Ep 6 - Patient Safety with Captain Martin Bromiley

Show notes

• Elaine Bromiley
  • Healthy 37 year old woman for elective sinus surgery in the UK in 2005
  • Can’t Intubate Can’t Oxygenate
  • Experienced anesthesiologist + another who joined when help was called for + a head and neck surgeon in the room + experienced OR nurses
  • Elaine’s oxygenation fell and the team could not get oxygen to her through intubation, face mask ventilation, or by using a laryngeal mask airway (LMA or rescue airway device)
  • Several minutes went by, meanwhile a nurse brought in a cricothyroidotomy kit for surgical Front of Neck Access (FONA). The nurse announced the kit’s presence to the operating theatre but received no response.
  • After 40 minutes (20 without sufficient oxygenation), an airway was established with an LMA.
  • A nurse had arranged for an ICU bed and returned to the OR to tell the team, but received a look from the physicians as if to say, “What’s wrong? You’re overreacting.”
  • Elaine was taken to the recovery room and the surgical team continued on with the rest of the patients on the list.
  • The nurses in the recovery room were concerned that Elaine may have been having seizures and called the anesthetist, but he was busy with a patient in the OR and could not attend.
  • Eventually, Elaine was transferred with an LMA (as opposed to a secured airway) to another hospital for ICU care.
  • Having confirmed an unrecoverable anoxic brain injury due to the lack of oxygen on induction of anesthesia, Elaine was removed from life-sustaining therapy and allowed to die naturally.
• Martin Bromiley
  • Elaine’s husband, and father to their two young children, was also a UK airline pilot
  • He told the hospital that he would “wait for the report” which is what would have happened if Elaine had died on or near an airplane in the UK. The accident investigation board, an independent investigatory body, would have determined the causes and contributing factors and then published an anonymized report with recommendations on how to improve safety.
  • Mr. Bromiley was told that no such process existed in the UK and that “that would only happen if you sued us.”
  • Martin commissioned just such a report, anonymized it and published it “so others can learn”.
  • Importantly, Martin did not seek punishment. He specifically stated that the physicians and nurses that were in that room were intelligent, hard working, caring professionals. He did not blame them. He blamed the system, but the inquiry did not end there. The system can be changed but first we need to know what happened and why.
• The report (see MSP Ep 1 - Elaine Bromiley)
• Professional, third-party investigation may help
  • Avoid the fundamental attribution error in medicine, which suggests that when we see another’s actions, particularly errors, we attribute them to individual failings, but when we see our own, we see them as products of the environment or context.
  • By running similar can’t intubate, can’t oxygenate scenarios, it was seen that many anesthetists at the time, fell into the same patterns of behaviour that led to Elaine Bromiley’s death, so arguments that “I wouldn’t have done that” are not credible when put to the test.
  • Provide a “win-win-win”
    1. Patients and loved ones win as they generally want to know what happened and how the system can learn to prevent it in the future;
    2. Hospitals and healthcare systems win because safety is tangibly improved; and
    3. Practitioners win by also becoming better, but also knowing that it wasn’t all on them. That the system failed and it was not a moral or individual failure on their part. This reduces moral injury and distress for the practitioner. In this way, we preserve a much needed resource in the healthcare professional, but also in the person who is less likely to self-harm.
  • Provide commentary about how the system as a whole, which includes the regulator, operates, as opposed to looking at one hospital or one profession.
• Blame-culture in medicine
  • The blame-culture in medicine is so ingrained that some view physicians as more culpable than pilots given a similar set of circumstances (physicians taking care of Elaine Bromiley vs pilots in United Flight 173).
  • The idea that the physician has all the answers and can save the day all on their own is an outdated concept that has no place in modern team-based medicine.
  • Human factors are so called because they are a part of the human condition and they exist amongst all high-risk industries.
  • There are many ways of getting human factors training and investigation into medicine, but perhaps the most likely to be permanent is when the front-line professionals demand it.
  • In medicine, we need senior clinicians to describe times when they’ve made mistakes. Not things that were mostly someone else’s fault, but time when they made a serious error. This will allow more junior members to talk about these issues and that is the starting point for fixing these issues. Those clinicians that do this, will be remembered as it is rare these days.
• Audio-Video Recordings (“Black Boxes”) in Healthcare
  • With much of society being recorded, patients are often surprised that we don’t audio and video record in resuscitation areas (ORs, ICUs, ED’s). One reason for this is the lack of specific legislation that exists for other industries (such as protects the black box recordings from being used in court). It is possible that current quality of care legislation can be invoked to protect such records should anyone want to start a pilot project, but certainly this is an area that needs to be explored before full implementation of nation-wide recorders would be likely. In the UK, the HSSIB has specific legislation protecting such recordings.
• Making it easier to get it right and harder to get it wrong
  • In general, we need more interventions in healthcare that make it easier to get things right and harder to get things wrong. As Professor James Reason’s work shows, errors are a part of the human condition and while we cannot change the human condition, we can change our work environment.
• The Health Services Safety Investigations Body
  • The HSSIB works a bit differently from the AAIB (the UK’s air accident investigatory body). While aviation investigations and reports focus on specific accidents, the HSSIB may start by looking at one incident, but generally looks at a number of similar incidents and publishes a report where all the incidents have a specific theme.
  • Independence of investigatory bodies from the regulator is of prime importance otherwise credibility is in question.
• Learning from excellence 
  • Medicine can export good ideas to other industries, such as “learning from excellence”. This means that we should be investigating notable times when things went right, so that we can improve our chances of success.
• Justifying the costs of safety endeavours
  • It is impossible to measure harm that is prevented (because it is a non-event);
  • Society spends millions of dollars investigating aviation accidents where only a few people died. Why should it matter that someone died on an airplane vs in a hospital, if there is the potential to prevent their death?
  • We spend billions of dollars helping heal people after the healthcare system has harmed them and there can be considerable cost savings associated with improved systems safety. 

Safety intervention worth mentioning

• The YouTube videos Martin Bromiley produced to improve patient safety
  1. Just a Routine Operation (YouTube - 6 min)
  2. Just a Routine Operation (YouTube - 14 min)
  3. Martin Bromiley: A patient’s perspective (March 16, 2018 - YouTube 23 min)

Other resources

1. A Life In Error: From Little Slips to Big Disasters by James Reason
2. Royal College of Anesthetists (RoCA) NovPod - S2E11: Prevention and management of pain during caesarean section (with Susanna Stratford)

Random recommendations

1. Martin: Confessions of a Hornet Pilot by Tug Wilson
2. Adam: Project Hail Mary audiobook, movie or Artemis II lore
3. Amir: The Drama movie

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Transcript

SPEAKER_00 0:04

When I started trying to look online at other examples similar to Elaine's, I couldn't find any. Whereas if I was to research a particular aircraft accident, I would be able to dredge up material published by accident investigation bodies, whether that was Child Support Canada, the NTSB, the UK's AAIB. That is published freely available to any member of the public. And I just thought, why is that not possible in healthcare? How are people going to learn?

SPEAKER_01 0:36

And welcome back to the Medical Safety Podcast. I'm Adam Shahada.

SPEAKER_02 0:40

And I'm Amir Hammid.

SPEAKER_01 0:41

And the Medical Safety Podcast is a place where we discuss how to improve the safety of our healthcare system through the integration of human factors into system safety, including medical incident investigation and proactive safety measures. Just a note for our listeners that this was recorded when Captain Romley was in London, Amir was in Ottawa, and I was in Kingston. So with the transatlantic communication and the podcasting software, there was a little bit of crosstalk, and it'll be helpful if everyone can be just a little bit forgiving for some of the cuts that had to be made due to that. Thanks, and we hope to have better audio performance in the future. Today we have the great pleasure and privilege of talking to Captain Martin Bromley. And many of you will know Captain Martin Bromley just through the previous episodes that we've done and so on, but Amir is going to do a bit of an introduction here.

Captain Martin Bromiley

SPEAKER_02 1:32

Captain Martin Bromley is an airline pilot and training captain for a major UK airline. In 2005, his then wife Elaine went into hospital for routine surgery. Errors occurred and she died after 13 days, never having regained consciousness. At Martin's insistence, an independent investigation was conducted. Initially, Martin used his expertise as a pilot to understand the safety issues that arose. In 2007, he founded the Clinical Human Factors Group to bring together world-class experts, policymakers, leaders, and frontline staff to work together to promote an understanding of safety, systems thinking, and human factors in healthcare. I don't think it's an understatement to say that his work has been pivotal to both mine and Adam's medical education and training, and certainly is a core or a fundamental building block of this podcast and what we strive to do going forward. So uh thank you, Martin, for joining us today.

