Medical Safety Podcast

Dr. Adam Shehata (former professional pilot turned physician) and Dr. Amir Hamid (anesthetist and emergency medicine physician) discuss how to improve our healthcare system by integrating human factors into systems safety, including medical incident investigation and proactive safety measures.

Medical Safety Podcast is a health podcast hosted by Unknown Host, with 9 episodes on record and a Required Pod Score of 80. PitchCentric scores this show on Booking Probability, Listen Score, and live audience signals refreshed every 24 hours.

Unknown Host hosts Medical Safety Podcast, a health show with 9 episodes published.

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  Episode #9

  Ep 9 - HSSIB Retained Sponges Report - Part II

  Aug 16, 202653 min

  Send us Fan Mail Show notes Risk management principles: Key elements of risk management Identifying hazards, or risk identification These are the things that could cause harm or problems assessing the risk The likelihood of a hazard causing harm Putting in place controls or making a decision Implementation of solutions that lead to risk reduction or prevention Documenting the management decisions A recording of the findings and outcomes of your intervention; if you don’t measure it, it doesn't matter Allows you to keep track of efficacy of changes Cyclical review Check if old interventions are still valid or if there is a better way of risk management now There is not the expectation that all risk will be eliminated but the goal is to reduce the risk to “as low as reasonably practicable” (ALARP) The utility of this framing is that it helps set reasonable limits on the degree of intervention needed to address a problem. The example used in the report is “An extreme example is that spending £1m to prevent 5 staff suffering bruised knees would be considered grossly disproportionate” This allows us to frame successes as reductions in adverse events rather than a total elimination of some events that are unavoidable The UK’s Health and safety executive, their national regulator for workplace health and safety actually sets a guideline for acceptable risk: death of one in a million per year for both workers and the public The utility of having this put out by a national board sets a benchmark for comparison The HSSIB performed some back-of-the-napkin math and found that in 2013 there were approximately 4.7 million surgeries conducted in the NHS per year. Then using the data of reported unintentional retained sponges, they found that the average was one incident every 270,115 surgeries. Since it was not known whether anyone had ever died of a retained sponge, they used a conservative estimate of 1 in 10 retained sponges resulting in death. This resulted in a “risk to life” (RtL) of The use of tools and technology for reconciliation The report provides some recommendations and comments regarding the way the count is currently conducted and they break it down into technical and non-technical tools Non technical tools The manner in which each scrub nurse laid out their scrub table allowed many of them to immediately identify a missing sponge; “Swabsafe” trays with specific placeholders for used swabs, but these were not favoured by everyone; other tools. Technical tools Radiofrequency identification (RFID) tags (preferred by HSSIB who noted that this measure has been adopted in the US for this purpose) Read multiple tags simultaneously Can be read when out of sight (e..g in the human body) at > 10m Many studies in the US showing they can reduce the number of retained sponges and improve the efficiency and effectiveness of the count, as well as reduce costs. Barcoding - swabs in and out, but must be scanned The findings of the report A range of interrelated system factors (tools, technology, organisation, task, environment, and people) influence the reliability of the sponge count. The reconciliation process has not been formally analysed or designed using human factors expertise (where the interactions between people and other elements of the system in which they work are explored) or any other process design expertise. Other safety-critical industries assess and control risks to be ‘as low as reasonably practicable’ (ALARP), where there is not an expectation to eliminate all risk. These risk management principles have not been applied to the risk of swabs being unintentionally retained. There is no accountability framework, and it is unclear who owns the risk for retained swabs and reducing the risk for retained swab events to as low