Human factors crucial to patient safety

Chaired by Mr John Black, president of the Royal College of Surgeons, the Clinical Human Factors sessions provided an emotive insight into what happens when human factors intervene and lead to surgical harm. The stories of Martin Bromiley and Jane Peters* had a powerful impact on delegates as they discussed the lessons that can be learned from such devastating experiences – where process design, failure to communicate, loss of situational awareness and lack of teamwork led to errors in the delivery of healthcare. Martin Bromiley, chair of the Clinical Human Factors Group, tragically lost his wife, Elaine, in April 2005 after a routine operation. He subsequently discovered that a range of human factors, and not technical skills, had directly led to her death. Elaine Bromiley was a fit and healthy young woman who was admitted to hospital for routine sinus surgery. During the anaesthetic she experienced breathing problems and the anaesthetist was unable to insert a device to secure her airway. After 10 minutes it was a situation of “can’t intubate, can’t ventilate” – a recognised anaesthetic emergency for which guidelines exist. For a further 15 minutes, three highly experienced consultants made numerous unsuccessful attempts to secure Elaine’s airway and she suffered prolonged periods with dangerously low levels of oxygen in her bloodstream. Early on nurses informed the team that they had brought emergency equipment to the room and booked a bed in intensive care but neither were used. Thirty-five minutes after the start of the anaesthetic, it was decided that Elaine should be allowed to wake up naturally and was transferred to the recovery unit. When she failed to wake up she was then transferred to the intensive care unit. Elaine never regained consciousness and after 13 days the decision was made to withdraw the ventilation support that was sustaining her life. A detailed investigation highlighted some of the following factors: • Loss of situational awareness – the stress of the situation meant that the consultants involved became highly focused on repeated attempts to insert the breathing tube. As a result of this, they lost sight of the bigger picture i.e. how long these attempts had been taking. This “tunnel vision” meant they had no sense of time passing or the severity of the situation. • Perception and cognition – actions were not in line with the emergency protocol. In the pressure of the moment many options were being considered but they were not necessarily the options that made the most sense in hindsight. • Teamwork – there was no clear leader. The consultants in the room were all providing help and support but no one person was seen to be in charge throughout. This led to a breakdown in the decision-making process and communication between the three consultants. • Culture – nurses who sensed the urgency early on brought the emergency kit to the room, and then alerted the intensive care unit. They stated that these were available but did not raise their concerns aloud when they were not used. Other nurses who were aware of what was happening did not know how to broach the subject. The hierarchy of the team made assertiveness difficult despite the severity of the situation. The clinicians involved were all experienced, trained and respected individuals who, in theory, knew how to deal with the developing emergency. Unfortunately, human factors intervened. Human factors, Martin Bromiley explained, are the things that make us different from logical, completely predictable machines – how we think and relate to other people, equipment and our environment. It is about how we perform in our roles and how we can optimise that performance to improve safety and efficiency. Some of the common human factors that can increase risk include: • Mental workload. • Distractions. • The physical environment. • Physical demands. • Device/product design. • Teamwork. • Process design. Following the death of his wife, Martin Bromiley decided to use his tragic loss to help bring about a cultural change in healthcare. The Clinical Human Factors Group was subsequently formed in 2007 to raise awareness and improve the management of human error in theatres. From an airline background, Martin Bromiley set about trying to understand the “business” of healthcare and found the sector was operating like the manufacturing industry – productivity and finance were the top priorities. “There was some understanding of systemic human error, but it was not really believed in. People thought it was just down to bad conditions,” he commented. “In the NHS there is a tension – is it productivity or safety that is the top priority? People are not quite sure. “Although there is increasing recognition of clinical human factors, some people say they have heard of this but are unsure of what this actually means. The role of human factors is an area that the vast majority of healthcare professionals, policy makers, managers and politicians are still unaware of.”

