In 2007, Martin Bromiley’s wife died due to medical error. The Bromiley case will be familiar to many of us. The lessons from this case can teach us stark lessons about our own leadership and teamwork.
Martin and his wife, Elaine had two young children. Elaine went into hospital for a routine sinus operation and during anaesthetic induction, it all went horribly wrong.
Her airway obstructed and the team was unable to gain a secure airway. For 20 minutes they attempted to achieve a stable airway, during which time her sats were around 40%.
Although she survived, she sustained serious hypoxic brain injury and 13 days later her life support was turned off.
Martin is an airline pilot with an interest in human factors and formed the Clinical Human Factors Group in 2007.
Here are the key teamwork lessons from his wife, Elaine’s case.
2. Have a plan
3. Listen to all the team members
In Elaine’s case, as well as the three doctors, there were three experienced nurses. Although the doctors did not appear to recognise the seriousness of the situation, the nurses did.During the resus, one of the nurses fetched a surgical airway kit and told the consultants that she had brought it in – but there was no response. One of the other nurses called for an ICU bed early on in the resus – when she told the consultants this they made her feel like she was overreacting (and she cancelled it).It transpired that the nursing staff didn’t know how to broach the subject with the doctors. Every member of the team needs to be able to show assertiveness, particularly when they can recognise trouble and have suggestions for a solution.But more than that, there must be culture of listening. Every team member is valuable and may have something helpful to add. Questioning what is happening and suggesting possible options is an important part of any resus and is essential for good team work. Everyone must be listened to.
4. Take control
As Martin Bromiley identifies, ‘we are all wrong no matter how good we are’.
We need people around us to tell us.
Be open to suggestions. Listen to your team. Step up and lead.
Follow @MartinBromiley on Twitter.
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