as reasonably practicable. Blame can be inappropriately placed on scrub nurses or surgeons when an item goes missing, rather than the reconciliation process being seen as a team activity and one that can be influenced by a wide range of interrelating factors. Staff and national organisations had varying views on the roles and responsibilities for swab reconciliation; limitations in training were identified. The investigation was told by various national organisations that there is a concern about removing Never Events from the NHS’s framework and how determining risk appetite (where it is accepted a level of harm will occur) will be perceived by the wider public. The design of swabs does not help staff to locate, identify, or track swabs during the reconciliation process. There are technologies and tools that could be used to improve the accuracy of the swab count; however, these have not been embedded into UK healthcare. The technology and tools have not been formally considered using risk management principles in terms of reducing the risk to as low as reasonably practicable, or how the technology could reduce other patient safety concerns while also supporting productivity and efficiency in healthcare. The Recommendations “HSSIB recommends that the Centre for Perioperative Care (CPOC) and Association for Perioperative Practice (AfPP) continue to work together with other key stakeholders to review, amend and embed the process and standards for the reconciliation of swabs ensuring it is robust. This review should utilise human factors expertise and user-centred design principles, to reduce the risk of retained swabs to as low as reasonably practicable. Any changes to either organisation’s processes should consider potential unintended consequences and the influence on other safety-critical tasks and include consideration of professional roles and responsibilities in relation to swab reconciliation.” “HSSIB recommends that NHS England develops a framework to assess whether risks, such as retained swabs, are reduced to an acceptable level. This will allow organisations to develop their risk strategies and document their risk acceptance criteria and tolerance.” “HSSIB recommends that the National Institute for Health and Care Research assesses the priority and feasibility of commissioning research to review the viability of implementing technology that could support reducing the risk of retained swabs. The review should balance patient safety, costs, benefits, design, implementation, and the various ways in which the technology could be used to reduce other patient safety concerns to as low as reasonably practicable.” HSSIB Safety Observations “Manufacturers of swabs can improve patient safety by facilitating better detection of retained swabs through user-centred design.” “The NHS can improve patient safety by ensuring procurement decisions about swabs are made on a risk-informed basis that incorporates evaluation trials and user-centred design processes in the design, manufacture and testing of products.” “Multidisciplinary team training can improve patient safety by increasing the understanding of team roles, responsibilities, teamwork, the interrelationships between the work system and people and ultimately improve the care of patients undergoing an invasive procedure.” “A user-centred evaluation of non-technical tools to aid the swab count can improve patient safety by helping national organisations and trusts assess whether their risk of retained swabs is as low as reasonably practicable.” Health Services Safety Investigations Body (HSSIB) reports HSSIB Report: Retained swabs after invasive procedures (April 16, 2024) HSSIB Interim Report - Retained swabs following invasive procedures: themes identified from a review of NHS serious incident reports (December 7, 2023) HSIB Legacy Report: Detection of retained vaginal swabs and tampons following childbirth (June 7, 2021) Random recommendations : Amir: Gardening It doesn’t have to be gardening but have a small plant or flower that you can take care of. It is helpful to watch something grow and develop. As a resident can be very low stakes Adam: Marty: Life is Short Documentary about Canadian Comedian, actor and writer Martin Short. Features many comedians and hilarious stories Some of the links in these show notes are Amazon affiliate links. As an Amazon Associate, we may earn from qualifying purchases, at no additional cost to you. Currently, we receive no outside funding, so we thank you for supporting the podcast, again at no additional cost to you.