SPEAKER_01 2:24

I just want to echo that. When I sent the email saying, oh, maybe somebody from his organization will come. I never thought that you'd come on. So thank you so much, Martin, for coming on.

SPEAKER_00 2:33

Delighted to help. Thanks for inviting me. It's really appreciated. No, that's great. Thank you for having me here. That's wonderful.

SPEAKER_02 2:39

I'll get started with a couple of questions. We like to ask our guests kind of how they meeted to where they are today. And so primarily I'm interested, or I should say Adam and I are interested, in how you got started in aviation principally.

SPEAKER_00 2:51

I got started in aviation. I guess my I was brought up in the 1960s in London. My father had joined the Royal Air Force in 1938 and left in 1945 at the end of World War II. He'd wants to be a pilot, but medically couldn't be, so he ended up working on the ground as a wireless operator. He deployed with his squadrons in Europe during the war as well. Meanwhile, my mum was at home in Wembley in the same house I was brought up in, and she was experiencing the war through the Blitz and through the use of weapons like the V1 Doodlebug and the V2 rocket. So both my parents' experience, which at the time I was born would have been fairly recent, were really affected by aviation, both good and bad. And they would talk about things, and maybe that got my interest going. And I think for me that just got a fascination with aviation, which has been with me ever since.

SPEAKER_02 3:52

And can you talk about how maybe that fascination with aviation led into your career as a pilot and then as a captain?

SPEAKER_00 4:00

Yeah, so I think I decided very early. I was probably about five years old when I decided I wanted to be a pilot. Naturally, I wanted to be a fighter pilot. You know, why wouldn't you? But when I was 16, I had a screening with the Royal Air Force to see if I could get a scholarship. And they basically said to me that because of some eye problems, I would never be a professional pilot. So my hopes were dashed at the age of 16, at 18. I left school, uh, unsure what I was going to do. And then I ended up in another career entirely. But I always wanted to fly, so I got a private pilot's licence. I did a bit of gliding, and uh I ended up in quite a good place in the career I was in. And one day, particularly frustrated with the job I was in, I remember phoning up the Civil Aviation Authority and saying, Hey, I've got a medical issue, I know, I know I've got some eyesight issues. Uh, maybe I could be allowed to do some instructing. Maybe you give me a medical waiver that would let me do something. I don't want to earn money, I just want to have fun basically in my spare time. And they put me in for a medical, they did the medical, and at the end of it, they said, Yeah, you've got a bit of a problem, but you're absolutely fine to have a full class one medical. A class one medical basically means that I would be medically qualified to fly an airliner. So my decision was instant. I spent the next few weeks planning out my route. I carried on doing the job I was doing, which helped me to uh earn some money to live, and basically went and did all my exams by correspondence course, as you could do in those days, and then started flying in 1996, building up on the hours that I already had as a private pilot. Uh started flying turboprops for about uh three years for a regional airline, then started flying for an airline here in the UK, which is now sadly uh out of business, but uh got to fly the Airbus A320, the A330 flying across the Atlantic. We visited the US and Canada a number of times, and then ended up working for a much larger airline where I got my role as a captain and now what's called a training standards captain. So I have the pleasure both of not only training our pilots, but I also get the pleasure of training our trainers and helping set the standards and also working in human factors as well in aviation and helping set a lot of the human factors policies in the company that I work for. Uh, still fly privately, still fly aerobatics a lot. In fact, that's what I was doing this morning. So still have a passion of aviation in all sorts of directions.

SPEAKER_02 6:23

Very cool. It sounds like not only has your career been very diverse, but your day-to-day looks quite diverse. Can you let us know what kind of a week in your life looks like? How do you balance your aviation work with your work with your patient safety advocacy work?

SPEAKER_00 6:36

I'm not too far off retirement now. We have to retire at 65, and I've only got uh just under three years to go to that point. So uh the uh I've started to reduce a little bit of the healthcare work I do. Uh so the charity that I set up still runs. It's got a fantastic board of trustees, and I'm technically a patron for it. When I'm doing my airline job, I work uh roughly a 50% schedule, and that gives me the time both to have a reasonably normal life, but also it gives me the time to get involved in certain patient safety initiatives. So these days I tend to be uh involved in fewer initiatives, but the charity itself is doing a lot more than I'm doing, which is great. But typically in a week, so for example, next week I'll be spending a day working on some issues around uh a national project we've got going on here in the UK at the moment, which is related to maternity. I will also be flying next week as well. So I'm flying over this weekend, coming weekend, Sunday and Monday. In the middle of that, I'll no doubt be dancing some emails and having some phone calls, both in terms of the charity, but also in terms of particular healthcare projects. And it's incredibly diverse what I get involved in now in healthcare. So it can literally be a doctor phoning me up to talk about something particular. It could be dealing with a particular campaign around patient safety for an organization. It might be occasionally speaking. I don't do as many speaking engagements now because I have a much more uh much better qualified group of uh people on the charity who can do this stuff. I think you have to remember that when I first got involved 20 years ago, really, 21 years ago, that at the time there were very, very few people talking about human factors and crew resource management in healthcare. It was almost like a niche speciality which didn't seem relevant to the front line. And so when I would go to talk to a room of doctors, for example, then I was the expert in the room. This was a brand new topic to them that they had never heard of. Whereas today there are so many fantastic healthcare staff, doctors, nurses, midwives, pharmacists, etc., who are absolutely passionate about patient safety and passionate about human factors. Many of them have now got masters in the topic. And so I actually don't bring a lot more than the people around me. They bring more than I do because they work in the healthcare environment. That's not to say that I don't still bring certain things with me. Through the history of the charity and the history of my work, I've been able to see a lot of things, and I can sometimes work out how the system works in a way that when you're in the system you can't.

SPEAKER_02 9:27

That's

Patient safety "wins"

SPEAKER_02 9:28

a very full answer, and I'm sure we'll we'll go back to that in some fashion. So normally at this point, we ask our guests how they get involved in this, but your story is well known to us, it's well known to our guests. If you could give us an example instead of something that's been a recent success of yours that really demonstrates the efforts that you put into it, it can be small, it can be large, but maybe a win or something acute that really has invigorated you and kept you going recently.

SPEAKER_00 9:55

I think the biggest piece of work which we've had real success in, and I know you'll talk about later, is the healthcare safety investigation branch or the HSSIB now in the UK, the independent regulator. Latterly, there's been some challenges in terms of rationalizing how the National Health Service here in the UK is organised. But the fact that the organization has survived that rationalization is actually a success, and that sounds bizarre to say, but the fact that the organisation is valued and the organization is respected for the work it does is a real kind of success for me. On a very different level, a particular safety campaigner, sadly somebody who suffered greatly during an anesthetic process, has been having some real success in her own campaign to try and highlight some of the challenges around obstetric anesthetics. And she's had some real success at the moment in that. And that's a slight side to my life that people don't see that I've often ended up working with harmed patients. It's done out of sight of everybody else, but trying to support, coach, whatever it might be, to get their message heard. And so I'm kind of happy with what we've achieved, but I think it's also fair to say, Amir, that I desperately want to achieve more, and I just get frustrated by the pace of change in healthcare.

SPEAKER_02 11:31

I was gonna say we echo that frustration 100%, and in fact, we have a whole you know a whole portion of this episode ideally dedicated to talking about that.

SPEAKER_01 11:40

Um I just say, Martin, I know that if you want to shout out to that person within her work, I'm happy for that. There is a movement I know these days, because Amir and I are both anesthetists, and so I know it sounds like what that person may have experienced was pain during cesarean section, or to some effect, that there is a whole movement, especially in anesthesia, about how to adequately tackle that, if that was the issue. But if you want to give this person's work uh a shout-out or anything where our listeners might be able to go and uh and and reach it by all means.

SPEAKER_00 12:07

Well, so the fact that you said to me is this about uh pain in caesarean is just amazing to hear, and it literally brings tears to my eyes because that is exactly what this person is working. Susanna Stamford, who's done some amazing work here in the UK about that, and now through uh collaboration with the New York Times, her voice has spread much wider. Uh, and it's just an example of the fact that you could even think about that without me giving you any more details, is a real amazing win for her, and the fact that we've been able to work together and give some support over the years is fantastic because she's gone off and she's doing some amazing stuff, which is well beyond the sort of things that I could possibly do. But it gives an indication, I think, that actually we've helped to make a difference in different ways. Sometimes it's big national projects, sometimes it's little things like Susanna's work in pain in Caesarean. As you both said at the start, that the work I've done has had an impact on you both. And occasionally it's an email I get. I'll get an email from somebody I've never met before, and they say, Hey, you don't know me, but I just want to let you know about something that happened last night in the operating theatre, and how at the time I recalled your late wife's case and it made the outcome so much better because I was able to do that. And it's those little wins that really helped me.

