Skip to 0 minutes and 9 seconds Back in 2005 my then wife Elaine went into hospital for a routine operation. Sadly, she never regained consciousness, and 13 days later she was dead. I simply wanted to understand what had happened, but as an airline pilot I had a slightly different perspective on how we learn when things go wrong. Eventually, I was granted an independent review which identified that there were issues all around the science of what we call human factors or ergonomics. I should say that human factors and ergonomics are interchangeable terms.
Skip to 0 minutes and 45 seconds In essence, it’s about how we design the system to make it easy to do the right things, and it’s about how we behave in a way that makes it easy for colleagues to do the right things. People sometimes ask me about the system, and what do we mean by system or systemic issues when things go wrong. Well, the system it’s something that we can design that makes it easy to do the right things or, conversely, hard to get it wrong. So the system is about the tools we use, it’s about the processes, the protocols, the culture we create.
Skip to 1 minute and 19 seconds All those things create the system, and when something goes wrong we often see that multiple things within the system led to the point that somebody on the front line got it wrong. And it’s easy to blame that individual, but by blaming the individual we don’t actually look at all the causal factors that might have made a difference.
The Story of Elaine Bromiley
In 2005, Mrs Elaine Bromiley, attended hospital for an elective routine nasal procedure. She was an otherwise fit and well 37 years old, mother-of-two. After induction of anaesthesia there were unexpected difficulties and prolonged attempts to secure her airway. Elaine suffered catastrophic brain damage and died 13 days later. In this video by the Clinical Human Factors Group (CHFG), Mr Martin Bromiley, her husband and an airline pilot, introduces the concept of Human Factors and Ergonomics (HFE) in healthcare.
Before watching the video, let’s briefly summarise what happened during Elaine’s case. The video “Just a routine operation” and the report of the independent enquiry, conducted by the then president of the Association of Anaesthetist of Great Britain and Ireland AAGBI, Prof Harmer, describe in more details the tragic events that led to her death.
At the pre-operative assessment visit, it was highlighted that except for a congenitally fused vertebra in her neck leading to an “ok mouth opening” and “slight limitation in neck movements” Elaine had a normal airway assessment. On the day of the procedure, after applying monitoring and carrying out routine checks, anaesthesia was induced.
Soon after, attempts at inserting a supraglottic airway device and face-mask ventilation with an oral airway were very difficult. Oxygen saturation dropped to 40% and her heart rate started to drop, too. Several attempts at laryngoscopy and intubation by two different consultant anaesthetists all failed. The team was now faced with a “Cant’ Intubate, Can’t Oxygenate” scenario.
After about 20 minutes, an intubating laryngeal mask was inserted and allowed some minimal ventilation, that resulted in the oxygen saturations to rise to 90%. Further attempts at passing a tracheal tube through the intubating laryngeal mask, first blindly then with a fiberoptic scope failed, and oxygen saturations deteriorated to 49%.
Suggestions by theatre nurses to perform an emergency front of neck airway and admit the patient to the intensive care unit were not acknowledged. Forty minutes later, in view of the events, it was agreed to abandon the procedure and to wake Elaine up. Drug infusions were stopped, the intubating laryngeal mask was removed and an oral airway inserted. Elaine started to breath spontaneously and her oxygen saturations improved and so she was transferred to the recovery room.
Unfortunately Elaine never regained appropriate consciousness, with erratic fluctuations in her vitals signs and was subsequently admitted to an intensive care unit. Her airway was definitively secured after more difficulties. Elaine sadly passed away 13 days later having suffered irreversible hypoxic brain injury.
After these tragic event, Martin insisted for an independent review to be carried out, to establish what happened that lead to Elaine’s death, not to point blame to any of the individuals involved, but to highlight and disseminate any learning points. The inquiry found that in Elaine’s case there were several issues that can be attributed to HFE, and we will look in more details at these later in this activity.
In the years since Elaine’s death, Martin has taken it upon himself to advocate for an improved safety culture in healthcare. He set up the charity Clinical Human Factors Group, that “works with healthcare professionals, managers and service-users partnering with experts in Human Factors from healthcare and other industries to campaign for change in the NHS and healthcare”. The CHFG says:
Human Factors and Ergonomics is a scientific discipline that aims to understand how humans behave in a system and how to optimise the system design, to make it easy for people who work in high-risk industries such as in healthcare, and have to perform complex tasks, to do the right thing, and difficult or ideally impossible to do the wrong thing.
On the CHFG website, you can find more information and resources on HFE in healthcare. In the next step, we will explore in more depth key concepts and terminology of HFE in relation to airway management and Elaine’s case.
What do you understand by “Human Factors and Ergonomics”? Can you think of any examples that may have played a role in Elaine’s case or in other situations you may have encountered during your practice?
© UCL, video shared with permission from the Clinical Human Factors Group