In the fictional hospital BBC drama ‘Bodies’, Mr Rob Lake is an NHS Medical Registrar in the obstetric and gynaecological department of a UK hospital. Very early on in Mr Lake’s tenure as an understudy to the senior consultant, he bears witness to a litany of clinical errors leading to patient harm events. He realises that speaking up to his senior colleagues could seriously damage his standing as a member of the clinical team, potentially damaging his career progression. Despite a number of attempts at raising his concerns with management, he has kept his head down.
Errors continue and Mr Lake becomes increasingly frustrated and concerned about his colleague’s unsafe clinical practice. Ultimately, Mr Lake, despite being on the receiving end of some extraordinary bullying and intimidation, finally succeeds and becomes a consultant. He moves to take up a position at another hospital. Never wanting to be the “whistle blower”, he kept his head down, choosing calmer seas, despite more patients being harmed unnecessarily and his junior colleagues remaining gravely concerned about some of their colleagues unsafe practice.
On January 15, 2009, US Airways Flight 1549, an Airbus A320 on a flight from New York City’s LaGuardia Airport to Charlotte, North Carolina, struck a flock of birds shortly after take-off, losing power to both engines. Unable to reach an airport for an emergency landing due to their low altitude, pilots Chesley “Sully” Sullenberger and Jeffrey Skiles successfully glided the plane until able to ditch in the Hudson River, off Midtown Manhattan.
All 155 people on board were rescued by nearby boats, with only a few serious injuries. This water landing of a powerless jetliner with no deaths became known as the Miracle on the Hudson.
Both Captain and Co-pilot performed their duties in a professional, calm and deliberate way, utilising all of their combined years of flying, training, crisis resource management experience, including the critical use of check lists. Their decision making was extraordinary under the most extreme pressure leading to a remarkable outcome.
Both events are remarkable in isolation yet share many common themes. Healthcare has learned so many valuable lessons from the aviation industry in relation to human factors. What are human factors:
Human factors consider three domains of system design: physical, cognitive and organisational.
The physical domain focuses on how the human body and physical activity interacts with work design, for example, the layout of a flight deck or an emergency department.
The cognitive domain focuses on how mental processes interact with other elements of systems. This includes memory, information processing and decision making.
The organisational domain focuses on how individuals and teams interact with tools and technologies.
Mr Lake’s story is a work of fiction and yet has the potential to play out in healthcare settings around the world resulting in poor teamwork, ultimately leading to unnecessary patient harm, due to clinical errors or near misses in clinical practice.
The miracle on the Hudson is a real-world event, which has been immortalised in the movie ‘Sully’. Watching the movie highlights the extraordinary decision making that took place in the cockpit, including the teamwork of the crew aboard the flight that day, leading to saving 155 soles.
Outside of training on real patients, health care simulation is an essential risk mitigation investment all healthcare organisations should embrace. Patient safety can only succeed if underpinned by investment in high-quality education and training, closely linked to organisational patient safety initiatives.
Recreating “real world” clinical events (just like the aviation industry does in flight simulator training) is essential in supporting effective interprofessional teamwork, critical thinking, situational awareness understanding, shared mental modelling, graded escalation (speaking up), including the rehearsal and replication of real world events. Structured and supportive debriefing can help to establish clear learning outcomes for participants, leading to an increase in confidence, competence and improved team performance.
In captain Sully’s case his human factor training, training in simulators and flying, made the difference between life and death for 155 people, unlike Dr Rob who crumbled under the weight of peer pressure and system failures experienced while working at the hospital featured in the program. Speaking up did not lead to a successful outcome for Dr Rob, and patients continued to suffer.
One approach to addressing communication challenges in healthcare has been taken up by Mater Education in Brisbane, Queensland Australia. They have developed a “speaking with good judgement” program, which has been rolled out to over 8,000 + Mater staff since its inception in 2018. The program aims to support open conversations with colleagues, questions unsafe behaviour, and ensures that the safety of patients and employees is prioritised. Initiatives such as this are critical in bringing about a positive behaviour shift in interprofessional healthcare collaboration and care delivery.
Some interesting reading?
The book “The check list manifesto” by Atul Gawande, focuses on the work undertaken to implement check lists in surgical settings, and touches on the many shared and important safety initiatives and learnings taken from the aviation industry. The book is well worth a read!