SPEAKER_02 13:36

All right, that that's amazing. This is exactly what we want to hear and capture and get across to people. So thank you for sharing that. Uh, I I was gonna pass the mic to Adam to summarize the events of your wife's death and kind of how that initiated all the work you'd been doing.

SPEAKER_01 13:51

On the topic of pain during the Caesarean section, I know there are a lot of people that are working on both sides of the curtain. A lot of anaesthetists are now considering this a whole lot more, in large part because of advocates like the person that you mentioned, and put that person's info link perhaps in the show notes, since it's really important work. And something that's not talked about a lot with these things is we're three men here that are talking about this, but this is experienced women, people who have uteruses, whichever language you would prefer. And there has been a long discussion about how you have often male anaesthetists that are making decisions with respect to something that is happening to the patient who is more often than not a woman. By

Elaine Bromiley's death

SPEAKER_01 14:26

now, listeners of this podcast are quite familiar with what happened to your wife Elaine, but for anyone who may be hearing this for the first time, I'll provide just a very brief recap. Elaine was a healthy 37-year-old woman who underwent induction of anesthesia for elective sinus surgery, where the experienced anesthesiologist encountered a can't intubate, can't oxygenate scenario. Despite having a well-experienced surgical team that included a head and neck surgeon as well as another experienced anesthesiologist and experienced OR nurses, Elaine's oxygen levels fell to dangerously low levels and stayed there for well over 20 minutes. This resulted in an anoxic brain injury which was unrecoverable. Surgical access to the airway was not attempted, despite the nurses bringing in the surgical kit and announcing its presence to the room. Elaine was eventually transferred to another hospital where she remained on life support until such time that it became clear that recovery was not possible. After 13 days, in accordance with her wishes and in consultation with her medical team, she was allowed to die naturally. She was survived by her husband Martin, to whom we're speaking today, and their two children, Victoria, then six, and Adam, then five. So that was over twenty years ago, and this case, thanks mainly and almost exclusively to Martin Bromley's efforts as a patient safety advocate, became quite well known in operating rooms around the world. Can I ask you, Martin, are there elements to it that either I didn't capture quite correctly or that you see differently now or that you think are missed by some people?

The pathway to an investigation

SPEAKER_00 15:52

I think the only thing I would say is that when people look back at what happened and the responses afterwards and what has gone on in the last 20 years or so since then, what they see is a well thought through approach, a very carefully planned approach. The reality was completely unlike that. The reality was I was thrown into a situation where I was fighting to, when I say fighting to survive, fighting to initially help Elaine survive, which clearly in the end did not work, but to support the people looking after her in intensive care, to to look after the children as well, and then to start to rebuild my life. So I never said, I never recognised early on that there was something that needed doing. But once we'd had the report and the inquest, which took about six months, I kind of thought, well, this is stuff that I I know something about in my day job, and this is stuff that I don't really know how it's handled in healthcare. So I started to, I was just given names of people and phone numbers, and I would phone somebody up and I say, Hey, you don't know me, but this is what's happened to me. And what are you doing around crew resource management or human factors? And there were many, many dead ends, but there were also many people who said, Oh, okay, well, you don't need to talk to me, but you do need to talk to this organization or this person. And over time, I built up a group of people, which eventually became a charity because it was just the easiest way to manage the process, and we needed just a tiny bit of funding to cover the expenses of some amazing people, most of whom, in the end, by the way, just gave their time and efforts for completely for free. But actually, in the early stages, we were trying to do something that just seemed almost impossible. That how do we get this stuff into healthcare? How do we make a difference? How do we uh campaign or or persuade? And so there's been a lot of learning along the way, and I'm sure we could have done it a lot more efficiently.

SPEAKER_02 17:56

What strikes me about your answer, Martin, is that it's a very human story about, as you said, the struggles to deal with this tragedy, the struggles of dealing with life after such an event, and then the real experience of trying to move this thing forward, but being met with real life obstacles and barriers that aren't as smooth as maybe in hindsight it looks. If possible, I actually want to go back to the impetus or the initial part that I see as starting this whole thing, which is the independent investigation and publishing the report. Can you talk us through how you got this idea, what you felt at the time, and that experience altogether?

SPEAKER_00 18:35

So it became obvious after some time in intensive care that Elaine was ultimately going to die. I remember a conversation with the head of the intensive care unit saying, I just assume that this will all be investigated, and I just hope something might be able to be learned. Not that I thought there had ever been an issue, and I quite accepted the fact that you could investigate it, and maybe there are no lessons that sometimes these things do happen. But it was when he said to me, Well, we won't investigate unless you saw or complain. And he genuinely wasn't being horrible, he was just explaining to me the system at the time. So there were no real causes for concern about what had happened, and that's just not what we do. But in aviation, you know, even the most minor incident that could cause, potentially cause harm, is investigated professionally. And because, you know, there's usually something that can be learned, maybe not that would have stopped it, but that could be done that would be useful for people in the future to know to help reduce the probability of it. And the fact that somebody who was broadly healthy could go into hospital and end up dead, and it was just a shrug of the shoulders and say, Well, these things happen, just was completely wrong to me. And so when I explained this to the consultant in intensive care, what I didn't know was that he'd gone off and made some calls to people he knew and uh spoken to the uh chief exec of the hospital. So that when I decided after Elaine died that that really this can't just be left without an investigation. And I'd written a letter to the chief exec that basically said, This is how we investigate in aviation, we do it to learn not to blame. That's what I want in Elaine's case, because it just seemed the right thing to do. And so when I presented that letter to her, she basically said, Yeah, okay, let's do it. And that was because the Anitha the sort of the intensivist in ICU had already spoken to her and given her a heads up of what might happen. And I think genuinely for the unit where it happened, the chief exec, she was in a place where they'd never had a patient come to them and said, This is what I want and this is why I want it. So they paid for the independent review, which was done by Professor Mike Harmer, who was the president of the Association of Anethetists of Great Britain and Ireland. And although there was lots of really good stuff in it, still in relative terms, in investigative terms, it was still uh relatively sketchy and perhaps not as good as you might expect today. But at the time, it was an amazing piece of work. And Mike Harmer actually, in the end, accepted the fees that he charged, but then gave that away to charitable work in Africa looking after mothers and young children. Because when I started trying to look online, for example, at other examples in healthcare similar to Elaine's, I couldn't find any. And whereas if I was to go online and research a particular sort of aircraft accident, I would be able to dredge up open source material published by accident investigation bodies. And it wouldn't matter whether that was Child Support Canada, whether it was the NTSB, whether it was the UK's AAIB. That sort of stuff is published freely available to any member of the public. And I just thought, why is that not possible in healthcare? How are people People going to learn. And so when I started talking to people and saying, Well, how will you find out about this stuff? The answer was really, well, we we won't. Unless there's a legal case, then we might get to see some output from it. And again, that just seemed wrong. Now, by the way, it's worth saying in the end that actually I did take action to recover the financial loss of what happened to Elaine. But that was more to make sure the children were provided for. There was no emotion in that. That was just a practical recovery of financial loss to look after the children. But my focus was on let's get this story out there myself, let's publish it myself, because if I don't, people won't learn. And in fact, after doing that, it was an organisation in the National Health Service that's no longer there, the Institute of Innovation, who came along and said, Hey, we'd like to make a film about this. And I said, Well, I don't mind you doing that, but I don't want you to have control over it because I want it to be freely available. And that was really a guiding principle that this stuff should be freely available. And so occasionally I'll get a message from somebody saying, Do you mind if we use your film or do we mind if we use Elaine's story? And I just say, you don't have to ask permission. I want it out there, I want it shared so that people, the maximum number of people, can learn from it.

SPEAKER_01 23:18

I had, again, coming from this aviation background, I had almost exactly the same sort of visceral reaction to any time that an incident would happen and there may or may not be an internal hospital investigation. And what bothered me is even if the system worked perfectly, where we had an investigation, which we know there isn't always, and the full investigation uncovers certain things, which it doesn't always, and that investigation got back to the front end the people at the Sharp and the clinicians that were working, which we know it doesn't always. Where I trained in my undergraduate medical education was in Toronto. And it's the biggest city in the country, and there's something called Hospital Row, which you have a series of hospitals that are literally right across from each other on the main, the big uh University Avenue there. So you could have something that happens at one hospital, but walk literally across the street and have the exact same set of circumstances that could happen there, and no one would necessarily know, even though there was the potential for the solution to have been wonderfully crafted in the hospital that you just left. So that was the one thing that really bothered me about the whole thing, and that's why we wanted to ask you that question in the sense of what did it look like to actually bring it together? Uh I'm imagining there was a fair bit of pushback, especially when you said, Well, now I want to anonymize it and publish it. It's different now because you in the UK have this health service safety investigation branch, which presumably would take over that role, and we don't have that here in Canada. Is there anything more that you want to say about how you managed to put that report together and get it out there?

