Medical error: the plane truthBMJ 2008; 337 doi: http://dx.doi.org/10.1136/bmj.a1281 (Published 12 August 2008) Cite this as: BMJ 2008;337:a1281
- Robin E Ferner, director, West Midlands Centre for Adverse Drug Reactions, City Hospital, Birmingham
“The complex sorrows of actions going wrong” was how Marianne Paget, a US sociologist, described medical error. The core of this BBC radio programme, introduced by the comedian, media commentator, and doctor Phil Hammond, was a story of tragedy that exemplified actions going wrong and the sorrows that follow.
Martin Bromiley is a pilot who in his professional life has taken a particular interest in human error. In 2005 his 37 year old wife Elaine went into a clinic for routine, day case sinus surgery. Something went wrong during intubation, and she died in the intensive care unit 13 days later. Mr Bromiley explained how his wife’s oxygen saturations dropped to 75%, then to 40%, and minutes ticked by with no one able to act effectively, until hypoxic brain damage was inevitable. He understood and at first accepted the explanations of the medical staff. “The problems weren’t expected,” he said. “They’d all made the right decisions, but it just didn’t work out.” Then he discovered that the hospital would investigate his wife’s death only if he sued or complained. He knew that had this been a death in aviation it would have been investigated automatically.
The programme drew repeated parallels between pilots and surgeons. The three consultants involved in Elaine Bromiley’s resuscitation were so intent on trying to intubate her that they ignored a nurse standing beside them with a tracheotomy set. Liam Donaldson, England’s chief medical officer, spoke sadly of “autocratic” pilots whose co-pilots were too scared of them to point out that they were about to fly into a mountain.
Dr Hammond asked another of his interviewees, Ara Darzi, health minister, surgeon, and co-author of an article on the first UK experience of robotic prostatectomy, how he would react if someone said to him, “Excuse me, Lord Darzi, Sir, I think you are operating on the wrong side.” His reply, “That is the most refreshing thing I would see in the operating theatre,” is most easily interpreted to mean that this would be a refreshingly new experience for a man who seems not to hear when general practitioners tell him he is wrong. He sounded surprised that his colleagues were unenthusiastic about the surgical equivalent of the black box flight recorder, complete with camera over the operating table.
Lord Darzi described how laparoscopic surgery could be learnt on simulators rather than patients. Pilots, it seems, must spend 16 hours a year on simulator training to maintain their skills. Chris Frerk, from Northampton General Hospital, explained that if all anaesthetists kept up their intubation skills in this way they would need expensive simulators to train on, and we would need to close a hospital to cover their study leave. The challenge was to show it would be worthwhile. It may not be: a recent newspaper report said that instead of spending thousands of pounds on state of the art, virtual reality surgical simulators, all you need is a games console. Playing “Marble Mania” on a Nintendo Wii substantially increased trainees’ skills in minimally invasive laparoscopic surgery (www.guardian.co.uk/technology/2008/aug/07/research.games).
Atul Gawande from Harvard Medical School described two simple lessons that surgeons should learn from pilots: that allowing all the team members to introduce themselves gives them a voice; and that checklists could save lives. This sounds sensible. As a trial published this year in Archives of Surgery (2008;143:12-17) put it, “Interprofessional checklist briefings reduced the number of communication failures and promoted proactive and collaborative team communication.”
There are limits to the analogy between aviation and medicine. Plane crashes are extraordinary and dramatic events that happen only if things have gone badly wrong. By contrast, some patients inevitably die in hospital. Finding out whether a patient died as the result of an error can be difficult or impossible. Although flying is complex, it is now highly automated, and the unexpected is rare. Medicine by contrast has little automation or computerised decision support, and it invites the unexpected. It is also extremely diverse: Dr Gawande counted 3700 different surgical procedures and “13 800 different diagnoses that we now have successful treatments for.”
This programme shares its title with a well known 1999 report from the US Institute of Medicine that emphasised the inevitability of error in human activity. The programme paid lip service to this notion while implying that medical hierarchies, obdurate consultants, and failure to embrace robots were more important than the lack of safe systems that are proof against inevitable human fallibility. Only Martin Bromiley said that we need ways to make sure that errors are caught before they cause harm. He has set up a charity to make medical practice safer, and he sounds like a man who can do it.
Cite this as: BMJ 2008;337:a1281
To Err is Human
Presented by Phil Hammond
BBC Radio 4, 11 August, 9 pm
Competing interests: REF sits on a committee that distributes research funds from the UK National Patient Safety Agency, which was criticised in the programme.
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