association of Anaesthetists of Great Britain and Ireland 2005 Catastrophes in anaesthetic practice – dealing with the aftermath London, AAGBI Association of Anaesthetists of Great Britain and Ireland 2007 Recommendations for standards of monitoring during anaesthesia and recovery London, AAGBI Association of Anaesthetists of Great Britain and Ireland 2010 Safety guideline: preoperative assessment and patient preparation. The role of the anaesthetist London, AAGBI
Berland A, Natvig GK, Gundersen D 2008 Patient safety and job-related stress: A focus group study Intensive and Critical Care Nursing 34 90-7 Cant RP, Cooper SJ 2011 The benefits of debriefing as formative feedback in nurse education Australian Journal of Advanced Nursing 29 (1) 37-47 Cooper N, Forrest K, Cramp P 2006 Essential guide to acute care Oxford, Blackwell Publishing Ltd Crimes N, Fritz P 2013 The vortex approach in management of unanticipated difficult airway Available from: www.vortexapproach.com/Vortex_ Approach/Vortex.html [Accessed December 2013] Critical Incidence Stress Debriefing Service 1997 Resource guide for critical incident stress and debriefing in human service agencies Melbourne, Critical Incidence Stress Debriefing Service Difficult Airway Society 2004 DAS guidelines flowchart 2004 London, DAS Difficult Airway Society 2007 DAS guidelines Available from: www.das.uk.com/guidelines/ guidelineshome.html [Accessed December 2013] Fioratou E, Flin R, Glavin R 2010a No simple fix for fixation errors: cognitive processes and their clinical applications Anaesthesia 65 61-9 Fioratou E, Flin R, Glavin R, Patey R 2010b Beyond monitoring: distributed situation awareness in anaesthesia British Journal of Anaesthesia 105 (1) 83-90 Francis R 2013 Mid-Staffordshire NHS Foundation Trust public inquiry (HC 947) Available from: www.midstaffspublicinquiry.com/report [Accessed December 2013] Gelenda E (ed) 2001 Respiratory nursing Edinburg, Baillière Tindall Gupta S, Sharma R, Jain D 2005 Airway assessment: predictors of difficult airway Indian Journal of Anaesthesia 49 (4) 257-62
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Harmer M 2005 Independent review on the care given to Mrs Elaine Bromiley on 29 March 2005 Available from: www.chfg.org/articles-films-guides/ elaine-bromiley-report [Accessed December 2013]
Royal College of Anaesthetists & Association of Anaesthetists of Great Britain and Ireland 2010 The good anaesthetist standards of practice for career grade anaesthetists London, RCA and AAGBI
Hatfield A, Tronson M 2009 The complete recovery room book Oxford, Oxford University Press
Seo SH, Lee JG, Yu SB et al 2012 Predictors of difficult intubation defined by the intubation difficulty scale (IDS): predictive value of 7 airway assessment factors Korean Journal of Anesthesiology 63 (6) 491-7
Healey AN, Undre S, Vincent CA 2006 Defining the technical skills of teamwork in surgery British Medical Journal (15) 231-4 Health Care Professions Council 2012 Standards of proficiency of operating department practitioners London, HCPC Hellaby M 2013 What can other industries teach us about safety? Technic 4 (3) 18 Henderson JJ, Popat MT, Latto IP, Pearce AC 2004 Difficult Airway Society guidelines for management of the unanticipated difficult intubation Anaesthesia (59) 675-94 Nursing and Midwifery Council 2008 The code: Standards of conduct, performance and ethics for nurses and midwifes London, NMC Ortega R 2011 Fixations errors Available from: http://www.google.co.uk/url?sa=t&rct=j&q= &esrc=s&source=web&cd=1&cad=rja&ved= 0CDYQFjAA&url=http%3A%2F%2Fwww.bu.edu% 2Fav%2Fcourses%2Fmed%2F05sprgmed anesthesiology%2FMASTER%2Fdata%2Fdownloads% 2Fchapter%2520text%2520-%2520fixation.pdf&ei= xF19UYqGOdDz0gW7_oGgCQ&usg=AFQjCNH5Ucsz UdpB3vCM-NHaXEcrJX-dow&sig2=weQQbGnJzAwGPJZ7_tiVQ&bvm=bv.45645796,d.d2k [Accessed December 2013]
Simpson PJ, Popat M 2002 Understanding anaesthesia London, Elsevier Ltd Smith G, Nielsen M 1999 ABC of intensive care: criteria for admission British Medical Journal 318 (7197) 1544-7 Takrouri MS, El-Bakry AA, El-Dawlatly AA et al 2003 Management of unpredicted difficult tracheal intubation due to soft tissue swelling: a report of five cases Internet Journal of Anesthesiology 7 (1) Vats A, Nagpal K, Moorthy K 2009 Surgery: a risky business British Journal of Perioperative Nursing 19 (10) 330-4 White S, Morris R 2010 Anoxic brain injury Headway: the brain injury association Available from: www.headway.org.uk/hypoxic-anoxic-braininjury.aspx [Accessed December 2013] Woodhead K 2009 Safe surgery: reducing the risk of retained items British Journal of Perioperative Nursing 19 (10) 358-61
Acknowledgement I would like to thank the former president of AfPP/visiting professor at Bournemouth University/Nurse Advisor National Quality Board (Human Factors Concordat)/NHS Non Executive Director/Researcher Queen Mary, University of London Professor Jane Reid and senior lecturer and simulation project manager at School of Health Sciences and Social Work, University of Portsmouth Mick Harper for their valuable advice during the preparation of this article.
