Team Training for Critical Incidents

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Team Training for Critical Incidents
Dr Andrew McIndoe Consultant Anaesthetist Bristol
Medical Simulation Centre
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Lecture content
20 minutes

• Why do we train teams?
• Course design
• Tackling specific problems
• Evaluation of team training

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Surgeons removed wrong kidney in 'catastrophic
error' By Terri Judd Tuesday, 13 January
2004 Two "grossly negligent" surgeons removed a
patient's only healthy kidney in an "appalling"
catastrophe which led to his death, the General
Medical Council (GMC) was told yesterday.
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Surgeons removed wrong kidney in 'catastrophic
error' Cardiff crown court was told that the
wrong kidney was identified on the hospital
admittance slip, and the error was transferred to
the operating theatre list. The case notes and
consent form carried the correct information, but
neither surgeon had looked properly at the case
notes. The surgeon later said that he thought he
might have looked at the x ray back to front. A
medical student who was observing the operation
looked at the x ray on the wall of the theatre
and said she thought it was the right kidney that
was not functioning, but the surgeon allegedly
told her she had got it wrong.
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February 7th, 2009 Doctor guilty of manslaughter
A doctor charged with gross negligence has been
found guilty of killing a patient by giving her a
fatal injection of adrenaline.
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Human error critical incidents

• Prevalence in Anaesthesia
• Craig/Wilson 1981 65
• Cooper 1984 65
• Kumar 1988 80
• Curie 1989 82
• Gaba 1990 66
• Williamson 1993 83

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INDIVIDUAL PERFORMANCE
TEAM PERFORMANCE
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INDIVIDUAL PERFORMANCE
TEAM PERFORMANCE
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Theatres
Wards
General practice
Resuscitation
Dentists
Delivery suite
Radiotherapy
TEAM PERFORMANCE
High dependency care
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SITUATIONAL AWARENESS
COMMUNICATION
RESOURCE MANAGEMENT
PREDISPOSING FACTORS
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Airline Industry
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Blunder that killed my wife. By JANE FEINMANN 12
December 2006 At the inquest, held in October
last year, the lead anaesthetist admitted that he
had lost control. "Fixation is a normal
reaction to stress but at some point, a decision
has to be made to break out of that pattern of
behaviour. The way to ensure that happens is for
all members of the team to see it as their duty
to speak out to keep the patient safe." Two of
the nurses knew how to save his wife's life.
"What they didn't know - and what Human Factors
would have taught them - is how to broach the
subject."
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Stressful problem
Correct management
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Stressful problem
ABC Hypothesis
Correct management
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Stressful problem
Early recognition
ABC Hypothesis
Verification
Correct management
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Anticipation
Stressful problem
Early recognition
ABC Hypothesis
Verification
Correct management
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Anticipation
Stressful problem
Early recognition
Protocol training
Verification
Correct management
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Anticipation
Stressful problem
Team training
Protocol training
Team training
Correct management
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Anticipate
Avoid
Trap
Recognize
Mitigate
Diagnose
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Developing a course

1. Involve key personnel
2. Define the specific learning objectives
3. Make it relevant
4. Design interactive sessions
5. Evaluate performance

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Example
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Preventation of airway incidents

• 1. Pre-op checks of patient and kit - AAGBI
  guidelines
• 2. System of machine alarms
• 3. Emergency protocols - DAS Difficult Airway
  Society Algorithms - Report to the CMO of an
  Expert Working Group on Blocked Anaesthetic
  Tubing

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(No Transcript)
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63 yr old, occasional reflux, sleeps with 2
pillows, gets hay fever in the summer.
Very difficult to bag after iv induction
intubation. He is rapidly turning blue
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BLOCKED AIRWAY FILTER
ETT CUFF HERNIATION
OESOPHAGEAL INTUBATION
LARYNGOSPASM
ENDOBRONCHIAL INTUBATION
CIRCUIT DISCONNECTION
BLOCKED CATHETER MOUNT
INHALED FOREIGN BODY
LVF
ASPIRATION
ANAPHYLAXIS
BRONCHOSPASM
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BLOCKED AIRWAY FILTER
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ENDOBRONCHIAL INTUBATION
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72
BLOCKED CATHETER MOUNT
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ANAPHYLAXIS
BRONCHOSPASM
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Reactive strategies
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Traditional Medical Approach

• 1. History
• 2. Examination
• 3. Investigation
• 4. Diagnosis
• 5. Treatment

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Common Emergency Approach

• 1. History
• 2. Examination
• 3. Investigation
• 4. Diagnosis
• 5. Treatment

Best Guess!
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Reactive strategies

• 1. Stabilise
• 2. Simplify
• 3. Get help
• 4. Review

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Reactive strategies

• 1. Stabilise
• 2. Simplify
• 3. Get help
• 4. Review

ABC approach Divide problem away Communicate
Does it fit?
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• BRIEFING
• SCENARIO
• DISCUSSION WITH PEERS

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MEDICAL SUMMARY Airway Breathing Circulation Disability Electrolytes/Metabolism Fluids Gut Haematology Interventions COMMUNICATION Verbal Written Human Machines Personality Body language
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TEAM DYNAMICS Leader Identifiable, receptive, goal/ plan, delegation, motivates, updates? Rest of the group Roles, responsibilities, supportive, feedback, advocate opinions? Use of available resources ERROR ANALYSIS Active Error Latent error Slips Lapses Mistakes
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Overall Learning Objectives

1. Identify situations in which I cannot cope alone.
2. To communicate more effectively.
3. Recognise good team leadership.
4. Perform effectively as a team member.
5. Make effective use of available resources.
6. Learn from mistakes and accommodate errors.

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Has it changed your practice?