SPEAKER_00 24:53

Mike Harbour, who did the report, published it and it did have the names on him. I I got an electronic copy and I crossed out the names and uh I started to email it to people, and eventually, once we got the charity going, we were able to put a copy of it uh online that people could access. Very quickly it seemed to spread. I'm not sure that there was much social media in those days, but it spread really quickly. I think people are drawn into a story, and that was the key, really, that I had to be a storyteller. And I think one of the key things about it was that we did not name the people and in the report, and we did not name the hospital where it happened. The reason for that is that when you don't know the hospital, you can't have any preconceptions. So if I said to you this happened at a such and such general hospital in the UK, people would say, Oh, yeah, they've always had a bit of a reputation or whatever, or a particular individual, if you give a name like David, for example, you can say, Well, David was probably uh a poor doctor or something like that, uh, as in just not very good. But when you don't have that, people too think, well, that could be me, that could be my hospital, that could be my unit. And that generally is the principle that applies in aviation, and it's generally the principle that the HSSIB have followed as well, with very, very few exceptions. They might publish the name of a patient where the patient has requested it, but generally it remains anonymized to open up people's minds to the ability to learn.

SPEAKER_01 26:38

I really was impressed by a few things in the report. One was that Professor Harmer went out of his way to say that these were well-regarded physicians. And I think that was incredibly important because when I relay the story to other people here, there is this assumption that they're bad apples or other things like that. And so um that was one. Two was the idea that in later discussion that I've seen of you online, you go to great pains to say that you wanted these physicians to continue working in all the people in the operating room because as you say, this was a system failure and not an individual failure. But I think those things are really important, that this could be any hospital uh in the UK or around the world, that this that these practitioners were well regarded. And the idea is that these are human factors that persist uh and are pervasive across the profession and across different industries as well. Uh Amir, I think you wanted to say something.

SPEAKER_02 27:27

I would say that the framing in which you put on it, Martin, that reading this report and hearing this story, I really do think that there, but for the grace of God, go I many, many times over. And the way this event has been presented to me, it's always from the lens of this could have been me. And this oftentimes comes from very senior and essentials, people I respect. And so having it framed in the way that this could happen to anyone, I think lends it a lot of weight. And we are very fortunate that you did a lot of work in making this public. In previous episodes, I've discussed with Adam that you know, more than the event happening, it was all the work you did to actually present this document that people can refer to again and again, which really carried the day. And I again I just want to thank you for your work. It really does make a difference.

SPEAKER_00 28:12

That's very kind, and I think I think it is about recognizing that I I suppose the bigger story here is that good people can still make mistakes, and and what is it that we do in other industries that helps guard against that or mitigate or trap or avoid those things?

The pathway to an investigation

SPEAKER_01 28:34

I I will say that the three of us uh clearly agree that this could happen to even cautious and careful practitioners. It's not the sole view that's out there. I speak to a lot of people and I work in a lot of different hospitals, as does Amir in Canada, and we're in operating rooms most days, and uh I have to say I find it really interesting that there are a number of people with whom I've spoken who seem to have a vested interest in saying, well, those physicians must not have been very good physicians. And there is still that culture there, I would say in medicine far more than in other professions, of well, we're going to blame those individuals. I just wanted to say, even after relaying this, they seem to take away the idea that, well, those physicians didn't follow the difficult airway algorithm, which first of all only had only come out the year before, but that was their takeaway. And in my view, that misses most of the human factors and the fact that this can be generalized to a number of people. They don't seem to understand that one of the nurses brought in the tracheostomy kit and announced it to the room. This is the kit that would allow them to get surgical access to the airway. And they announced that this kit was present and they didn't get any response. And then later on, another nurse, as we talked about, went and got an ICU bed and came back in and was met with a look when she said, We have an ICU bed, saying, What's wrong with reacting? Before I go any further, Martin, I think you sounded like you were going to say a couple things. I know there's a bit of a delay, so please go ahead.

The fundamental attribution error (practitioners tell themselves they wouldn't make the same mistake and evidence suggesting otherwise)

SPEAKER_00 29:53

Yeah, I think it it's interesting because people would, particularly anethetists, would say not long after when I was doing a presentation, they'd say, Well, I wouldn't have done that. And they can talk about the algorithm and all that sort of stuff. But interestingly, the Scottish Clinical Simulation Centre up in Stirling, just after they got hold of the report that I published, started to run a simulation. And what they'd do is they'd get a group of, they'd get a multidisciplinary team, an operating theatre team, and etherists and surgeons and scrub nurses, etc. And they would brief them on Elaine's story. And then a week later they would come back and they'd put them in a simulation, which was a very different scenario. It was a simulation of a knife attack victim who needed um who needed help. But during that scenario, it started to degenerate to the point that it became a can't intubate, can't ventilate scenario. And what was interesting is the majority of people who went to that simulation carried on and did pretty much what happened in Elaine's case. They fixated on intubation. So you can sit around a coffee table and have a chat and with hindsight say there is no way I would do that, and that's what every anethetist says, but then put them in the situation where they're under pressure, lots is lots going on, and your cognitive bandwidth is reduced, and they were all falling down pretty much the same route. So you have to ask yourself, were these bad individuals, or was this actually something about the system? And by the system, what I mean is not just the kind of system and processes of working at that moment, but also the systems and processes that though that team had trained in over the years, both together but more likely individually, as they went through the kind of undergraduate, postgraduate training as a doctor or a nurse or an anesthetic assistant or whatever the role was, what was going on in their training? How were they working? Were they exposed to simulation? Were they exposed to real life error? And were they able to reflect properly on it? Did they have a process of briefing before a procedure? Did they have a process of running through the potential emergency procedures, etc.? And so all these things count as the system. And quite clearly, when this was being done at the Scottish Clinical Simulation Centre, you could see that the system clearly was driving these behaviors. Because if everybody pretty much is doing the wrong thing, then it can't be all bad people.

SPEAKER_02 32:27

You you don't know this, but our previous guest was someone who does a lot of simulation work in in the field of medicine. And it's just very interesting to hear your framing of this because it is a nice through line about what we mean by when we talk about systems. It is the level of undergraduate medical education, it's the postgraduate level of medical education, it's the hospital environment that we work in, and it's not necessarily the knowledge base. I wonder if you could speak about your work in the airline industry and how you saw the difference between their approach to systems issues and ours in medicine.

SPEAKER_00 33:04

I think the problem with um aviation today is that the systems are so fundamentally good that we forget about the system. When the system works really well, you don't notice it.

SPEAKER_01 33:16

We were talking about how Elaine's story is so well known and when it is, there are certain features that people take from it and certain features that people shy away from. And it's interesting that one of the things that we did with this podcast was show parallels between this and other things. We're not the first to do this, especially with something like United 173, where also another fixation-induced loss of situational awareness where they fixated on trying to troubleshoot a landing gear indication problem, and they ran out of fuel, and obviously people died from the resulting crash. And we saw that in aviation in the 70s and 80s, which is one of the impetuses for putting in what became known as crew resource management. And what I find really interesting is I have talked to surgeons who will say, Well, those pilots obviously they they were very careful and so on because they would lose their lives if they hadn't. But those doctors in the room with Elaine Bromley, well, that's not the same thing. How could they not hear the monitor going boop, boop, boop, which is an audio and visual indication of the oxygenation problem? And so there are some people in this profession whose minds won't change. Perhaps it's this idea that, well, if it could happen to them, perhaps it could happen to me, but those must be bad apples, because if it wasn't, then I'm potentially vulnerable to the same situation, and that just can't be. Um, does just before I move on to something else, does that strike you in any way? Do you think that's accurate in other areas? I'm wondering what your thoughts are on that.

