To instil Practitioner& Patient confidence ..

Dr M BlochConsultant Anaesthetist

NHSG

Plan:

• Why?• How?• When & Where?

Teams:

• Different equipment.• Different education and training.• Different perspective, pressures and pitfalls.

100,000 Americans die each year as a result of medical errors

43,458 - motor vehicle accidents42,297 - breast cancer 16,516 - AIDS

equivalent to a full Jumbo Jet crashing each day

over a full year

Good patient outcome by luck alone is no longer acceptable:

It is important for the appropriate process to occur in all interactions, including those between:

patient and staff staff and staff the individual and the ‘systems’ within which they

work

How: Crisis evolution / avoidance:

active / latent factors: • environmental• organisational• cultural• individual• team• patient

Shared Mental Model:

Communicate appropriately & effectively

•voice modulation & non-verbal communication

•direct specific instructions

•close communication loop

•open exchange of information

•Try see others perspective when

communicating with them:

Situation Awareness:

Know what is going on around you:

LocalRegionalSystemic

‘Staying ahead of the game’

Aviation video

Good Clinical Practice:

• Human factors is not a substitute for technical proficiency.

• High technical proficiency cannot guarantee patient safety.

When & Where?

All the Time &Everywhere!

Conclusion: Systematic approach

• Knowledge, skill and understanding is required to make the appropriate clinical judgement decisions.

• Non-technical skills are also required to optimise patient outcome including:

– Anticipating and planning.– Appropriate team leadership.– Effective communication & sharing

mental models.– Maintaining situation awareness and

utilising appropriate personnel and resources.

– Calling for help early enough.