Human Factors MasterclassesDenis Campbell Human Factors Training Consultant

Training Human Factors with Atrainability has demonstrated to me the importance of the correct design and use of Checklists and procedures. They should be there to help the Team and ensure that something is not missed.

They should not be an affront to the professionalism of the team nor are they the recipe to bake the cake.

They are there to ensure that something important is not missed that could lead to patient harm.

The one story that sticks with me occurred whilst coaching in an Orthopaedic Theatre. The senior nurse started to read the Time Out Check prior to the procedure commencing, however the Consultant Surgeon became agitated and did not want her to complete it. The nurse continued and supported by her colleagues covered all the items. After the procedure was finished the Surgeon became aggressive saying the Checklist was unnecessary and was a waste of time. The senior nurse then pointed out that the Consultant Anaesthetist had forgotten to administer antibiotics to the patient but was reminded by the Checklist and was able to rectify the situation before the operation started. After contemplating for a short time the attitude of the Surgeon changed completely and he announced that the Checklist would be used for all subsequent procedures. Success!

A very regrettable Human Error occurred when a 42 year old man was admitted for Cardio-thoracic surgery. Fluid was building up in his chest cavity and it was decided to insert a chest drain. When the drain was inserted some bleeding was noticed and the drain was connected to suction. The patient rapidly exsanguinated and died. The drain had been inserted into the heart and not the chest cavity. The doctor inserting the drain had failed to follow laid down procedures.

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