About the author Jaroslav Kamensky ODP Theatre Practitioner, Cardiac Theatres, University Hospital Southampton NHS Foundation Trust
No competing interests declared Members can search all issues of the BJPN/JPP published since 1998 and download articles free of charge at www.afpp.org.uk. Access is also available to non-members who pay a small fee for each article download.
Woodhead K, Wicker P 2005 A textbook of perioperative care Philadelphia, Elsevier Churchill Livingstone
Pinnock C, Lin T, Smith T 2003 Fundamentals of anaesthesia London, Greenwich Medical Media Ltd Reason J 1995 Understanding adverse events: human factors Quality Health Care 4 80-9 Reid J, Bromiley M 2012 Clinical human factors: the need to speak up to improve patient safety Nursing Standard 26 (35) 35-40 Reid J, Clarke J 2009 Progressing safer surgery British Journal of Perioperative Nursing 19 (10) 336-41
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Disclaimer The views expressed in articles published by the Association for Perioperative Practice are those of the writers and do not necessarily reflect the policy, opinions or beliefs of AfPP. Manuscripts submitted to the editor for consideration must be the original work of the author(s). © 2014 The Association for Perioperative Practice All legal and moral rights reserved.
The Association for Perioperative Practice Daisy Ayris House 42 Freemans Way Harrogate HG3 1DH United Kingdom Email: [email protected] Telephone: 01423 881300 Fax: 01423 880997 www.afpp.org.uk
The power of Elaine’s story: A personal reflection
by J Kamensky Correspondence address: Theatre Practitioner, Cardiac Theatres, University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton, SO16 6YD. Email: [email protected]
There will be few perioperative students (nursing, ODP) or surgical and anaesthetic trainees, who will not have heard of the tragic case of Mrs Elaine Bromiley. A 37 year old mother of two, admitted for an elective endoscopic sinus surgery and septoplasty, Elaine suffered major complications during the induction of general anaesthesia that resulted in her death due to hypoxic brain damage (Harmer 2005). As a student ODP, watching the DVD of the reconstruction of the events that contributed to Elaine’s death, I am conscious of the profound impact it had on me and the key learning points for practice. The importance of preoperative assessment Appropriate preoperative anaesthetic assessment is vital to ensure patient safety during general anaesthesia (AAGBI 2010) and sets the foundation for individualised anaesthetic care. Assessment highlights potential anaesthetic risks and enables optimisation of a patient’s preoperative condition because it includes physical examination of the airway, as well as careful assessment of the patient’s medical and family history, general health condition and life style. Physical examination of a patient’s airway prior to general anaesthesia helps to predict potential difficulties with airway management (Gupta et al 2005, Simpson & Popat 2002). Unanticipated difficult airway can cause delay or failure of intubation for general anaesthesia, which can result in hypoxaemia and ultimately lead to tissue hypoxia (Seo et al 2012). Prolonged tissue hypoxia can cause permanent hypoxic brain damage, which can result in disability or death of the patient (Gelenda 2001).
