What we can learn from fatal mistakes in surgery

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In 2005 Elaine Bromiley, a 37-year-old woman attending hospital for what was supposed to be a routine operation on her nasal air passages, suffered catastrophic brain damage after unexpected complications occurred at the start of the procedure.

An emergency had arisen shortly after the anaesthetic drugs had been injected. Elaine's airway - the path from her mouth to her lungs through which air normally flows - had become obstructed. It was a rare event, of the type that occurs in fewer than one in 50,000 routine cases.

But that day the anaesthetic team suddenly found themselves unable to assist Elaine's breathing or get fresh oxygen into her lungs. During a desperate struggle that lasted some 20 minutes the medical team were unable to remedy the situation.

As a result Elaine's brain became starved of oxygen. She was transferred to the intensive care unit but died several days later.

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Presenter Kevin Fong

If someone you loved - your wife or husband - died unexpectedly in a hospital during a routine operation you'd have a right to feel angry. You'd be forgiven for looking for someone to blame, you'd demand perhaps that someone should be fired from their job.

In 2005 Elaine's husband, Martin Bromiley, faced precisely this nightmarish scenario but - remarkably - decided to do none of those things. Martin instead focussed his energy on trying to understand what had gone wrong and why.

As a commercial airline pilot Martin was familiar with how the world of aviation would have responded to a similarly catastrophic event.

Human fallibility

There would have been an independent investigation, the goal of which would have been to discover the root cause of the incident. And the primary focus of that exercise would not have been to apportion blame or determine legal liability but to learn lessons - lessons that might save lives in the future.

Why do we make mistakes under pressure?

Artistic representation of the brain
  • Our powers of reasoning are easily overloaded
  • Professor Nilli Lavie from University College London, specialises in a mental process called load theory
  • She has discovered that if one part of our brain is overloaded by concentrating on a single activity, our brain's capacity to monitor other situations is severely compromised
  • It is referred to as losing our situational awareness

The independent investigation into Elaine's death, carried out in large part because of Martin's insistence, was revealing. It highlighted many elements of the incident in which those present could have performed better.

But upon reading the report Martin's conclusion was that the system had let Elaine down, that the team members were insufficiently protected from their own fallibility.

In the airline industry, faced with a complex task in which human life is at stake, steps are taken to standardise operational procedures, leaving as little as possible up to chance or the frailties of human psychology.

But in examining the events surrounding his wife's death it appeared to Martin that such measures were often absent from the practice of healthcare as it stood in 2005.

In the years since Elaine's death Martin has taken it upon himself to advocate fiercely for an improved safety culture in medicine, using his personal experience as a sober illustration of how exposed medical teams are when control of a situation is suddenly lost.

He has told his tragic story to all in healthcare who are prepared to listen, addressing conferences and delivering lectures spelling out the lessons that we as medical professionals should learn.

Dr Fong is fitted with an EEG cap, to measure how quickly his brain responds to making mistakes

In so doing he has succeeded in forcing a radical rethink amongst healthcare workers, particularly those involved in frontline anaesthetic practice.

The message he sends is clear - in healthcare there should be greater standardisation of procedures and more use of checklists to ensure that vital tasks are not omitted.

But most importantly there should be systems of blame-free reporting and, in the wake of disasters, investigations that seek essential lessons rather than scapegoats.

This is not to say that all of healthcare should be run the way our airports and commercial airlines are. There are fundamental differences between the aviation industry and the practice of medicine that make it unsafe to draw too close an analogy between the two.

The scenarios we face in medicine are more variable in character and evolve less predictably. And substantial risks often have to be accepted in pursuit of life saving medical benefit.

But this is not a reason to completely ignore the lessons we might learn from other organisations. There are indeed important aspects of airline safety culture that the health service would do well to adopt.

Martin has pursued this agenda relentlessly. I met him while we were lecturing together at a patient safety conference some years ago.

We have for some time been trying to find ways to bring these messages to a wider audience, to help people understand simultaneously how great the challenge of safe delivery of healthcare is, and underline how far we still have to go in pursuit of this goal.

The importance of checklists

  • Surgical checklists are now standard in all hospitals
  • Inspired by other high pressure industries like aviation
  • Checklists have helped cut death and complication from surgery by more than a third
  • A checklist helps to minimise the traditional hierarchy of the operating theatre
  • It helps all team members to follow basic procedures

Source: Dr Atul Gawande - Lead advisor to the World Health Organisation on patient safety

This incident happened in a private hospital. But that is beside the point. This is not about the relative merits and demerits of the NHS. It is about lessons that should be learnt by all those involved in the delivery of healthcare, in whatever sector, at whatever level of hierarchy.

The detailed investigation into the death of Elaine Bromiley identified many elements which could or should have been managed differently. The report states, however, that even if the management of this case had been perfect, Elaine's life might still have been lost.

The loss of control of a patient's airway during anaesthesia is a rarely experienced event. And it is hard to prepare for situations which may arise only once in a career lifetime.

But there are nevertheless steps that can be taken, to give ourselves the best of all possible chances, no matter how slim the chances of success.

And none of this is about a search for blame. Martin never sought the dismissal of those involved in his wife's case. On the contrary, if he or any member of his family were to have an anaesthetic today he tells me that he would be happy to have that same anaesthetic team.

He feels that, through this process of review, they have collectively learnt the important lessons that stemmed from this tragedy and moved on - safer as practitioners of healthcare than they were before.

Amongst the many things that we might all take away from Martin Bromiley's experience, this is perhaps the most important.

Dr Kevin Fong is a Consultant in Anaesthesia at UCLH

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