How to avoid mistakes in surgery.

Presented by Dr Kevin Fong, consultant anaesthetist at University Colleage Hospital, London, the programme takes us through the weakest link in surgery - the surgical team. Unfortunately, under pressure, they can make mistakes without checks and balances being put into place. A case history to illustrate this is the case of Elaine Bromiley who was 36 years old when she went into hospital for a routine operation in 2006. Unfortunately when her throat became blocked, the anaesthetist was unable to intubate her, leading to Bromiley being unable to breath, going into a coma and then dying 13 days later. Without checks and balances, Fong believes that there could be further fatalities and he demonstrates how we can better understand our decision processes by learning from other professions. Fong speaks to Professor Nilli Lavie, a cognitive psychologist, who uses a card counting game to illustrate how if one part of the brain is overloaded by concentrating, then other things such as time keeping become overlooked. This is called losing 'situational awareness'. This is further explored by visiting a fire service training situation led by instructor Gavin Roberts. Also in civil aviation, a flight simulator takes all commercial pilots through regular training programmes. Guy Hirst who trains pilots there talks about the need for a simple check list as 'we all have bad days'. Similarly in surgery, Atul Gawande, an in demand surgeon and professor at Harvard University, carried out a study in 28 hospitals and discovered that death and disability usually resulted from known problems. With the aid of a patient safety checklist, which was also trialled at Queen Mary's in the UK, this has helped to flatten the hierarchy in hospitals. In fact at Queen Mary's there is a surgical simulation suite and Dr Sarah Chieweley-Williams trains anaesthetists there. This is also helping in the screening of new recruits into this profession. As successful surgery is about teamwork, the programme turns to Formula 1 and the interaction between the pit crews. Great Ormond Street Hospital for Sick Children has implemented learning gained from racing to improve post-operative change-overs. Dr Allan Goldman who is in charge of ICU explains about their version of the checklist (an 'aide memoire'). When a patient is ready to be moved; the anaesthetist decides, there is task allocation and the move is managed in three stages. The result is a 40% drop in human error. Returning to aviation, the programme looks at the case of Flight 1549 which spectacularly crash landed into the Hudson River in 2009 when both engines were disabled by a flock of geese damaging them. Chesley (Sully) Sullenberger, the captain, talks about his decision making processes. Finally, Professor Jason Moses from Michigan State University contributes on how to avoid making mistakes with his research into being positive about your mistakes in a crisis.