SPEAKER_00 34:44

Yeah, I think uh you're absolutely right. Uh so if

Why the individual error / blame-centric model persists in medicine

SPEAKER_00 34:49

you go back to the history of aviation, the history of aviation is relatively recent. We've only been flying for what, a hundred and hundred and twenty years or so in total. And very, very quickly when a plane crashes, it's a very public event. You can't hide it, you can't say there's nothing to see here, move on. And clearly, visually, it looks frightening. Often the accidents in the early days were about the structural integrity of the aircraft instead. But because of the public outing of aviation accidents, we had to be seen to respond. If you look at the history of healthcare, though, we're talking thousands of years. The Royal College of Surgeons of Edinburgh, with which I have a great relationship, have been around for over 500 years. And so over time there's been a real kind of inertia in our healthcare has developed. And it's the same around the world, by the way, when you look at it. An operating theatre isn't one or two people, it's a large number of people. It's supported by a system that buys drugs and a system that provides equipment. There is still an element, I think, in healthcare where people are scared of admitting fallibility, of admitting that things could go wrong. We recruit in healthcare the very best people. The people in healthcare are generally, especially doctors, and I particularly single-out doctors here, are straight A students. They're bright, they're pumped full of knowledge. And if you're pumped full of knowledge, how can you possibly get it wrong? But the reality is that when you put that same doctor in a highly stressful situation under pressure, when things get really bad, you have the cognitive capacity of a hamster. The reality is that you are just a human being. No matter how bright and intelligent you are, you are just as capable of making some silly mistakes that somebody else can make. Yes, your training will help you a bit, but actually the training you really need is how to work with other people so they can help, help you to do your best, but also help to intervene to keep the resilience of whatever it is you're doing. And you learn how to interact and design a system that makes it easier to get it right and harder to get it wrong, and you learn how to work in a way that gives you multiple layers of defence, whether that be through certain personal things or through checklists or or electronic systems doesn't. And moving away from that idea that the physician, the nurse, or the midwife or the pharmacist knows everything and the patient doesn't, is a hard move to make. But you have to make that. We've been through that in aviation. But fundamentally, if I'm going to be operated on by a surgeon, for example, I want to be operated on by a surgeon who says to me, You know what, Martin, I've learned my trade, I've got some things wrong in the past, but I've got a team around me who can work with me and help to keep you safe. I do not want to be operated on by somebody who says, No, I've never had any problems, I've never made any mistakes, and there's no reason for you to worry your pretty little head, Martin. Because I know the reality of human performance.

SPEAKER_01 37:53

I just wanted to double-click on this idea that yes, doctors and nurses in certain healthcare professionals are incredibly well trained and knowledgeable, but

Differences in aviation and medicine origins which help explain cultural differences

SPEAKER_01 38:00

we call them human factors for a reason. They are a part of the human condition, and none of us is infallible. And this idea that the training that we really need is what some would have called stress inoculation, and we've talked about that in a simulation context. The response in aviation, as you well know, Martin, has been from these similar accidents. And again, I'll just briefly talk about Eastern Airlines, I think 401 had an altitude alert, for example, uh, where they deviated from their altitude because the autopilot was the one that was flying, and they were over unlit terrain, and the air traffic controller, in a roundabout way, tried to call their attention to the altitude, and in the end, they crashed because they lost altitude from an unintentional descent. And in a very similar way, I look at that, and I look at United 173 and Eastern 401 as if you put them together being very similar to what happened to your wife Elaine's situation, where you had a number of things. In United 173, you had the junior members of the team trying to tell the captain, we're low on fuel, we don't have the fuel for this, and we have the missed altitude alert chime from Eastern Airlines 401. If I bring that into the operating room, I can see the parallels, and we've talked about this in other episodes, where the nurse comes in and says, Well, we have the trait kit here and gets no response. And that very well could have been stimulus that was simply not perceived by the physicians for the same fixation-induced loss of situational awareness. We know that the audio is one of the first things that happened. Um, and we talked about time dilation and all of those things that appear to have happened on United 173. Aviation's response was crew resource management, but and we talked to an airline captain in Canada, his name is Mike Schuster, who talked about the evolution of that, and now we see six-generation CRM in aviation, and we see it's built into not just the initial training for private pilots all the way up through multi-crew, and we see now that they train at a company-specific level, and we see things like line indoctrination and line-oriented safety audits, all of these things that we've talked about in the previous episodes. The question that I have for you, Martin, now that you've worked for 20 years or so on the patient safety side of things, do you see a time when we're going to have a more formalized CRM curriculum in medicine? And if so, are there certain things that you think might need to be done to achieve that environmental, cultural, or other considerations?

SPEAKER_00 40:19

So we're starting to make inroads to that in some specialities. For example, again, I mentioned the Royal College of Surgeons of Edinburgh, the Royal College of Surgeons of Dublin, in Dublin of Ireland, so I should say. So we're perhaps not talking about crew resource management training, but we're talking about some form of training for healthcare staff. More broadly about patient safety, but specifically around human factors and elements of crew resource management or non-technical skills. And I think the drive here, we could look to the government, the regulators to drive it, which has worked well in aviation. We could look to the unions, for example, the doctors' unions, the midwifery unions, etc., to drive it, which is how it works in rail in the UK, it's the unions that drive a lot of safety. Or maybe we look to the professions themselves, and that's really where I've kind of focused my effort because I've always felt that you can get a law or government regulation change that enforces something. Fundamentally, until the healthcare staff say, why aren't we getting that training? Why aren't we getting that support? Why aren't we getting that education? We want it. When the professionals start saying they want it, that's when it will become permanent.

SPEAKER_01 41:56

Thanks very much for that. I really appreciate that. The reason I ask the question is because, at least the way it is in Canada right now, it's very much left up to the individual practitioner. There are many people that are very invested in this and will take extra simulation courses and upskill and do all of these sorts of things, but it is not currently a requirement. So you can have a family physician who wants to now work in the hospital as a hospitalist and will occasionally be called to run a resuscitation, or you can have a long-term emergency physician or somebody like myself who provides anesthesia or surgeons or any of these people who are quite far removed from their initial training, and it's not something that they have necessarily thought of or if it's not come to them. So right now it's very practitioner-dependent. And as we've just talked about, there are some people who don't necessarily see the need. And part of that is because until you're placed in that situation, uh, you just may not understand the realities behind it.

SPEAKER_02 42:47

Your phrasing, Martin, in the way you frame this problem, I think is very key, especially referring to your example of if you were to undergo uh an operation what you would look for in a surgeon. Looking at how we select and how we envision what happens to our medical trainees, I think that the public at large has an assumption that all these skills come together, like having extensive textbook knowledge, having extensive technical skills goes hand in hand with having excellent CRM skills and excellent crises management skills. But in fact, as you've mentioned, they're actually very different things and they take a different skill set to develop. I wonder in your work communicating with people in the healthcare space, what are the messages, examples, phrasing tools you found most effective when uh talking about CRM or doing patient safety advocacy work?

SPEAKER_00 43:36

I think first of all, telling a story is really important. Uh, and there's lots more stories I can tell from other people's experience. But people remember stories. I I was talking to a colleague just a few days ago about how Jim Reason's work around the Swiss cheese model is sometimes being misinterpreted by academics and by professionals in other industries. And the important thing here is it's a very well-known piece of work that people remember. Why do they remember it? Because it's a pretty simple model that you can almost understand without having to read the book. And so we have to have kind of simple models, simple ideas. Yes, they there is a danger they get misunderstood, simple stories that we can take a feeling, a sensation away from. And that really helps us. I think the second thing for me is this is about really getting to grips with the idea that it could be you. So we have to talk more openly about human fallibility. We have to talk about errors, mistakes, whatever you want to call them that we have made or that a senior clinician has made. I remember with a certain grin, I was lucky to go across to the Netherlands to do some speaking engagements and to work with some people over there. And they had produced a booklet in which they got senior doctors in this booklet to talk about an error they made. But as they pointed out to me, what was fascinating was a lot of the errors were, for example, somebody saying, Yes, I remember an error I made. It was when I allowed a junior doctor to carry out a procedure, and I should have been more careful about who I gave that task to. So what they were trying to say was, it wasn't really my mistake. It wasn't that I was a bad doctor, it's just I I perhaps delegated to the wrong person. No, we

Stories as a way to drive home safety concepts

SPEAKER_00 45:25

actually need people, senior people, to stand up and say, no, you know what? I'm going to tell you about a really bad error that I made and only I can take responsibility for. And I think that's a fundamental. And I think in aviation we're very good at that. As a training standards captain, if I've got a trainee who's struggling with something, to say to them, hey, look, I can tell you many mistakes, I've made that myself, I've made that mistake, I've done that thing, and I can tell them a specific story about a circumstance where I've got something wrong. And I think that's so important because when people recognize that, then they can start to pay attention to, well, what is it? If I am going to make mistakes, what is it I can do about it? And and then in simple terms, they're investing in human factors and crew resource management. And that's what we really want to get to.

SPEAKER_02 46:13

I really like your point about the strength of narratives and the strength of stories. I find it challenging because in medicine we've kind of live in this world of sometimes these things happen, sometimes bad things happen, and it's unexpected, and you know, it is what it is. How do you go from either selecting or finding those uh events to a convincing narrative?

SPEAKER_00 46:35

I think uh it it's very hard because the source document might not help you. For example, if you take a transcript from a court case where uh a doctor is being sued over a particular situation, the language is very uh combative, uh it's very blame-ridden because that is the nature of the legal system. And often it is a case of trying to work with somebody who has suffered a situation and help them to maybe add a different lens to that story.