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While Elaine’s medical history didn’t suggest she had experienced difficulties with past anaesthetics, it should never be presumed that difficulty in airway management will not be encountered in future. Physical assessment described in the independent review of Elaine’s care (Harmer 2005) highlighted congenitally fused vertebra in her neck that could have inhibited neck movement, potentially causing difficulty in establishing a secure airway. Although a little restriction of Elaine’s neck movement was identified and the Mallampati score was two, normal mouth opening and thyro-mental distance did not suggest major difficult airway potential. This invites consideration that, despite the complex airway assessment, some patients with difficult airway will remain undetected. As much as 20% of difficult intubations are not predicted (Pinnock et al 2003), therefore the anaesthetic team must always be prepared for the unexpected and must plan the patient’s airway management before the induction of anaesthesia (DAS 2007).
Monitoring as essential Monitoring of vital signs during the induction of anaesthesia is important in early recognition of a patient’s deterioration and adverse events. However, monitors and alarms alert only to the existence of a problem; they do not offer a solution. Therefore, monitoring has to be used in conjunction with other clinical examinations and appropriate skills to interpret the patient’s vital signs (AAGBI 2007). Noninvasive monitoring of blood pressure, electrocardiograph and pulse oximetry were used to monitor Elaine’s vital signs during the induction of anaesthesia. These should have been accompanied by airway gases and airway pressure monitoring (AAGBI 2007). Although these are usually an integral feature of anaesthetic machines, Elaine’s status was unreported. Most adverse respiratory events can be readily diagnosed by pulse oximetry and capnography (Baraka 2010). Capnography is an established clinical tool, because it offers a good estimate of the partial pressure of carbon dioxide in arterial blood.
March 2014 / Volume 24 / Issue 3 / ISSN 1750-4589
OPENING LEARNING ZONE CLINICAL FEATURE
Monitoring of vital signs during the induction of anaesthesia is important in early recognition of a patient’s deterioration and adverse events
It reflects adequacy of ventilation, cardiac output and pulmonary blood flow, which are important variables in early recognition of respiratory or cardio-vascular compromise.
The value of pre-oxygenation There was no record that pre-oxygenation was provided for Elaine (Harmer 2005). Routine pre-oxygenation before the induction of general anaesthesia is not mandatory, however it is an additional safety precaution. Replacing alveolar gas with 100% oxygen allows for a longer period of apnoea as the airway is secured, without a drop in oxygen saturation. This ‘extra time’ can be lifesaving in cases of unanticipated difficult airway situations. Despite the
Reflect
Watch the video: ‘Just a routine operation’ available from the Clinical Human Factors Group website www. testing.chfg.org Reflect on the role of theatre practitioners in this procedure. a. Identify what the practitioners did right and what they did wrong. b. What should they have done? c. Think of the reasons why they did not do so and how could these communication barriers be overcome. Now think of your clinical environment. d. Are there similar communication barriers present? e. What can be done and what can you do to promote an open culture and fearless communication across the hierarchies in your clinical environment? f. Bring any areas for development to the attention of your line manager.
Notional Learning Hours 1 Hour for reading and reflection
Knowledge and skills dimension ✔ Personal and people development ✔ Make changes in own practice and encourage others to do so
recommendations of several studies in favour of routine pre-oxygenation prior to administration of general anaesthesia, there are currently no national guidelines or mandatory requirements, for this practice in elective patients. It is highly likely that if Elaine had been pre-oxygenated, the oxygen reserves in her lungs would have delayed the occurrence of hypoxaemia. Although an alternative outcome to this case will never be known, pre-oxygenation would undoubtedly have shortened the total period of hypoxaemia and allowed for a lower degree of hypoxic brain damage (Gelenda 2001). On the balance of probabilities, it is beneficial to establish compulsory routine pre-oxygenation prior to the induction of general anaesthesia.