The case of Chloe Peters

Following Martin Bromiley’s introduction to the concept of human factors, Jane Peters gave a harrowing account of the chain of events that led up to and followed the death of her five year old daughter, Chloe*. She bravely recounted what had happened and the effects it had on her and her family. Diagnosed with the hereditary condition spherecytosis, Chloe Peters had an operation to remove her spleen using laparoscopic surgery to reduce the visibility of scarring. The surgeon told the family, when obtaining consent that there was “no need to talk about complications, as they were not going to happen”, she claimed “We took our amazing and beautiful little daughter to theatre and told her everything was going to be ok and we would be there when she woke up, but this was never to happen,” she explained. “A team of blood stained surgeons, nurses and the anaesthetist suddenly burst into the hospital room unexpected and announced that ‘something terrible had happened’. I had to ask the question, as they did not say it: ‘is she dead?’ “They told me they had cut through the bone muscle and she had bled to death. We were in shock and distraught. I was hysterical. We had to tell our other children that their sister would not be coming back. Stephen*, my husband, said it was the most difficult thing he had ever had to do.” The way in which Jane Peters and her husband were treated after the death of their child also highlighted lessons to be learned in the way families are dealt with following such events. After Chloe’s death, an appointment previously made for counselling for the parents was cancelled by bereavement services as they lived outside the area – they were told they were “not entitled” and handed some leaflets instead. They went to the ward to collect a picture, that Chloe had painted before she went to theatre, only to find that staff had thrown it away. “How could they not understand that everything Chloe had ever touched had now become precious?” Jane Peters exclaimed. “It took five months, when I was driving along one day, to fully acknowledge in my heart that she was really gone. Eventually you realise that you cannot bring your child back, but you would still give up all your worldly possessions for just five more minutes with them. All you have left is memories of your child and you find that you simply must know everything – you have to understand why your daughter died,” she commented. However, in a meeting with the hospital, Jane and Stephen Peters were told a very different story to the one they were given at the time of Chloe’s death – obtaining information on how their daughter died proved to be extremely difficult and distressing. “We left the meeting hurt and upset that our questions were left unanswered. We fought for copies of Chloe’s notes, which showed there were significant errors in procedures. We had a meeting with the surgeon. They had been using a new piece of equipment – a morcellator, used to dissect organs internally,” she explained. A morcellator is a device with a 1cm-wide blade that rotates at up to 1,000 rpm. It is designed for use in hysterectomies, enabling surgeons to cut the uterus into tiny pieces to allow it be removed laparoscopically, through small incisions. Until Chloe’s operation, the morcellator had not been used in paediatric surgery in the UK and it has not been used since. “A trainee surgeon was using the device at the time of Chloe’s collapse – it was the only piece of equipment in use at the time,” said Jane Peters. “The notes were incomplete and we had to fight for every detail to be released. Stephen and I were way over our heads. Neither of us had the medical knowledge needed and we had no one to help us. It was extremely stressful.” Jane Peters said that the hospital would not give them a clear account of what happened – she felt that there was an attempt to confuse them and the issues were clouded so that they followed irrelevant lines of enquiry, to distract them from the main issues. The couple also discovered that vital evidence had gone missing – including the bag containing the extracted spleen, the swabs, the blood Chloe had lost and all the disposable parts of the morcellator. Important records had not been kept and the labels from the blood transfused were not retained, so it was impossible to establish how much blood Chloe had been given, she explained. The post mortem examination revealed Chloe’s aorta had two complete cuts, approximately 1cm apart. With regard to the cuts, the testimony by the surgeons, present in the operating theatre, shifted from: • July 2006 (following Chloe’s death) – Blood vessel accidentally cut with morcellator resulting in major blood loss and death, to: • January 2007 (recorded meeting) – Aorta cut in two places, probably with the morcellator, but the resulting blood loss was not significant. Cause of death unclear, to: • November 2007 (inquest) – Aorta certainly not damaged by the morcellator, and the two cuts found have no explanation. Blood loss from the cuts insignificant, and cause of death unclear. Cuts were also found to her large intestine and stomach, in addition to those found in the aorta. No explanation was given as to the cause of these. The doctors dismissed all suggestion they caused her death either through their actions or inaction, but did not present any alternative explanation. “We were