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  Medical Safety Podcast

  Ep 8 - HSSIB Retained Sponges Report - Part I

  Aug 2, 20261h 15m

  Send us Fan Mail Show notes The reference event: Helen’s CABG Helen had heart surgery (CABG x3 “triple bypass open heart surgery”). The day after the procedure, Helen had trouble breathing and a Chest X-Ray (CXR) taken for another reason, identified a retained sponge. She was taken back to the OR and had the sponge removed. As she was quite unstable, the decision was made not to X-ray her in the OR and to close her chest and stabilize her. At 7:30 pm, a CXR identified a second sponge in the same location as the first. The following morning, she had another surgery to remove the swab from her chest. A CXR performed in the OR showed no foreign objects. Helen was in the ICU for 7 days and was discharged 13 days after her final surgery to remove the second sponge. At home, Helen had ongoing health problems. Helen’s family referred the incident to the HSSIB. When the investigators first met Helen six months after the incident, she was visibly upset by what had happened and she reported she had received limited mental health support. According to the report, Helen continues to have health and wellbeing issues.” Background Investigation began: Sep 28, 2022. Interim report: Dec 7, 2023 (14 months later) highlighted common themes in 31 serious incident reports (investigations carried out by local healthcare trusts). Final report: Apr 16, 2024. Never Events Defined as ‘patient safety incidents that are wholly preventable where guidance or safety recommendations that provide strong systemic protective barriers are available at national level and have been implemented by healthcare providers’ (NHS Improvement, 2018).” [emphasis added] Multiple UK reports call for Never Events to be renamed because the events described are not entirely preventable, there are not strong barriers available to prevent them, and by calling them Never Events, it invites stigma and shame and discourages reporting and thorough investigation. “The count” / reconciliation Sponges are counted in a specific way, by two nurses, who must agree on the count before the sponges are used Analysis and findings regarding the reference event (Helen’s CABG) The HSSIB: “Limitations in the evidence meant it was not possible to identify precisely what happened during Helen’s surgery to result in two swabs being retained." It is curious that the first finding of this report is that the available evidence made it impossible to determine precisely what happened during Helen’s surgery, yet there is no mention of recording devices in the report. In aviation, they had to invent a robust means of recording what occurred in order to determine what happened and how to prevent future accidents. In this case, OR Black Boxes would almost certainly have provided the evidence needed. Patients continue to be placed at risk by the unavailability of this information. Factors affecting the sponge count responsibility for swab counts (surgeon vs scrub nurse) communication of information about swabs Surgeons not informing scrub nurse when a sponge was inserted visibility of swabs Not in direct line of sight Soaked with blood and therefore lacking contrast with surrounding tissue Radiopaque stripes appear similar to other lines on XR and when an XR is performed for another reason, no one is looking for a sponge. the make-up of the operating theatre team When there is a change of nurses, the count wasn’t always being conducted between the outgoing and incoming nurses the timing of the count and its confirmation at Sign Out the type and duration of the surgical procedure professional culture and practice Surgeons taking swabs directly from the nurse’s table without informing the nurse. distractions and interruptions competing tasks (counting while doing other tasks) time pressure time of day More common in surgeries between 2 pm and 7 pm, raising concerns of fatigue (HSSIB noted further data are required here) clarity of policies and