Most people harmed by medical error want to prevent it happening to others

SPEAKER_00 47:10

I have worked with so many patients and relatives of patients who've been harmed or died, and usually they'll say to me something along the lines of, I don't want this to happen to anybody else, and then they'll follow it up with, and I get the fact that people make mistakes. So they understand that, and they understand that generally the people involved never go out to do a bad job, but the bad things do happen, and what they're trying to do is to find a way to make sure it never happens to anybody else. And when they realise that there is a different way of communicating that story, that can be very powerful. And sometimes, Amir, you know, I think it has to be your own stories, your own stories of near misses and that,

Blame-centric approach in medicine, professionals having outsized feelings of responsibility for bad outcomes, and the lack of a proper investigatory system in medicine causing harm to healthcare professionals

SPEAKER_00 47:53

which which say, you know, well, this is something that happened to me. Now that's very challenging in a in an organization or in a business where people don't still feel comfortable talking about errors and mistakes, but you will get remembered when you do that because it is so unusual in healthcare that people talk about these things.

SPEAKER_01 48:13

I think there's a few good reasons for that. One is the stigma that still exists around that, particularly in medicine. And Jim Reeson, as you said, talks about this in his memoir. And we still very much have that blame-centered approach in medicine because we often internalize it. And I spoke to a psychologist who dealt almost exclusively with pilots who had accidents, and as professionals, and I think doctors fall in this category, we take an outsized ownership of some of these things that happen because we are professionals, and perhaps we think that we have more control over the outcome than we really necessarily do. So one is the stigma that makes us hide things, and what are our colleagues and other people going to think about this? But the other one is a lack of the investigatory process that we have in medicine also doesn't permit us to really uncover some of these things. I'll give a very simple example of that, which is I had an engine failure when I was a flight instructor in a single-engine airplane shortly after takeoff. We were doing circuits to practice takeoffs and landings, and more by luck than by skill, I managed to bring the airplane around and land on the runway. I carried that with me, thinking for a solid week that I had caused this engine to fail because we had gone to the practice area, done some upper air work, come back, and done some circuits, and that engine was operating perfectly fine for a solid hour until it failed. So I assumed that I had done something to cause it to fail, until a friend of mine who was the director of maintenance came over and shook the exhaust manifold for me, and it sounded like a Maraca. And he says, Those, by the way, are the exhaust baffles that have broken off and clogged the exhaust, and no exhaust means no engine uh output, and therefore that's why the engine failed. The engine broke, and that's why. And I just assume that it was me, because that's I think what we do as professionals. And had that person not come to me with that broken piece of the aircraft, I would still to this day be thinking that that is what happened. And we hide these things so people don't necessarily know about them, then we don't have a full investigation, so we can't look into it, and maybe there is something else that that we don't know about.

SPEAKER_02 50:03

The first time I heard the story, I didn't really appreciate the connection to what we're talking about. But hearing it now, I fully buy into it. What I take away hearing this story is that there's a very real chance that there would have been a fatality involved and they would have said, Oh, you know, Shahada was not a very competent pilot, he didn't manage the situation correctly, etc. etc. Not that you are, but that could have been a narrative that came out of this, right? Like it was quote unquote pilot error, everything else was fine. But only when you go and examine the whole thing where you see, hey, there were factors beyond your control that led to this. These are the exact system factors we're

How independent healthcare investigation is a “win” for patients, healthcare providers, and organizations

SPEAKER_02 50:36

talking about. And what I commend the airline industry in doing that, I think medicine should do more, is when an error occurs, they go through step by step all potential breaking points and failures. I think what we do in medicine far too often is the second we get to a first degree or a first mistake or first error that's encountered, we say, well, that's obviously the breaking point. We don't need to look further. And what I again I commend the airline industry for doing is they give each issue the best case scenario.

SPEAKER_00 51:03

So it's very interesting to hear you saying that, Amir, because it takes me back to some of the very early work we did about independent investigation and the eventual setting up of the HSSIB. The point I was trying to make was that the independent investigation was a win-win-win. And I hate to use that term for a patient or a relative who's lost somebody, but what you want to know what's happened and you want to know that it can be helped in some way to not happen again. So that's what I mean by a win. So independent investigation delivers that win for the relative or family or whatever. It develops a win for the organization because the organization can learn from it and the organization can get better, and there is always a financial cost and emotional cost, more importantly, a moral injury, if you like, of harm to a patient. But then the other win, again, not the right term, but it is for the people involved because they want to understand what happened. And just as Adam was describing there, about understanding that actually this was something to do with the engine, it wasn't that they'd run out of fuel. Likewise, you want to learn from what happened, and you don't want that learning to be about blame. You know, that there will be some learning from it that means it's less likely to happen in the future. And yes, okay, you played a small part, maybe, but actually there were many things uh at play

Moral injury when healthcare error results in harm to a patient

SPEAKER_00 52:20

here. And I think we lose too many healthcare professionals after things go wrong because they don't have that form of closure, that ability to be able to sit there and say, I understand what happened, things will change as a result, and I can change my practice as a result as well. And it's interesting that earlier on, Adam, you said in accidents that the pilot dies as well, whereas in healthcare and in Elaine's case, that's not true. But if you look at the impact on clinicians of cases of harm, it is unbelievably tough. I had the pleasure of getting to know and working with a surgeon who removed the wrong kidney many, many years ago. The patient, of course, died. I've worked with an anaesthetist who had a very similar situation to Elaine's many years before, and the patient died. And the impact on that is is just unbelievable. And in many cases, I suspect they would have preferred to have died. And I know in Elaine's case, the anaesthetist was on a kind of an informal suicide watch a number of times in his department because they were really worried about him. Now, I'm glad to say that he uh has just retired from his role last year, I believe it was, and so has carried on and had a full working life.

SPEAKER_01 53:37

I have felt very much what you just said, this moral injury. I feel like perhaps one of the best things, if we were to ever in this country have an independent investigatory body for medical incidents, is not only do we actually tangibly improve safety for everyone else, but the people involved also see a tangible benefit. The family members from everyone that I've talked to just want to know A, what happened, as you say, and B, is there perhaps just a less likelihood that this will happen again in the future? And then for the practitioner, just as you say, it reduces that moral injury, and in some cases, perhaps it'll it'll uh maybe absolve it altogether, but even just the idea that it will reduce their feelings, will have them as a resource, they're less likely to have them harm themselves, all of these things are incredibly important, and it's some of the best, I think, healthcare dollars that could ever be spent. That's my view.

The potential for medical "black boxes" (AV recorders)

SPEAKER_01 54:30

And if we turn it back to aviation, we interviewed Canadian airline captain Mike Schuster, who told us that CRM and aviation evolved over time in line with the evidence, and that evidence was gathered through their strong investigatory system, which was significantly aided by technologies such as cockpit voice recorders, flight data recorders, otherwise known as the black boxes, which are in fact day glow orange in order to be more visible to be retrieved. But we have the technology in healthcare to audio and video record certain areas. So as you said, Martin, aviation is not a perfect analogy, and I don't think anyone here is saying that it is. Obviously, it doesn't necessarily apply to all sectors medicine. However, I think it's more apt for certain areas, such as the resuscitation room in an emergency department, the operating room, ICU rooms, very high acuity areas that work in teams. I think it's quite apt there. There is the potential that that kind of technology, audio and video recording, for later use, just as in the C VR and FDRs are used for the black boxes in aviation, to better and improve patient safety. Do you think that medicine could be made safer using similar technologies, or are there perhaps other interventions that you think might be more appropriate?

SPEAKER_00 55:40

When you talk to patients about this, they look at you and say, but surely they record it all anyway? Because in society we have certainly the UK, for example, probably has more CCTV around the country than pretty much any other country. And so many people are recording that when something goes wrong, maybe a car accident or something like that, the the visuals, the audio is available very, very quickly, and people are just stunned that that isn't normal in healthcare. So, first of all, I think society would support it. The problem though is although the technology is there and easy to roll out, it's how it might be used. And that's I think where healthcare can really learn from aviation. So, for example, if I'm involved in an incident at work and there is the flight data and also the copy voice recorder, they go to the investigators who are looking into it. And that first of all, that black box is not usable by a court of law. It is protected evidence and referred to protection of sensitive information. For example, the air accident investigation branch here, Transport Canada, where you are, will receive that black box of the flight data. That will be very carefully listened to and worked out what was happening. And then it will form part of the investigation, but the contents of it are not releasable to anybody, certainly in the UK, without a high court injunction. And that's a very high bar, which has never been approved, to the best of my knowledge, in the UK. And in fact, there was a case very recently where legal people tried to get access to a recording of a particular accident. It was a display pilot who crashed and sadly killed some people on the ground. But the judge refused to release it to the legal teams because he said that it would have a chilling effect on aviation safety, because basically people would not want to be part of a system which recorded them and then could be used against them. So those devices are used by the investigators. They will form part of a report, but the actual precise words may not do unless it's immediately relevant to what happened. And that's a really important protection. And you can take it from two sides. For example, if let's say we recorded a procedure in healthcare and somebody came to harm, and you can say, Well, I want to know as a patient or as a legal person, I want to know exactly what was said and what was done in that.

