Whats New in the Patient Safety World

May 2013

BBC Horizon 2013 How to Avoid Mistakes in Surgery



The BBC has a great video How to Avoid Mistakes in Surgery that is now on YouTube. Its an hour-long presentation that incorporates human factors principles into a variety of surgical scenarios. It begins with a case where a patient dies because the team focused on trying to intubate an obstructed airway and overlooked performng an emergency tracheostomy. It emphasizes how we focus our attention and may develop tunnel vision and lose situational awareness. It also shows how both lack of a person in charge and the authority gradient come into play (a nurse brought an emergency tracheostomy kit into the OR but did not speak up to suggest it be used). It gives great examples from other industries about human factors involved in emergent situations. It shows firefighters going through a simulated exercise emphasizing the importance of situational awareness. It includes Atul Gawande discussing the WHO Surgical Safety Checklist. It has good segments on the value of simulation and handoffs, again using analogies with Formula-1 race cars. Then it talks about dealing with emergencies for which you have never been trained, using Sully Sullenberger and the plane he landed safely on the Hudson River. It even includes neurophysiological substrates of how we think about errors and how a positive attitude about errors can foster the sort of quick solutions used by people like Sullenberger.


Its a very well done presentation that really shows how human factors should be incorporated into our every day healthcare world. Its an hour but one that will be well spent.






BBC Horizon 2013 How to Avoid Mistakes in Surgery







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