Medical Safety Podcast

Send us Fan Mail Watch the full video podcast on YouTube here: https://youtu.be/wDgv5gnRDX8?si=T6jKII0V5-QI9cTs Show Notes The National Confidential Enquiry into Patient Outcome and Death (NCEPOD) is an independent UK charity and company that started in 1988 that reviews medical and surgical care in the UK to improve care for patients  Started with anesthetists focused on post-operative outcomes,...

Send us Fan Mail Show Notes The National Confidential Enquiry into Patient Outcomes and Death (NCEPOD) - Common Themes 2024 Report The NCEPOD Common Themes Report was first published in 2018 as a “living report” of key topics to be discussed in the care of hospital patients. It was subsequently updated in 2024 to the current edition with a stronger focus on communication, transition planning, and...

Send us Fan Mail Show notes Colon Cancer Screening Colon cancer screening is conducted in Ontario with the Fecal Immunochemical Test (FIT). The test detects microscopic blood in the stool. An abnormal FIT leads to a colonoscopy which can detect colon cancer or polyps before they turn into cancer. Screening tests A screening test is used to test populations that are at average risk for a disease. I...

Send us Fan Mail Show notes The Health Services Safety Investigations Body (HSSIB) investigates patient safety concerns in the UK. They are an independent body with the aim of making healthcare safer. Excellent care is one goal, but well-connected and easy to navigate care is an entirely different matter. In the current healthcare system, it is practitioners that are keeping people safe by filling...

Send us Fan Mail Show notes Risk management principles: Key elements of risk management Identifying hazards, or risk identification These are the things that could cause harm or problems assessing the risk The likelihood of a hazard causing harm Putting in place controls or making a decision Implementation of solutions that lead to risk reduction or prevention Documenting the management decisions...

Send us Fan Mail Show notes The reference event: Helen’s CABG Helen had heart surgery (CABG x3 “triple bypass open heart surgery”). The day after the procedure, Helen had trouble breathing and a Chest X-Ray (CXR) taken for another reason, identified a retained sponge. She was taken back to the OR and had the sponge removed. As she was quite unstable, the decision was made not to X-ray her in the O...

Send us Fan Mail Show notes Errors occur when a planned sequence of events fails to achieve its goal without an element of chance. Slips and lapses are absentmindedness. Trips and fumbles are maladroitness. Mistakes involve higher order cognition Main classification of errors: Skill-based slips Rule-based mistakes Knowledge-based mistakes Examples of skill-based slips: putting cat food in the teap...

Show notes Elaine Bromiley Healthy 37 year old woman for elective sinus surgery in the UK in 2005 Can’t Intubate Can’t Oxygenate Experienced anesthesiologist + another who joined when help was called for + a head and neck surgeon in the room + experienced OR nurses Elaine’s oxygenation fell and the team could not get oxygen to her through intubation, face mask ventilation, or by using a laryngeal...

Show notes How to make simulation effective Although equipment is expensive and may seem like a barrier to establishing a simulation program, the emphasis of a simulation focused on CRM principles should be communication and having skilled debriefers who can facilitate skills development Using simulation to have someone experience a crisis and reflecting on why things didn’t go well, with the help...

What is Crisis Resource Management (CRM)? It is a set of skills that helps improve team performance through communication, leadership, and interpersonal skills. It can help build a common language and shortcuts so that even people that have not worked together before can work well together. Used well, it can improve efficiency. While it is more formalized in other industries (aviation, military),...

Aspects of CRM Making a welcoming environment, so that others feel they can speak up CRM is not about being perfect. It’s about identifying and mitigating the times of increased risk of making mistakes and identifying why a particular mistake was made. The perceived tension between performance and “soft skills” (CRM) Some people view these non-technical skills as costing time and money and not con...

In this episode Amir and Adam discuss three aviation accidents that parallel the Elaine Bromiley case. Human factors in medicine: As Captain Bromiley put it, this was not an individual failure. It was a system failure. It was a failure of human performance. In aviation, 75% of airline accidents are due to human factors rather than mechanical failure.  Eastern Airlines Flight 401 (1972) Fixation-in...

Welcome to the Medical Safety Podcast where we aim to improve the safety of our healthcare system through the integration of human factors into medical incident investigation and proactive safety measures. This podcast is hosted by two Canadian anesthetists, Drs. Adam Shehata and Amir Hamid. In the inaugural episode, we take a look at the 2005 death of Elaine Bromiley and the lessons learned from...