getting nowhere and the hospital did not want to investigate. They left us fumbling around in the dark, so we enlisted the help of a friend with medical knowledge, who accompanied us to a meeting. Suddenly, things become clearer – the hospital finally had a qualified opponent,” Jane Peters continued. She believed that the hospital had not gained informed consent to use the morcellator. Had they been made aware that a new approach was to be used by a trainee surgeon, with the associated extra risks, they would not have given their consent. “The operating surgeon had received five minutes training (undocumented) by another surgeon who had seen the device in action, when used five years previously. They had undertaken no risk assessment and had not followed correct procedure in implementing a new technique in surgery. The surgeon who was experienced in the procedure was out of the operating theatre area, supervising via a camera. Moreover, it was only the third laparoscopic splenectomy that the surgeon had carried out and the technique had never been carried out on a child before, anywhere in Europe. “Consider this analogy – if you were told that the aeroplane you were travelling on had a new piece of landing equipment on board, and a trainee pilot would be using it; his co-pilot had little flying time experience and had been trained on the new landing gear for five minutes by a pilot sitting in row five; would you stay on the plane?” Jane Peters commented. “The difference between pilots and surgeons is that the latter do not put their own lives at risk. If they did, perhaps they would be more keen to embrace simulation training and debriefing, and there would be less rule breaking. “What mindset did those doctors have when they thought they could carry out such a procedure without any risk assessment or thought to human error? It was the surgeon’s first ever procedure of this kind – did they not think that the introduction of a new piece of equipment was a step too far? It added pressure to the whole operation,” she exclaimed. In her account, she said that the nursing team were unfamiliar with the morcellator, but were expected to put the device together – without having received training. The theatre team also decided to use a bag to hold the spleen despite the fact that the instructions clearly stated “not be used with a morcellator”. “Why would they break a specific rule?” asked Jane Peters. “Not one person in that theatre considered: should we step back and think about this? If they had, Chloe may still be alive to today.” Jane Peters said that they continued to “hit brick walls” and were told “that information is not available to you, but would be available if you appointed a legal team”. The Peters family had to instruct a solicitor before a full inquest was held, therefore. “All we wanted was to hear was ‘sorry, we don’t know exactly what happened, but we will do everything we can to find out, and ensure that everything is done correctly in the future and that lessons are learned’. We wanted openness, compassion and honesty. “We did not want to bring a negligence claim, we just wanted answers. It was never for a second about the money. Why would it be? What would you do with it anyway? Buy a new TV? How do you place a value on a child’s life?” A “horrific” three-day inquest followed, she recalled: “Numerous people were tortured with no possibility of escape. We even had to endure seeing pictures of Chloe’s autopsy,” she said. She recalled that a witness, in giving evidence, said in response to the issue of consent: “I use new equipment all the time – I do not see the need to tell the patient or the parents”. However, she argued that the rules of consent are clear: “You must gain proper, informed consent.” Jane Peters said she was concerned that human factors were not mentioned at any stage during the inquest by the coroner. “This is when I realised that not all surgeons are the same. Some believe they do not make mistakes and, therefore, human factors training is irrelevant to them. They are so detached from the patient that this has become arrogance – which suppresses the needs of patients and their families. “This, in my view, is what enabled a surgeon to decide that they only needed five minutes training on the equipment, without thought to procedure or human error,” she said, adding that theatre teams need to step back and think about what is happening; to take things at a considered pace. Having lost her daughter and endured a lengthy battle for answers, there was further tragedy to follow. A fit man of 31 with no history of heart disease, Stephen Peters died suddenly 19 months after the death of Chloe from a heart attack – brought on, the family believe, by stress. “Deep down, Stephen felt he should have been able to keep Chloe alive,” said Jane Peters. “Before Chloe’s operation, we were a normal family of five, now we are only three... I am now raising my two little boys on my own and will work tirelessly until all doctors understand human factors and incorporate this into their practice everyday. “Everyone must understand that mistakes happen, but they can be minimised through teamworking, training and support. We all make mistakes, but it is how we prepare ourselves for them and learn from them that matters,” she concluded. Jane Peters received a standing ovation from the audience, who were visibly moved.