Paediatric surgeons learn safety tricks from pit stop rituals

BMJ 2010; 340 doi: (Published 10 June 2010) Cite this as: BMJ 2010;340:c3112
  1. Nigel Hawkes
  1. 1London

    When the first Grand Prix was held at Le Mans in 1906, the dust cleared after two days’ racing to reveal one spectator killed, a donkey run over, and a flock of chickens destroyed. The French press described the event as “an unqualified success.”

    Telling the story to an audience of junior doctors at a conference on 7 June, Formula 1 expert Richard West suggested that the history of motor racing had lessons to teach about inculcating a safety culture into medicine. Together with Alan Goldman of Great Ormond Street Hospital, London, he described how the intricate ballet of a pit stop had been studied to devise a better way to make the hand over from operating theatre to intensive care unit after babies had undergone neonatal arterial switch operations.

    Dr Goldman said the trick was ensuring that babies who were stable in the operating theatre remained stable when transferred. “It was an incredibly fragmented process,” he admitted, “and a very unforgiving operation.”

    Ensuring that the set up in the intensive care unit was the same as that in the theatre, making the handover smoothly, briefing the staff about each individual baby, was a process never properly analysed until there was a run of deaths at the hospital. With this in the back of his mind, he happened to be watching a Grand Prix on television and saw a pit stop perfectly performed.

    Visits to McClaren and Ferrari followed, and the process was analysed. The first revelation was that the teams practised the pit stops repeatedly, at least 1500 times a year. “We never practised,” he said.

    The second was to create a team leader, …

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