The principles of airway management Evidence has suggested (Chrimes & Fritz 2013, DAS 2004) that the decision to intubate after an unsuccessful attempt to secure the airway with a laryngeral mask airway (LMA), and inadequate ventilation via a face mask and oro-pharyngeal airway (OPA), was justifiable. The laryngoscopic view – classified on the Cormack-Lehane scale as grade IV – indicated great difficulty in tracheal intubation. Consequently, multiple attempts of laryngoscopy caused bleeding and swelling of the larynx, which further compromised the visualisation of vocal cords. Three attempts of direct laryngoscopy using different size and shape of blades should be followed by fibre optic intubation and, if unsuccessful, by surgical airway by tracheotomy or cricothyroidotomy, if ventilation via a facemask is not sufficient (Takrouri et al 2003). However, fibre optic intubation should not be performed if the airway is occluded by blood. In the case of an unsuccessful intubation attempt and possible ventilation via a face mask, the difficult airway algorithm requires using alternative approaches in intubation (ASA 2003). To prevent trauma to the larynx, the maximum number of laryngoscope insertions should be limited to four because multiple and prolonged attempts at tracheal intubation are associated with
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morbidity and mortality (Henderson et al 2004). To minimise the damage of laryngeal tissues, indirect laryngoscopy is preferred rather than attempting a blind intubation. However, further attempts of laryngoscopy should not be performed in cases where there is great difficulty in ventilation via a face mask, an oropharyngeal airway (OPA) or four-handed technique (DAS 2004). The situation Elaine experienced is classified as ‘can’t intubate, can’t ventilate’ (CICV) (DAS 2004) which is a well-recognised clinical emergency with a clear algorithm of management (Reid & Bromiley 2012). In case of failed intubation and insufficient ventilation of a patient’s lungs, immediate surgical access to the trachea for adequate oxygenation is required (DAS 2004, ASA 2003). This is particularly indicated if the rapid development of hypoxaemia is associated with bradycardia (Henderson et al 2004). Failure to oxygenate leads to hypoxia, followed by brain damage, cardiovascular collapse and death. The DAS guideline (2004) for CICV states that cannula cricothyroidotomy or surgical cricothyroidotomy should be performed at this stage. Although this procedure can have serious complications, the presence of an ear-nose-throat consultant and senior theatre practitioners in the anaesthetic room, as well as immediate availability of tracheotomy equipment, should have provided extra reassurance and skills to establish a definitive airway solution. Moreover, acknowledgment of availability of the tracheotomy set made by one of the practitioners was ignored (Harmer 2005). Unfortunately, the failure to secure a definitive airway in this situation contributed to Elaine’s death.
Fixation and fallibility: being human The team failed to manage the CICV situation by not following the DAS (2004) guideline. Instead, due to pressure of the situation, clinicians developed ‘cognitive tunnel vision’ (Ortega 2011), and became fixated on intubation, failing to consider any other means of oxygenation. ‘This and only this!’ fixation type errors occur where clinicians concentrate solely on a single aspect of a case and overlook 51
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The power of Elaine’s story: A personal reflection Continued
other important features (Fioratou et al 2010a). Fixation errors are a natural human vulnerability that we all need to be aware of. Fixation errors in anaesthesia can contribute to significant morbidity and mortality and anaesthetic practitioners should be sensitive to the circumstances that increase the likelihood of them happening (HCPC 2012, NMC 2008). Examples of such circumstances are: high stress cases, confidence wobbles, poor teamwork, absence of a designated team lead, lack of assertiveness, fear of speaking up and communicating across the hierarchies, as well as in the case of a sudden emergency standing back from direct intervention. Although it is impossible to prevent all human errors, strategies need to be implemented to minimise their occurrence and the degree of harm they cause. A useful strategy in ameliorating fixation errors is actively to seek a second opinion (Ortega 2011). In Elaine’s case, although a second and third opinion was invited, given the intensity of the situation, all three clinicians became fixated on intubation as the only option.
their potential impact for the immediate and near future (Endsley 1995 cited by Fioratou et al 2010b). It is one of the most essential skills for effective and safe perioperative practice. Lack of situation awareness was exacerbated by poor communication between clinicians. As much as 70% of harm associated with perioperative care arises from poor communication (Vats et al 2009). Moreover, humans are more prone to error in stressful situations (Woodhead 2009). The human potential to error can be mitigated by checks and stop/pause moments at different stages of the perioperative pathway, performed by different professionals (Vats et al 2009). Catching medical errors can be lifesaving if they are identified early and managed appropriately.
The positive influence of effective communication
To mitigate biasing individuals, from whom we may seek a second or third opinion, it is important to avoid subjective interpretation of the situation. If the second opinion is not available, it is worth considering a change in point of view and seeking alternative explanations (Ortega 2011). To handle the emergency situation as experienced by Elaine, anaesthetists have to be able to recognise the need for an alternative approach to the problem and produce a different solution (Fioratou et al 2010a). Equally, theatre practitioners have to be able to modify and adapt their practice to emergency situations (HCPC 2012, NMC 2008).
