To instil Practitioner & Patient confidence..

Dr M Bloch Consultant Anaesthetist NHSG

Plan: Why? How? When & Where?

Teams: Different equipment. Different education and training. Different perspective, pressures and pitfalls.

100,000 Americans die each year as a result of medical errors 43,458 - motor vehicle accidents 42,297 - breast cancer 16,516 - AIDS equivalent to a full Jumbo Jet crashing each day over a full year

Good patient outcome by luck alone is no longer acceptable: It is important for the appropriate process to occur in all interactions, including those between:  patient and staff  staff and staff  the individual and the ‘systems’ within which they work

How: Crisis evolution / avoidance: active / latent factors: environmental organisational cultural individual team patient

Shared Mental Model: Communicate appropriately & effectively voice modulation & non-verbal communication direct specific instructions close communication loop open exchange of information Try see others perspective when communicating with them:

Situation Awareness: Know what is going on around you:  Local  Regional  Systemic ‘Staying ahead of the game’

Aviation video

Good Clinical Practice: Human factors is not a substitute for technical proficiency. High technical proficiency cannot guarantee patient safety.

When & Where?

All the Time & Everywhere!

Conclusion: Systematic approach Knowledge, skill and understanding is required to make the appropriate clinical judgement decisions. Non-technical skills are also required to optimise patient outcome including:

–Anticipating and planning. –Appropriate team leadership. –Effective communication & sharing mental models. –Maintaining situation awareness and utilising appropriate personnel and resources. –Calling for help early enough.