Celebrating Success 01

Celebrating Success 01
Why is it so hard to get journalists interested in the good news stories? I mentioned this  to the editor of a health publication recently and he grinned and said "not good journalism". Really? They tried it recently on breakfast TV and made a joke out of trying to find good news. Well if we continue in that vein we have no chance of really saving the NHS. So we are going to start publishing success stories about individuals and teams where people have saved the day and indeed lives.
A laparoscopic procedure went wrong when one of the ports punctured the patient's aorta. The scrub nurse immediately called for the Crash Team  and disregarded standard protocol of counting swabs, because they were being used so rapidly. Instead she announced loudly that she was just counting the strings. This is termed a 'situational violation' - breaking the rules for an exceptional problem. I believe this can be quite supportable in exceptional circumstances, provided the perpetrator announces the action. This should save other team members using limited spare cognitive resources wondering what is going on. It also gives the chance for someone to offer a different opinion and maybe challenge the logic. In this case the patient was saved and was sitting up in ITU the following day. Great save team.
So what could we learn? Well who was the ‘leader’? Some teams and individuals get quite hung up with hierarchy issues. I believe the leadership should move around the team depending on the situation. The worst option would be no functioning leader at all! Here you have a scrub nurse who may be quite senior and certainly appears experienced, who is prepared to take the lead at a critical stage. How do you debrief afterwards?  Let’s try this:
What did the team do well? They reacted quickly and called for help when needed. A member of the team was prepared to step up and make a swift crucial decision.
What could they do more of? Discuss possible problems and practice emergency drills - in this case if the worst happened and we punctured a critical organ, who would do what?
What could we do less of? Perhaps start a procedure without appropriate planning – in this case double checking port location?
Please note the focus on learning rather than blaming whoever pranged the aorta. For plenty of successful organisations within and outside the NHS celebrating success is a given. How do successful organisations succeed and keep on doing so? They encourage, empower, listen and ..... learn.

Francis Report 1
Medical Protection Society


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Wednesday, 04 August 2021

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