procedures - lack of clarity on specific times counts are to be performed The report again identifies weaknesses in the level and quality of the evidence available in the investigation and finds that there may be other factors that affect the reliability of the count that could not be identified because of that. Factors affecting the detectability of the sponges in Helen’s chest Sponges come with tails, but these were cut off before the sponges were used. Sponges absorb blood and then look like tissue. Sponges can be very deep in a cavity and be obscured from view by organs. Factors affecting the detectability of the sponges on x-ray There were many other items visible on the CXR (tube, lines etc) making the sponges more difficult to detect. The clinicians were focused on other theories for Helen’s deterioration. Factors affecting detection of the second retained sponge Staff thought there was only one sponge. Helen was unstable and it was deemed unsafe to conduct an extensive search of the chest cavity or an X-ray. Analysis and findings of the wider investigation The low frequency of retained foreign objects following invasive procedures indicates that the counting system is largely successful, however, counting items is not a strong systemic barrier. There is a tension between spending more time on something that seems to be largely working well (the count) and the need to be efficient with operating room time (or else harm comes to patients). HSSIB explicitly identifies the conflict that is present in frontline healthcare workers’ minds: ‘every minute that is spent attempting to improve a process that works most of the time is a minute of OR time that another patient cannot receive’ The HSSIB resolves this tension by pointing out that while ‘Frontline workers generally operate under rules and procedures which provide a normative standard against which their behaviour can be judged. In contrast, designers, managers, and such generally operate with more degrees of freedom.” Meaning we may be able to design better sponges and use system measures rather than people-focused measures to reduce this risk without a tradeoff. OR Black Boxes & Medical Culture (Patreon-only) Safety intervention worth mentioning: The Hierarchy of Intervention Effectiveness ( see diagram ) In North America, medical culture places the emphasis on the frontline staff to get it right and when incidents are made known to staff, there is an expectation that that awareness should be sufficient to prevent it from recurring. This is as opposed to changing the working conditions, which is Professor James Reason’s main conclusions in his life’s work. In the interim report, the HSSIB refers to “The Hierarchy of Intervention Effectiveness” from Cefazzo and St-Cyr, 2012, which shows various interventions and their relative effectiveness. “The hierarchy is a tool for ranking the effectiveness of measures used to reduce the risk of a safety event. Measures that rely on people are considered to be less effective.” The solution is to change the working conditions Health Services Safety Investigations Body (HSSIB) reports HSSIB Report: Retained swabs after invasive procedures (April 16, 2024) HSSIB Interim Report - Retained swabs following invasive procedures: themes identified from a review of NHS serious incident reports (December 7, 2023) HSIB Legacy Report: Detection of retained vaginal swabs and tampons following childbirth (June 7, 2021) Other resources Willful Blindness by Margaret Heffernan Selective Attention Test (Simons & Chabris, 1999, YouTube) (1 min) Cognitive bias in diagnostic radiology (radiopaedia.org) Random recommendations Adam: Go see the RCAF Snowbirds! 2026 Schedule Snowbirds to be grounded after the 2026 season until 2030 when they acquire new aircraft Some of the links in these show notes are Amazon affiliate links. As an Amazon Associate, we may earn from qualifying purchases, at no additional cost to you. Currently, we receive no outside funding, so we thank you for supporting the podcast, again at no additional cost to you.

