Team Training for Critical Incidents

1. Team Training for Critical Incidents Dr Andrew McIndoe Consultant Anaesthetist Bristol Medical Simulation Centre

2. Lecture content 20 minutes: • Why do we train teams? • Course design • Tackling specific problems • Evaluation of team training

3. Surgeons removed wrong kidney in 'catastrophic error' By Terri Judd Tuesday, 13 January 2004 Two "grossly negligent" surgeons removed a patient's only healthy kidney in an "appalling" catastrophe which led to his death, the General Medical Council (GMC) was told yesterday.

4. Surgeons removed wrong kidney in 'catastrophic error' Cardiff crown court was told that the wrong kidney was identified on the hospital admittance slip, and the error was transferred to the operating theatre list. The case notes and consent form carried the correct information, but neither surgeon had looked properly at the case notes. The surgeon later said that he thought he might have looked at the x ray back to front. A medical student who was observing the operation looked at the x ray on the wall of the theatre and said she thought it was the right kidney that was not functioning, but the surgeon allegedly told her she had got it wrong.

5. February 7th, 2009 Doctor guilty of manslaughter A doctor charged with gross negligence has been found guilty of killing a patient by giving her a fatal injection of adrenaline.

6. Human error & critical incidents Prevalence in Anaesthesia • Craig/Wilson 1981 65% • Cooper 1984 65% • Kumar 1988 80% • Curie 1989 82% • Gaba 1990 66% • Williamson 1993 83%

7. INDIVIDUAL PERFORMANCE TEAM PERFORMANCE

8. INDIVIDUAL PERFORMANCE TEAM PERFORMANCE

9. Theatres Wards General practice Resuscitation Dentists Delivery suite Radiotherapy TEAM PERFORMANCE High dependency care

10. SITUATIONAL AWARENESS COMMUNICATION RESOURCE MANAGEMENT PREDISPOSING FACTORS

11. Airline Industry

12. Blunder that killed my wife. By JANE FEINMANN 12 December 2006 At the inquest, held in October last year, the lead anaesthetist admitted that he had lost control. "Fixation is a normal reaction to stress but at some point, a decision has to be made to break out of that pattern of behaviour. The way to ensure that happens is for all members of the team to see it as their duty to speak out to keep the patient safe." Two of the nurses knew how to save his wife's life. "What they didn't know - and what Human Factors would have taught them - is how to broach the subject."

13. Stressful problem Correct management

14. Stressful problem ABC + Hypothesis Correct management

15. Stressful problem Early recognition ABC + Hypothesis Verification Correct management

16. Anticipation Stressful problem Early recognition ABC + Hypothesis Verification Correct management

17. Anticipation Stressful problem Early recognition Protocol training Verification Correct management

18. Anticipation Stressful problem Team training Protocol training Team training Correct management

19. Anticipate Avoid Trap Recognize Mitigate Diagnose

20. Developing a course Involve key personnel Define the specific learning objectives Make it relevant Design interactive sessions Evaluate performance

21. Example

22. Preventation of airway incidents 1. Pre-op checks of patient and kit- AAGBI guidelines 2. System of machine alarms 3. Emergency protocols- DAS Difficult Airway Society Algorithms - Report to the CMO of an Expert Working Group on Blocked Anaesthetic Tubing

24. “63 yr old, occasional reflux, sleeps with 2 pillows, gets ‘hay fever’ in the summer.” “Very difficult to bag after iv induction & intubation. He is rapidly turning blue”

25. ETT CUFF HERNIATION BLOCKED AIRWAY FILTER OESOPHAGEAL INTUBATION LARYNGOSPASM ENDOBRONCHIAL INTUBATION CIRCUIT DISCONNECTION INHALED FOREIGN BODY BLOCKED CATHETER MOUNT ASPIRATION LVF BRONCHOSPASM ANAPHYLAXIS

26. BLOCKED AIRWAY FILTER 33% ENDOBRONCHIAL INTUBATION 33% 72% BLOCKED CATHETER MOUNT 56% 44% BRONCHOSPASM ANAPHYLAXIS

27. Reactive strategies

28. Traditional Medical Approach 1. History 2. Examination 3. Investigation 4. Diagnosis 5. Treatment

29. Common Emergency Approach 1. History 2. Examination 3. Investigation 4. Diagnosis 5. Treatment Best Guess!

30. Reactive strategies 1. Stabilise 2. Simplify 3. Get help 4. Review

31. Reactive strategies 1. Stabilise 2. Simplify 3. Get help 4. Review ABC approach Divide problem away Communicate Does it fit?

32. BRIEFING • SCENARIO • DISCUSSION WITH PEERS

35. Overall Learning Objectives • Identify situations in which I cannot cope alone. • To communicate more effectively. • Recognise good team leadership. • Perform effectively as a team member. • Make effective use of available resources. • Learn from mistakes and accommodate errors.

36. “Has it changed your practice?”