Effective communication within the perioperative team is especially important in successful management of medical emergencies (Reid & Clarke 2009). A common challenge is that some members of staff find it difficult to communicate across the hierarchies. In Elaine’s case, all the necessary equipment to perform surgical airway was available in the anaesthetic room, theatre practitioners were aware of the need and suggested it. Despite the fact that the anaesthetic practitioner made the tracheotomy set visible to the team of clinicians and stated that it was available, this did not prove to be sufficient external artefact to break their fixation on intubation. Regrettably the anaesthetic practitioner’s voice was not loud or assertive enough, to register with his colleagues, as is encouraged in such situations (HCPC 2012, NMC 2008).
In Elaine’s case it was evident that the clinicians were not aware of the rapid passage of time or that there was a problem with ventilation. This is indicative of a lack of situation awareness among the anaesthetic team and a failure to communicate the seriousness of the situation appropriately. Situation awareness concerns the perception of elements in the environment, the volume of time and space, and the capacity to assess and comprehend
Lack of assertiveness, can often be attributed to strict hierarchal cultures between professions in operating theatres, impacting psychological safety and the degree to which all staff are encouraged to speak out (Harmer 2005, Reid & Bromiley 2012). A telling sign of a poor safety culture is the failure of clinicians to pay due regard to and actively encourage safety suggestions offered by theatre practitioners. In the absence of psychological safety,
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health professionals are unable to perform to the best of their capabilities, despite their high level of technical skills (Reid & Bromiley 2012). The negative effect of hierarchies can be reduced by promoting communication within the perioperative team and creating an environment in which clinicians actively encourage suggestions from theatre practitioners and theatre support staff (Reid & Clarke 2009). Speaking up is integral to the professional accountability of each health practitioner (Reid & Bromiley 2012). The recent report of the Mid Staffordshire NHS Foundation Trust Public Inquiry (Francis 2013) highlighted that not being able to speak up can result in neglect and cause unnecessary deaths. To enhance the quality of patient experience and outcome in the National Health Service, we need to learn from errors, and the operating theatre is an excellent place to start. All members of the multidisciplinary team should feel able and encouraged to stand up and point out if they see that something is not right for the patient. Health professionals have to act as patients’ advocates, by promoting their rights and interests (HCPC 2012, NMC 2008). The lack of leadership during the management of this crisis was evident (Reid & Bromiley 2012). This was also one of the reasons behind the neglect, highlighted in report of the Mid Staffordshire
Review
Locate your local policy on difficult airway. Locate and review the difficult airway trolley to make sure that it is in agreement with the policy and fit for its purpose. Report any discrepancies to your line manager.
Notional Learning Hours 2 hours
Knowledge and skills dimension ✔ Personal and people development ✔ Health safety and security
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OPENING LEARNING ZONE CLINICAL FEATURE
Effective communication within the perioperative team is especially important in successful management of medical emergencies
NHS Foundation Trust Public Inquiry. Forty percent of human errors can be ameliorated through effective leadership and the standardisation of procedures and processes supported by checklists, stop/pause moments and clear allocation of roles (Catchpole et al 2007 cited by Hellaby 2013). In Elaine’s case it is possible that the reluctance to perform a surgical airway was due to a confusion of each team member’s role and the absence of a clearly defined leader. Too much time was wasted trying to intubate Elaine; the outcome was compounded due the exclusion of any other intervention.
It could be any one of us Anaesthetists must act promptly and appropriately when anaesthetic complications arise (The Royal College of Anaesthetists & AAGBI 2010). Effective management of medical emergency requires the clear definition of a leader and clear delegation of tasks to the members of the team (Healey et al 2006). Wellcoordinated, effective team-work increases the potential of successful management of emergency scenarios such as Elaine’s. Once airway is achieved via intubating laryngeal mask airway (ILMA) and the ventilation and oxygenation appear sufficient, further attempts in intubating the trachea should not be performed (Harmer 2005). Although, ILMA has been shown to reduce the number of intubation attempts, in case of unanticipated difficult airway in elective surgery, the patient should be woken immediately once the ventilation and oxygenation is achieved (DAS 2004, Henderson et al 2004). In Elaine’s case, there were clear indications that she had suffered some degree of hypoxic brain damage as a result of the prolonged period of hypoxaemia. This required controlled ventilation with 100% oxygen (White & Morris 2010). Without doubt, surgical airway should have been performed, to ensure adequate ventilation and oxygenation (DAS 2004).
