Safety, Human Factors & Teamwork in Crisis Management
The Elaine Bromiley case is a frequently cited case example of the importance of human factors in medicine. The case vignette has been reproduced in the following video and we encourage you to watch it.
Elaine Bromiley, a 37-year-old mother of two, presented to hospital for elective sinus surgery in March 2005. After routine anaesthetic induction, a consultant anaesthetist attempted laryngeal mask airway (LMA) insertion but was unsuccessful. Further attempts over the next 20 minutes consisted of facemask ventilation with an oropharyngeal airway, and numerous intubation attempts. None of these were successful and she remained severely hypoxic during this period. Eventually, an intubating LMA was placed and her oxygenation improved. Unfortunately, Elaine never regained consciousness and she died of a severe hypoxic brain injury 13 days later.
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Elaine’s husband, Martin Bromiley, was an airline pilot who subsequently advocated for an improved safety culture within healthcare, mirroring the aviation industry’s approach to learning from failure. You can read more about his work through his charity, the Clinical Human Factors Group.
Whilst there were a number of areas where the care of Elaine fell short of what might be reasonably expected, it was a breakdown in the non-technical skills, or human factors, which was uniformly criticised during the subsequent review. These are the cognitive, social and personal resource skills that complement technical proficiency, whilst contributing to safe and efficient task performance.
The Elaine Bromiley case can also be presented as an example of an error chain, or ‘Swiss cheese model’, where both system errors (eg. understaffing, poor organisational culture, fatigue, inadequate equipment or protocols) and human errors (mistakes, inaction and procedural violations) combine to contribute to adverse outcomes. These are alternatively referred to as latent factors and active factors respectively [1]. By identifying and addressing these gaps and weaknesses, organisations can reduce the likelihood of accidents and failures.
The Swiss Cheese Model
Leadership & Teamwork
Effective management of crises requires both skilful leadership and cohesive teamwork. In a clinical emergency, there needs to be a single, clearly identifiable leader who must have good technical knowledge, skill competency, and ability to maintain organisational structure.
Leadership styles can be divided into two main categories: directive or empowering [1,2]. Directive leadership is an instructive style which is comparative to a military chain of command and is effective in situations where simple tasks need to be allocated and/or the subordinate lacks sufficient self-direction to complete tasks independently. Empowering leadership allows team members to assume responsibility over tasks that may be complex or multifaceted, whilst the leader concentrates on team cohesion, coordination, and communication.
Empowering leadership styles are superior in achieving complex tasks, as this helps to offset cognitive overload. The clinical context is important. In the airway crisis, it is likely that both leadership styles need to be intelligently employed to create success. The leader is responsible for identifying and allocating team roles, developing a plan for airway securement, and clearly communicating key steps prior to, and during, the intervention.
Human performance under stress can become severely impaired, with even highly competent and experienced clinicians being vulnerable to these effects. Teamwork has been shown to increase successful task completion by reducing individual cognitive load [3,4]. Cohesive teamwork requires communication, situational awareness and hierarchical flattening.
Situational Awareness, Decision Making & Cognitive Aids
When dealing with a clinical emergency, there are usually multiple streams of information superimposed on a rapidly changing situation. It is critically important to maintain awareness of the “big picture” as well as the human and technical resources available to manage this crisis. This is called situational awareness, defined by Haines and Flateau as:
“one’s ability to remain aware of everything that is happening at the same time, and to integrate that sense of awareness into what one is doing at the moment.” [5]
However, not only is it about our analysis and comprehension of what this information means now, but also how we predict things will evolve into the future. We can further explore the concept of situational awareness by breaking it down into three key stages [6]:
This is a dynamic process which evolves over time with the addition of further information and feedback. If we lose this awareness because of stress, cognitive bias or overload, or fixation errors, this can set us up for potentially catastrophic consequences in crisis situations.
Fixation errors occur when clinicians become fixated on a particular detail of the clinical situation, without considering additional data or tasks. The error may be task- or diagnosis-oriented:
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Task fixation: personnel become preoccupied with completing a single task, such as inserting a difficult peripheral cannula, even when their energy may be better served in a different direction at that point in time.
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Diagnosis fixation: reaching a provisional diagnosis, and subsequently directing all attention at managing that diagnosis, and thus failing to consider other reasonable explanations for the clinical situation.
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Cognitive aids and decision-making tools assist in keeping the team on track and avoid fixation errors, as well as reducing cognitive overload. Uncertainty about when to declare that optimal supraglottic airway attempts have failed, and therefore the need to move to infraglottic rescue, is a key contributor to adverse outcomes in airway management. The two frequently used visual airway cognitive aids are the Vortex approach, and the Difficult Airway Society algorithm. They are simple and memorable, and define trigger points to aid the team leader in moving from one plan to the next. There is evidence that decision-making is enhanced when teams are encouraged to review them regularly [7].
Graded Assertiveness
In the enquiry into Elaine Bromiley’s death, it was determined that assistant nursing staff felt that a ‘cannot intubate, cannot oxygenate’ (CICO) emergency had occurred and provided a prompt to the clinicians to the location of the surgical airway kit. This prompt was not acted upon, due to a multitude of factors including task fixation and hierarchical constraints leading to communication failure.
The concept of graded assertiveness arose from the aviation industry, where nearly 50% of air transport disasters prior to 1990 were found to be the result of the first officer failing to monitor and challenge a captain’s decision [8]. As a result, assertiveness training has become established not just in aviation but in many high-risk industries. Communication methods to employ graded assertiveness are now widely recognised in healthcare and are endorsed by many specialty colleges including
ANZCA, as it is recognised that the ability to manage upwards and communicate assertively within the healthcare team is essential to optimal performance and minimisation of adverse events. It is important to distinguish aggression from assertiveness - the latter is communicating in a way that is clear, concise and constructive and built on the understanding that the needs and opinions of all parties must be considered.
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A frequently used approach
of graded assertiveness is
the PACE model [9]:
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