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  Episode #7

  Ep 7 - "A Life in Error" - Remembering Professor James Reason

  Jul 19, 202653 min

  Show notes Errors occur when a planned sequence of events fails to achieve its goal without an element of chance. Slips and lapses are absentmindedness. Trips and fumbles are maladroitness. Mistakes involve higher order cognition Main classification of errors: Skill-based slips Rule-based mistakes Knowledge-based mistakes Examples of skill-based slips: putting cat food in the teapot, getting into the bath with your socks on, trying to open a door with the wrong key. Examples of rule-based mistakes: proceeding when it’s not your turn at the intersection (most driving errors are rule-based. Examples of knowledge-based mistakes: devising an alternate route when there is a road-block, devising a differential-diagnosis and arriving at a working diagnosis. In order to prevent, trap, and mitigate errors, we need a common language to discuss errors and how to manage them. Violations are intentional deviations from norms and rules. Corner-cutting or routine violations committed to avoid unnecessary effort or to circumvent inappropriate procedures (the written vs unwritten rules); Thrill-seeking or optimizing violations (e.g. speeding); Necessary violations that occur because the people making the rules are not the ones performing the actual work; and Exceptional violations: one-off events that occur under exceptional circumstances. The Swiss Cheese Model of defences in depth Defences protect against hazards reaching losses, like barriers. These barriers have holes in them, like swiss cheese The holes are latent conditions and active failures Latent conditions exist for years and are due to system factors (understaffing, policies etc) Active failures are errors created by people at the front-end (doctors, nurses, pilots, technicians etc) that are closely connected in time to bad outcomes. The current medical model is not error tolerant. It expects practitioners to be perfect. If a pharmacist, nurse, physician etc makes a mistake, the safety margins are so razor-thin that it can easily result in a bad outcome for a patient. Conversely, the response in most medical safety protocols is to warn practitioners of the dangerous conditions and then blame them when the bad outcome occurs, because this time they knew about the dangers. We should instead insist on changing the working environment, which produces the errors. Medicine being one of the oldest professions in the world and certainly one of the most complex, contributes to the difficulty in changing its culture. In changing the culture of medicine to improve the overall system, we also need to consider how the training of healthcare professionals entrenches the stigma of reporting errors. There is no true tension between training excellent physicians and reporting systemic deficiencies, because “stress testing” of physicians can happen in simulations and true-emergencies, while we also work to improve day to day conditions for everyone. We are moving towards a model of care where we speak of Centres of Excellence, rather than “who is the orthopaedic surgeon?” Medicine is team-based and even, or perhaps especially, community hospitals whose teams are well-known to each other can deliver excellent and safe care. R v Omstead , [1999] OJ No. 570 1999 in Leamington, Ontario Nurse Omstead was charged with manslaughter (criminal negligence causing death) after she gave potassium chloride thinking it was furosemide because they were lookalike drugs stored close together. The judge acquitted Omstead because the Crown failed to prove beyond a reasonable doubt that her actions were a marked departure from a reasonable nurse in her situation. The judge noted that latent conditions such as the drugs looking alike and being placed together were significant factors in the error. The judge also noted that the error had been reported by Omstead herself and a conviction could have a chilling effect on future reporting of errors. Criminal trials are held to determine criminal blameworthiness and judges in such cases cannot make recommendations to hospitals or policymakers. Investigating errors as being produced by the working conditions and being related to systemic deficiencies does not mean that individuals cannot be held accountable for gross negligence (e.g. intoxication). It does mean that if, for example, training deficiencies are found, the training system can be corrected and everyone who was similarly situated can benefit. Safety intervention worth mentioning: leadership walkthroughs Dr. John Dornan, New Brunswick’s Health Minister, spends 24 hours in Moncton Hospital’s ED Dr. Warren Thirsk challenges Alberta Premiere Danielle Smith to come on shift Other resources Martin Bromiley: A patient’s perspective (March 16, 2018 - YouTube 23 min) A Life In Error: From Little Slips to Big Disasters by James Reason Random recommendations Adam: Politics Without Politicians by Helen Landemore Amir: The Black Swan by Nassim Taleb Some of the links in these show notes are Amazon affiliate links. As an Amazon Associate, we may earn from qualifying purchases, at no additional cost to you. Currently, we receive no outside funding, so we thank you for supporting the podcast, again at no additional cost to you.

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  Episode #7

  Ep 7 - "A Life in Error" - Remembering Professor James Reason

  Jul 19, 202653 minS0

  <p><b>Show notes</b></p>Errors occur when a planned sequence of events fails to achieve its goal without an element of chance.Slips and lapses are absentmindedness.Trips and fumbles are maladroitness.Mistakes involve higher order cognitionMain classification of errors:Skill-based slipsRule-based mistakesKnowledge-based mistakesExamples of skill-based slips: putting cat food in the teapot, getting into the bath with your socks on, trying to open a door with the wrong key.Examples of rule-based mistakes: proceeding when it’s not your turn at the intersection (most driving errors are rule-based.Examples of knowledge-based mistakes: devising an alternate route when th...

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  Medical Safety Podcast

  Ep 6 - Patient Safety with Captain Martin Bromiley

  Jul 5, 20261h 20m

  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” 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; Hospitals and healthcare systems win because safety is tangibly improved; and 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 Just a Routine Operation (YouTube - 6 min) Just a Routine Operation (YouTube - 14 min) Martin Bromiley: A patient’s perspective (March 16, 2018 - YouTube 23 min) Other resources A Life In Error: From Little Slips to Big Disasters by James Reason Royal College of Anesthetists (RoCA) NovPod - S2E11: Prevention and management of pain during caesarean section (with Susanna Stratford) Random recommendations Martin: Confessions of a Hornet Pilot by Tug Wilson Adam: Project Hail Mary audiobook , movie or Artemis II lore Amir: The Drama movie Please consider donating at medicalsafetypodcast.com or becoming a patron of the show at Patreon.com/medicalsafetypodcast where you find full episodes

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