Post-anaesthetic care Patients with a high possibility of brain damage should always be transferred to the intensive care unit (ICU) rather than to recovery (Smith & Nielsen 1999, White & Morris 2010). Although a successful outcome could not have been guaranteed in Elaine’s case, there are suggestions that early ICU admission would have allowed for a lower degree of hypoxic brain damage (Cooper et al 2006). Elaine’s care could have been further enhanced had she been transferred ventilated and with invasive monitoring in situ. As Elaine’s emergency unfolded, an ICU bed was ordered by one of the nurses, but was subsequently cancelled; the nurse doubted her initial judgment because the clinicians weren’t behaving in a way that indicated that the situation was as serious as she had perceived it to be (Reid & Bromiley 2012). This raises the issue of confirmation bias, which dissuades us from responsive action, because those around us are carrying on as normal (Reason 1995). Before the anaesthetist leaves the recovery room, the patient’s vital signs should be stable and the recovery practitioner should formally agree to take over the care for the patient. Instead, Elaine was transferred to the recovery unit self-ventilated but unconscious; she was haemodynamically unstable and recovery practitioners were reportedly very unsatisfied with her condition. They were particularly concerned about her seizures, which are common after hypoxic brain injury (White & Morris 2010). Seizures can be signs of cerebral irritation, indicating the potential of further brain damage (Hatfield & Tronson 2009). Elaine’s condition indicated that the recovery area was not the right place for her immediate management. Recovery practitioners should not accept such cases, unless they are confident that they can deliver the same level of the care that is provided in ICU. Such situations require staff to exercise their professional judgment and insist on transfer to ICU (HCPC 2012, NMC 2008). Accepting patients inappropriately to a recovery area can occur in the absence of a formal handover of care that qualifies the level of patient dependency and required intervention (Harmer 2005). Such situations
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are unsatisfactory; there is often confusion about who is in charge of the patient and patients fall between the potential of someone, everyone and then no-one. Failing to share vital information about Elaine’s condition with her designated postoperative practitioner, via formal handover, further compromised her care and safety. In addition to a verbal handover, anaesthetists should provide detailed written postoperative instructions to support immediate and continuing care (AAGBI 2002). Recovery practitioners are encouraged to advocate for their patient and should refuse to accept them without a formal handover of care and clear postoperative instructions (Hatfield & Tronson 2009). The fact that Elaine’s transition of care took place without a formal handover, suggests poor communication between the anaesthetist and post-anaesthetic practitioners, as well as lax procedures. The independent review of Elaine’s case reported that the anaesthetist was not always available when called for by recovery practitioners (Harmer 2005). Anaesthetists have a continuous duty of care for the patient in the recovery room and should be readily available if needed (AAGBI 2010). In case of crisis or deterioration, anaesthetists should take an interest in their patient’s progress, by visiting the recovery area or ICU (AAGBI 2005). Anaesthetic and recovery practitioners should always feel empowered to raise concerns, even when presented
Project
Locate your local policy on management of ‘can’t intubate, can’t ventilate’ situation and discus with your colleagues how you would implement the policy in your clinical environment.
Notional Learning Hours 1 hour
Knowledge and skills dimension ✔ Personal and people development ✔ Health safety and security
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The power of Elaine’s story: A personal reflection Continued
with an unapproachable anaesthetist, for the safety and quality of patient care depends on it.
Caring for staff: the second victims of any adverse event Reflecting on the independent review of the case (Harmer 2005) it was surprising that, despite the tragedy and trauma of Elaine’s experience, staff were encouraged and expected to remain on duty and to continue working. After the critical incident, and certainly one of such magnitude, a time should be allowed for debrief and reflection (Critical Incidence Stress Debriefing Service 1997). Debriefs provide an opportunity to analyse an incident and to learn from it. It is vital that the extenuating circumstances and contextual factors that contributed to an incident are acknowledged; it is also very important to give staff time to express their distress at what happened. In situations of patient harm, if the situation is not managed compassionately and effectively through a model of commitment to learn versus blame, some staff never recover and never return to work (Berland et al 2008). The thorough analysis of the error, slip or lapse is essential in identifying and implementing countermeasures that can prevent or decrease the likelihood of the same error occurring in future (Cant & Cooper 2011).
Reflect
Think about the article you have just read and tasks you have completed. Did you learn anything new? If yes, how is this knowledge going to influence your practice? Reflect on your learning experience using a model of reflection of your preference.
