Silas is a Paramedic in Kent and runs the Critical Care in Pre-hospital Practice Twitter and Facebook page. Silas has an interest in critical care and human factors and the following blog piece is a summary of a paper he wrote for his PGCert Critical Care. Tweet us @CCinPP and let us know what you think!
A 60-year-old male in cardiac arrest required endotracheal intubation. Suction was not prepared prior to the intubation attempt and was required due to the airway being soiled. Bag-valve-mask ventilation was reverted to while suction was prepared for the second attempt at intubation. An endotracheal tube was passed with a grade 3 view and secured.
In 1711, Alexander Pope famously said: “To err is human…”. This is a quote often overlooked in modern medicine, a world in which systems and service users hope for, and often expect, complete success.
Over 20 years ago, Leap (1) analysed the frequency of harm in medicine, concluding that as many as 180,000 patients per year may be harmed in the United States (US) alone. A few years later, the Institute of Medicine published a pivotal report entitled To Err is Human: building a safer healthcare system, which found preventable adverse events (AE) to be the leading cause of death in US (2), implying that preventable AE kill more people annually than road traffic collisions, breast cancer, or AIDS. Although these statistics were based on only two studies, and the report is now almost 20 years old, an overview publication in recent years emphasised the points made by the Institute of Medicine, while highlighting the positive change that has occurred as a result (3). This was not exclusive to the US, with the Department of Health (2000) in England concluding that as many as 1 in 10 patients were harmed during medical care, of which 50% were avoidable (4).
A large (n = 74,485) systematic review of retrospective data corroborated these statistics (5) however the studies reviewed are now over 10 years old, and only one included pertained to the United Kingdom (UK). Furthermore, a more recent publication by The Health Foundation (2011) found that the rate of harm was between 3% and 25% (6). Although this was a meta-analysis and thus presents a strong evidence base, the studies included were also in a less robust, retrospective format, and represented a broad definition of the term AE.
Paramedics often work in environments that are unpredictable, unclean, and ever changing. As such, the risk of AE occurring in out-of-hospital care (OHC) has the potential to be higher than many clinical environments. Bigham et al (7) reviewed 88 papers relevant to OHC and found there was a paucity of data relevant to this field. This review however lacks external validity when considering AE in the context of healthcare globally, as articles were only included in the review that were in English, and relevant to OHC.
Human factors versus case study
An extremely influential publication by James Reason (8) categorised human error in two ways. ThePerson Approach which represented the traditional opinion that mistakes occur due to individual error (inattention, fatigue, negligence, etc.) and The Systems Approach which suggested that errors were consequences of systemic failures, rather than individual factors. This model has since become the dominant paradigm for analysis of errors in healthcare, however understanding of the model by healthcare professionals has been shown to be poor (9).
The Persons Approach in this case study may highlight the a lack of experience in endotracheal intubation (ETI), or perhaps forgetfulness prior to performing the procedure, however analysis using the systems approach highlights a number of preventable causes:
Storage of suction equipment separately to airway kit
No standard operating procedure (SOP) for ETI
No checklist prior to ETI
The now well-publicised case of Elaine Bromiley is considered by many to be a pivotal point in the application of HF to healthcare. During induction for a routine operation, Elaine was found to have an unexpected difficult airway, which was not successfully managed by the staff caring for her, and she subsequently died of hypoxic brain injury some days later (10). The inquest into Elaine’s death found the cause to be related to a number of HF, however Elaine’s husband Martin, an airline pilot, made a clear point of highlighting those considered in The Systems Approach, as had been commonplace in aviation for a number of years (11).
A pivotal trial by Haynes et al (12) showed that by considering Reeson’s (2000) Systems Approach and implementing a checklist prior for use at key points during the surgical journey, mortality can be significantly reduced (1.5% to 0.8%). This was a rigorous study of 7,688 patients across eight countries, demonstrating strong external validity. Since the studies success, the World Health Organisation's (WHO) Surgical Safety Checklist (below) has been adopted by hospitals across the world as routine practice.
World Health Organisation (2009)
Forgetting items required for ETI could be negated in this manner by employing a challenge-response checklist prior to ETI. Air ambulance services across the UK use a challenge-response checklist when performing pre-hospital anaesthesia to reduce error (13), a practice that is advocated by the Association of Anaesthtists of Great Britain and Ireland (14). Although paramedic airway management is clearly simpler than pre-hospital anaesthesia, it is the same skill that is being performed. As such, it is therefore proposed that paramedics should employ the use of a checklist in preparation for ETI to standardise the process, such as has been designed below.