Legal protection for black box recordings

SPEAKER_00 58:14

And the problem is if that happened, then people would stop recording and lessons might not be learned. So I think that legal protection over that data is very important. Now, don't get me wrong, you can still, as a victim of an aircraft accident, you can still take the pilot or the organization to court, you can still sue, and the incident report, accident report will still be admissible in court, but the actual collection of evidence will not. That could be done by somebody else, whether that's a legal team, whether that's a police force or something like that. They can still do that. So these black boxes don't take away any existing rights, but they're an additional layer of safety, and that's what they are, is they're there for safety. So until staff in healthcare have the same legal protection, then those devices will not be around. Now, the HSSIB has legislation which means any recording devices are treated in the same way as they are in aviation. But to date, we've not seen an increase in use of such devices in healthcare, interestingly.

SPEAKER_01 59:19

I'm a lawyer here in Ontario, and this isn't legal advice, but what I will say is it's important to highlight a couple things that you just said. One is that people can and still do recover financially from lawsuits from aviation accidents, notwithstanding that legislation. That's the first thing. The second thing I'll say is in every jurisdiction in the country, we have legislation to protect the evidence that's gathered during what's called a quality of care investigation. And in every province and territory, it's a little bit different, is what their wording is, but there are pieces of legislation that can be invoked to provide such a privilege, privilege meaning that that evidence that's gathered cannot be used in court, and hospitals' lawyers whose legal opinions can be sought and so on. But all of this is to say that should there be anybody listening to this that has the idea that, well, perhaps we could do this by putting this audio video recording in for just such a purpose, I would say that it is quite likely that without any new legislation being passed, there would be protection provided for such audio video recording if it was done and implemented in the appropriate way. So that shouldn't be a barrier to anyone who might be listening to this who might want to try these things. And then, of course, perhaps Canada will one day have something like the HSSIB that the UK has, and there may be future legislation that is passed to protect any of these recordings.

Patreon has our extended cut with Captain Martin Bromiley

SPEAKER_01 1:00:37

If you've enjoyed this conversation, we've actually got another 35 minutes of our interview with Captain Martin Bromley that's available exclusively on Patreon. For just five Canadian dollars a month, you'll get access to that extended interview while helping keep the Medical Safety Podcast going. We don't receive any outside funding, so your support goes directly toward producing future episodes. In this exclusive conversation, Martin shares his insights on the UK Health Services Safety Investigations body, why its independence matters, what led to its creation, whether there's evidence that independent investigations save lives and reduce costs, and why healthcare needs organizations like the HSSIB in the first place. You can find the link to our Patreon in the show notes or just go to patreon.com slash Medical Safety Podcast. Thanks for helping us keep these important conversations going.

The future of healthcare safety

SPEAKER_01 1:01:27

And now we're back to the rest of our content in the free version.

SPEAKER_02 1:01:30

Obviously, there have been great strides made, particularly in the UK and Norway, hopefully in Canada soon. We have these independent investigation safety boards. We're developing better cultures and better training around CRM, crew resource management, and crisis resource management. We are hopefully increasing our openness to talking about medical error and uh improving the discourse around that. But where do you see as the next steps from here with regards to medical safety, patient safety, whether it's in your home country or generally speaking?

SPEAKER_00 1:02:03

Well, gosh, that's a really difficult question, uh Amir, because I think there is so much still to do. I think it's really getting the basics right. One of my part of my life is working with some sports coaches at the moment, trying to understand how they achieve high performance in the sporting world and what we can learn from that in aviation and potentially in healthcare as well. And I think it comes back to getting the basics right, whatever those basics might be. There is so much work to do, so much work to do in healthcare to make the basics easy to do by the design of the system. And we all know that the regulatory burden on healthcare is significant because healthcare is trying to over-regulate as a way of assuring itself that things won't go wrong, but then they miss the big picture of that interaction where things can go right if the clinician is just allowed to do what they need to do and to do it properly. How we reskill people in healthcare in becoming risk and safety managers. So, as a pilot flying an airliner with 200 people, or whether it be like this morning doing aerobatics, well, my daughter was doing the aerobatics, I was just helping coach her. We are safety and risk managers in those roles. People talk in aviation about pilots don't hand fly their aircraft as much as they used to, and that maybe we've lost some skills that people in the 1950s and 1960s have. And maybe that's true, but I wouldn't say we've lost skills, we've been re-skilled. We are much, much better now at safety, we're much better at understanding risk and threats and how we can avoid trap and mitigate those. And that's what we need to do in healthcare. We need to take a generation of people in healthcare and we need to help them become re-skilled to manage safety and risk based on what's going on in front of them and the real system they have to work in. And then we need to help train other people using human factors experts, real experts, not people like they, who can actually help design the systems itself as well. So I worked out once in just using UK that basically everything in healthcare is ten times bigger than aviation. The budgets are ten times bigger, the number of establishments, ten times bigger, the number of organisations, ten times bigger, the number of specialities, ten times bigger. I think it's an exponential increase of complexity. So but I do believe that things have changed. When I've had to attend hospital myself, or when I've had family members, I've had colleagues at work who've gone to a hospital, they've met an anethetist or a surgeon, and when they discover this individual's a pilot, they say, Do you know Martin Blombey? And then they say, Oh yeah, well, so we do this, we do that, which is lovely. I'm not interested in being recognized myself. I don't give a stuff, but what I'm really interested in is the fact that things are are happening. So I genuinely see better things, but I also see since the pandemic that we've almost taken a bit of a step back. There is more pressure on healthcare systems everywhere in the world. There is more demand from your customers, if I can call them that, than there ever was before. And fundamentally, healthcare is getting technically better able to treat conditions so people are able to survive longer, but that also then gets complex as well. So, well, yeah, there's the you know, there are definitely things getting better, but the demand is also increasing, and that's a never-ending challenge, I'm afraid.

SPEAKER_02 1:05:40

That is a perfect answer. I think it really captures what you you have said a number of times, and what we have alluded to, in that when we really focus on the basics, we make doing the right thing easy and doing the wrong thing hard, and with good fundamental.

SPEAKER_01 1:06:01

It's a very eloquent reformulation of what Jim Reeson used to say about error. He came up with the Swiss cheese model, as we know, and he used to say errors are a part of the human condition. We can't change the human condition, but we can change our working conditions. In that way, hopefully we make the system, as you've said, Martin, something that we can hopefully make it harder to do the wrong thing and easier to do the right thing.

Closing

SPEAKER_01 1:06:25

So I just wanted to say that Martin, you became a world-famous patient safety advocate out of absolutely horrific circumstances. And I hope that I'm successfully identifying that as post-traumatic thriving. Uh, I think I speak for many, many healthcare professionals in Canada, and I'm certain around the world, when I say thank you for the immensely difficult work that you've done in sharing what must have been one of the darkest times in your life, and as you say in your dedication, that you did so so that others may learn and even more may live. You've lived the kind of experience that many of us can only imagine uh that hopefully we would be so magnanimous, but you actually did so. And in so doing, you've embodied the very best traditions of aviation and helped show us in medicine another way. So I just wanted to say thank you very, very much.

SPEAKER_00 1:07:11

That's uh that's really kind of you to say that, but I think I'll be honest and say I think I just did what probably any other pilot would do, because they would have seen the same situation and they would have seen felt the same frustrations, and um I just wanted to make sure that when the uh children were older I could turn around and say, Yeah, your mum died, but actually you know, some good has come of that, and and hopefully I I can do that. So thank you.

SPEAKER_01 1:07:41

I wasn't sure whether I wanted to ask this, but I believe your children must now be in their mid-twenties. Uh and you mentioned that I think Victoria, you were coaching her with aerobatics, and it sounds like at least one of them is involved in aviation. Can I ask you how they're doing generally?