Notional Learning Hours 1 hour
Knowledge and skills dimension ✔ Personal and people development
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Full and proper understanding of the incident can positively reduce the stress among team members, enabling them fully to focus on their work, to rehabilitate and grow on from the trauma, and to become more situational and self-aware practitioners (Cant & Cooper 2011). Conversely, the failure to address psychological distress caused by containment, repression and lack of understanding of the incident, can have a negative effect on performance. Practitioners with impaired performance or judgement through psychological distress may never regain their capacity to practice (Berland et al 2008)
References
Conclusion
Baraka A 2010 ‘Routine’ preoxygenation before induction of and recovery from anesthesia Middle East Journal of Anesthesiology 20 (6) 769-71
Review of Elaine’s story and the independent inquiry conducted by Professor Harmer (2005) provide a powerful lesson for every practitioner. Careful reading of the independent review and viewing of the film that recreates the events of the fateful day of 25/03/2005 should feature in the continuing development program of every perioperative professional, for we can never be complacent about the trust that patients and their families put in us. We work in a very risky environment. As we become more familiar we can become blind to, or accepting of the associated risks, with potentially serious consequences. We also are human and prone to lapses, slips and distraction. The case of Mrs Elaine Bromiley is the story of human error that was detected by theatre practitioners but not effectively communicated back to clinicians. It is also a reminder that everyone is capable of making mistakes, therefore everyone should be open to suggestions from others. Of my studies to date, Elaine’s story is probably the most powerful learning experience. I value the courage of Martin Bromiley in sharing it with us, in the spirit of learning versus blame. Finally, I would like to highlight the valuable work of The Clinical Human Factors Group in their open discussion of how understanding of human factors can improve patient safety.
American Society of Anesthesiologists 2003 Difficult airway algorithm Available from: http:// airwayeducation.homestead.com/ASA.html [Accessed December 2013] Association of Anaesthetists of Great Britain and Ireland 2002 Immediate postanaesthetic recovery London, AAGBI Association of Anaesthetists of Great Britain and Ireland 2005 Catastrophes in anaesthetic practice – dealing with the aftermath London, AAGBI Association of Anaesthetists of Great Britain and Ireland 2007 Recommendations for standards of monitoring during anaesthesia and recovery London, AAGBI Association of Anaesthetists of Great Britain and Ireland 2010 Safety guideline: preoperative assessment and patient preparation. The role of the anaesthetist London, AAGBI
Berland A, Natvig GK, Gundersen D 2008 Patient safety and job-related stress: A focus group study Intensive and Critical Care Nursing 34 90-7 Cant RP, Cooper SJ 2011 The benefits of debriefing as formative feedback in nurse education Australian Journal of Advanced Nursing 29 (1) 37-47 Cooper N, Forrest K, Cramp P 2006 Essential guide to acute care Oxford, Blackwell Publishing Ltd Crimes N, Fritz P 2013 The vortex approach in management of unanticipated difficult airway Available from: www.vortexapproach.com/Vortex_ Approach/Vortex.html [Accessed December 2013] Critical Incidence Stress Debriefing Service 1997 Resource guide for critical incident stress and debriefing in human service agencies Melbourne, Critical Incidence Stress Debriefing Service Difficult Airway Society 2004 DAS guidelines flowchart 2004 London, DAS Difficult Airway Society 2007 DAS guidelines Available from: www.das.uk.com/guidelines/ guidelineshome.html [Accessed December 2013] Fioratou E, Flin R, Glavin R 2010a No simple fix for fixation errors: cognitive processes and their clinical applications Anaesthesia 65 61-9 Fioratou E, Flin R, Glavin R, Patey R 2010b Beyond monitoring: distributed situation awareness in anaesthesia British Journal of Anaesthesia 105 (1) 83-90 Francis R 2013 Mid-Staffordshire NHS Foundation Trust public inquiry (HC 947) Available from: www.midstaffspublicinquiry.com/report [Accessed December 2013] Gelenda E (ed) 2001 Respiratory nursing Edinburg, Baillière Tindall Gupta S, Sharma R, Jain D 2005 Airway assessment: predictors of difficult airway Indian Journal of Anaesthesia 49 (4) 257-62
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Harmer M 2005 Independent review on the care given to Mrs Elaine Bromiley on 29 March 2005 Available from: www.chfg.org/articles-films-guides/ elaine-bromiley-report [Accessed December 2013]
Royal College of Anaesthetists & Association of Anaesthetists of Great Britain and Ireland 2010 The good anaesthetist standards of practice for career grade anaesthetists London, RCA and AAGBI
Hatfield A, Tronson M 2009 The complete recovery room book Oxford, Oxford University Press
Seo SH, Lee JG, Yu SB et al 2012 Predictors of difficult intubation defined by the intubation difficulty scale (IDS): predictive value of 7 airway assessment factors Korean Journal of Anesthesiology 63 (6) 491-7
Healey AN, Undre S, Vincent CA 2006 Defining the technical skills of teamwork in surgery British Medical Journal (15) 231-4 Health Care Professions Council 2012 Standards of proficiency of operating department practitioners London, HCPC Hellaby M 2013 What can other industries teach us about safety? Technic 4 (3) 18 Henderson JJ, Popat MT, Latto IP, Pearce AC 2004 Difficult Airway Society guidelines for management of the unanticipated difficult intubation Anaesthesia (59) 675-94 Nursing and Midwifery Council 2008 The code: Standards of conduct, performance and ethics for nurses and midwifes London, NMC Ortega R 2011 Fixations errors Available from: http://www.google.co.uk/url?sa=t&rct=j&q= &esrc=s&source=web&cd=1&cad=rja&ved= 0CDYQFjAA&url=http%3A%2F%2Fwww.bu.edu% 2Fav%2Fcourses%2Fmed%2F05sprgmed anesthesiology%2FMASTER%2Fdata%2Fdownloads% 2Fchapter%2520text%2520-%2520fixation.pdf&ei= xF19UYqGOdDz0gW7_oGgCQ&usg=AFQjCNH5Ucsz UdpB3vCM-NHaXEcrJX-dow&sig2=weQQbGnJzAwGPJZ7_tiVQ&bvm=bv.45645796,d.d2k [Accessed December 2013]
Simpson PJ, Popat M 2002 Understanding anaesthesia London, Elsevier Ltd Smith G, Nielsen M 1999 ABC of intensive care: criteria for admission British Medical Journal 318 (7197) 1544-7 Takrouri MS, El-Bakry AA, El-Dawlatly AA et al 2003 Management of unpredicted difficult tracheal intubation due to soft tissue swelling: a report of five cases Internet Journal of Anesthesiology 7 (1) Vats A, Nagpal K, Moorthy K 2009 Surgery: a risky business British Journal of Perioperative Nursing 19 (10) 330-4 White S, Morris R 2010 Anoxic brain injury Headway: the brain injury association Available from: www.headway.org.uk/hypoxic-anoxic-braininjury.aspx [Accessed December 2013] Woodhead K 2009 Safe surgery: reducing the risk of retained items British Journal of Perioperative Nursing 19 (10) 358-61
Acknowledgement I would like to thank the former president of AfPP/visiting professor at Bournemouth University/Nurse Advisor National Quality Board (Human Factors Concordat)/NHS Non Executive Director/Researcher Queen Mary, University of London Professor Jane Reid and senior lecturer and simulation project manager at School of Health Sciences and Social Work, University of Portsmouth Mick Harper for their valuable advice during the preparation of this article.
About the author Jaroslav Kamensky ODP Theatre Practitioner, Cardiac Theatres, University Hospital Southampton NHS Foundation Trust
No competing interests declared Members can search all issues of the BJPN/JPP published since 1998 and download articles free of charge at www.afpp.org.uk. Access is also available to non-members who pay a small fee for each article download.
Woodhead K, Wicker P 2005 A textbook of perioperative care Philadelphia, Elsevier Churchill Livingstone
Pinnock C, Lin T, Smith T 2003 Fundamentals of anaesthesia London, Greenwich Medical Media Ltd Reason J 1995 Understanding adverse events: human factors Quality Health Care 4 80-9 Reid J, Bromiley M 2012 Clinical human factors: the need to speak up to improve patient safety Nursing Standard 26 (35) 35-40 Reid J, Clarke J 2009 Progressing safer surgery British Journal of Perioperative Nursing 19 (10) 336-41
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Disclaimer The views expressed in articles published by the Association for Perioperative Practice are those of the writers and do not necessarily reflect the policy, opinions or beliefs of AfPP. Manuscripts submitted to the editor for consideration must be the original work of the author(s). © 2014 The Association for Perioperative Practice All legal and moral rights reserved.
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