SPEAKER_00 1:07:54

Yeah, they're doing great, actually. Uh so I do like the idea of post-traumatic thriving. I think that is absolutely a thing. Um, I think uh so so what happened uh to me after Elaine died, uh I actually ended up remarrying. I met somebody else, um, which was never deliberate. It was just an encounter through a friend of a friend, and uh so I remarried, uh, a lady called Jane, and she had two older children. She's younger than me, but she had two older children, so we ended up with a blended family of four, uh, who have all done very well, one of whom, Jane's daughter, Megan, is now a cardiac nurse and has been working in that role for a number of years. And Victoria and Adam are doing really well. So Victoria is actually cabin crew at the moment for the same airline I fly for, but she is also got a private pilot's licence and is working to go commercial over the next couple of years. And Adam works in cyber security and he's doing some great work, and he's actually working on cyber in large machines. So he's actually paid to go and hack cruise ships, helicopters, power plants, and things like that. So uh the kids have grown up well, they've coped with it in their their own way, I guess. What happened? I think um they've both become very resilient, which is great. I think at the same time as great resilience sometimes also has its weaknesses, and they know that. But I'm very proud of how they've grown up. I'm very proud of actually all four of the children, how they've all grown up, and I feel very blessed that despite everything that might have happened in my life, that you know, that the family's been a good experience for us.

SPEAKER_01 1:09:35

That's uh that's so nice to hear.

SPEAKER_02 1:09:37

Agreed.

SPEAKER_01 1:09:38

Is there any particular work that the Clinical Human Factors Group or somebody else that you think is doing some leading work that you would like to shout out? Um we never know who's listening.

SPEAKER_00 1:09:47

I I think there are so many people that I've been involved in and so many things going on that I am just so grateful to all the people I've met around the world, and including people from Canada, um, for everything they're doing uh to try and make a difference in the future because it really will help. So it'd be wrong with me, I think, to pick out anybody, but just to say thank you to everybody who's listening to this and everybody who's who's trying to make just a little bit of difference where they work to make it easier for those around them to get it right. And also thanks to to both of you, uh Amir and Adam, for for helping, you know, to share, share this stuff because it's it's really critical.

SPEAKER_01 1:10:29

Thanks very much, Martin. It's uh it's really kind of you to say um when we got this idea, the first thing I did was I said, Oh, somebody must have done this before. Clearly, somebody has some kind of a medical safety podcast that's out there and uh talking about this. And there are some things out of the United States. I thought that this would be a completely saturated market. And I was absolutely astonished to find a dearth of information on this. We didn't think that two safety nerds like Amir and I would be able to come and find a place and and talk about these sorts of things. So it's our absolute privilege to have you on and talking about this, and so it's been really good. So thank you for that. When we look at who can do what tomorrow at various levels, I mean, we've heard how the UK has this health safety services investigations body, and that is absolutely something that we could implement in Canada, and that's at a very high policy level, and it's not going to happen tomorrow necessarily, but it's something that could be worked towards. Uh, at a more local level, provincially, you know, there are lots of things that could be done within the province or even at the hospital level. It could simply be a pilot project where somebody decides that they'll have hopefully a legal opinion that will protect whatever recordings from being used, and then therefore they could have in one OR, for example, one essentially black box and that's just audio video recording, essentially, and see what happens and choose an incident that inevitably will come up, whether it's big or whether it's small, uh, and then take that forward. And then the then game changer would be to not just look at it from within the hospital, but to anonymize and potentially publish it. So, as we talked about, if you were in Toronto, for example, where you have six hospitals literally within a city block, that they could all sort of learn from that. So there's lots of different things that can be done. And of course, on an individual practitioner level, there's the idea of a reporting culture trying to foster that, trying to get to those human factors and making that explicit. So I think in terms of the who can do what tomorrow, I think that's who will leave that. Amir, do you want to talk about uh the right recommendations or was it?

SPEAKER_02 1:12:36

Yeah, no, that's great. So also, Martin, please feel free to jump in at any point in time here. But we like to give a recommendation of something that has happened interesting in our lives or in our weeks. This is inspired by another anesthesia-related podcast that we listen to. Uh, and my recommendation for this episode is the movie called The Drama. I've recently watched it. So recommendations don't have to be related to anything we've talked about. These are just things that keep people interested and something that's captured your imagination recently. So, mine for this episode is the movie called The Drama. It stars Robert Pattinson and Zendeya. I think the premise of it is absolutely fantastic without giving too much of it away. It's about a young couple on the cusp of their wedding day, and they decide to disclose to each other the worst thing they've ever done in their lives, and it's just so good because not only is it funny, it is really well acted, and I think it brings up a lot of socially relevant questions that I think are really poignant to right now, and and watch it with other people. It is the most amazing thing to see other people's reactions to this movie. So if you have the chance, please, please, please go watch it.

SPEAKER_01 1:13:38

Adam. In terms of random recommendations, probably people are familiar with this, but Project Hail Mary is, of course, an excellent movie, but it's a very good book and a really good audiobook, especially for kids, if anyone is interested in that. The narrator, in this case, is Ray Porter. He does a fantastic, fantastic job. And if you are sort of over that or you've already done that, I keep seeing on TikTok and elsewhere all the Artemis II crew and Dr. Christina Cook, who has just become just an icon. I see TikToks, not even about the astronauts coming back and being on various talk shows and so on, but I see things like just some random person saying, if Christina Cook can go to the moon, then I can do my laundry. You know, and if Christina Cook can do this, then I can do that. She's become this absolute icon. And I have a 14-year-old daughter who just absolutely the same thing. She's become a hero of mine, and I'm sure a hero of hers as well, and so on. So those are my those are my two, sort of Artemis II and Project Hail Mary for sure. And Martin, if you have any kind of a it could be it could be local to you, you know, if we ever find ourselves in your neck of the woods, or it could just be anything that to that for fun that that you've been reading or or doing whatever with.

SPEAKER_00 1:14:41

I can tell you about a book actually. The book I'm reading at the moment actually is a really interesting one. I find the writing in it pretty pretty amusing. So it's called Confessions of the Hornet Pilot. The author is Tug Wilson. And Tug Wilson is a British, he's a Royal Air Force pilot, but he went on exchange with the US Marine Corps. It's both a fascinating uh reflection on how aviation has developed in military aviation. Uh, but also it's what's really interesting. Uh, if those of you are in healthcare, uh I mean, apart from the fact he's actually, I think it's really well written, he he talks a lot about leaving your ego at the door and the importance of a full and honest owning up to your mistakes. And I I think you know what he describes in that is absolutely how I like to work. Uh, there's a few exclusives in the book, so perhaps I wouldn't recommend it for a younger audience.

SPEAKER_01 1:15:35

I've absolutely written that down, and I'm definitely going to be reading that. I'm always on the lookout for uh for something like that. And for what it's worth, there's a Canadian astronaut, Dave Williams, who was a physician first, and he then became an astronaut, and then he came back and was talking to the chief residence uh to the University of Toronto one year. He might still hold the record for the longest EVA in Canadian history or period, I can't remember. Uh, and he has a picture of a wrench that is floating away in space as he's on an EVA. And and he had a few of these great lines that I think you can only have after a career like his. You know, one is he says that at the Canadian Space Agency we had a rule where uh you're only allowed to be upset for 10 seconds and then you have to get over it, and then you have to finish the job or whatever it happens to be. So you get to swear a few times and then you can do that. And then, you know, the other thing that uh that he was talking about was he says, you know, in in space, it is part of your job to get yourself into a good mood. You don't have to go all be chipper and hyper and that sort of thing, but you don't want to be the person that sort of brings everyone down. And he personified this idea for the chief residents at the time that, you know, you're a leader and so on, and you need to manage your own mood as you as you would manage sort of anything else. It was just a perspective that I had never heard before, and I thought it was phenomenally interesting.

SPEAKER_00 1:16:46

I don't know if you've come across Jim Beijing. So Jim Beijing was a shuttle astronaut, but also doctor, and subsequently became a director of the VHA in the US, the Veteran Uh Association. And uh very interesting character I managed to meet a couple of times. But when you read books about the shuttle, he had quite a profound impact on the people he worked with as well. So a real character. But I don't think he's written a book, sadly, but he's in lots of other books. And I found the Dave Williams one here, actually, so that's one I'm gonna have to read.

SPEAKER_02 1:17:19

Okay, that's it for this episode of the Medical Safety Podcast. A huge, huge, huge thank you and um an expression of gratitude towards Captain Uh Martin Bromley and all the work he's done. I I think it's again safe to say that he's him and his work has had a profound impact on our careers, this podcast, and the work we do, and I hope that by um uh having him on this episode we can only amplify his voice and uh emphasize that uh that we are all moving forward together. But I'm Amir Hamid and I'm Adam Shahada. And thank you. As one TV doctor said, What?

SPEAKER_00 1:18:00

You have to say it.

SPEAKER_02 1:18:03

It's a beautiful day to save glasses. Please consider following us on all the socials. We look forward to having you join us next time.

SPEAKER_01 1:18:10

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