Thursday, January 15, 2009

Prosecuting doctors won’t stop them making mistakes

Article in The National (Abu Dhabi)by Justin Thomas 4 January 2009.

It appears that there are draft proposals for criminal sanctions to be brought against negligent doctors in Abu Dhabi.

Justin says that whilt he agrees healthcare professionals need to be held accountable, "such accountability and possible culpability, should only be a small part of a system-wide approach to reducing errors and improving patient safety. In fact, individually punitive measures are actually more likely to lead to a deterioration in patient safety rather than improvements."

All human beings make errors. Punishing people for slips and lapses does not improve safety or performance; if anything, it breeds resentment and fear, which in turn can lead to the development of a blame-culture, scapegoating and cover-ups.

The article says that several studies in the UK have estimated that at least 10 per cent of all hospital admissions result in adverse events, with 50 per cent of these mishaps being viewed as preventable. Also, the UK government estimates that annually there are 10,000 adverse drug reactions, 400 deaths involving medical devices, 28,000 complaints about medical care, and £400 million (Dh2.1 billion) paid out in clinical negligence settlements.

"In terms of improving patient safety, the dismissal or even incarceration of errant professionals will have little impact, and in some cases may even make the situation worse, especially if practitioners become defensive, risk averse and demoralised."

"The answer to preventing error and improving patient safety lies in the development of organisational safety cultures, where staff have an active awareness of the potential for things to go wrong and know about things that have gone wrong previously, as well as the circumstances and causes leading up to such incidents. Such a culture should actively encourage people to speak up about mistakes, with a view to learning from them and minimising the likelihood of a recurrence."

Andy Brazier

100 years of flight safety advances

A very interesting article from Flight International by David Learmont published 5 January 2009

Well worth reading the whole article, but some of the key messages are summarised below.

Wilbur Wright wrote to his father: "In flying I have learned that carelessness and overconfidence are usually far more dangerous than deliberately accepted risks." Whilst, in the 1930s First World War pilot Capt A G Lamplugh described of the risks of flying as "Aviation in itself is not inherently dangerous. But to an even greater degree than the sea, it is terribly unforgiving of any carelessness, incapacity or neglect." Both had clearly learnt that no activity can be completely risk-free, but that risk should be managed so as to remain within acceptable bounds.

Most safety lessons are learnt through experience. Father of the Flight Safety Foundation Jerry Lederer said in 1939 that "strange as it may seem, a very light coating of snow or ice, light enough to be hardly visible, will have a tremendous effect on reducing the performance of a modern airplane". The challenge has always been to disseminate learning. In January 2002 a Bombardier Challenger 604 business jet at crashed on take-off from Birmingham. It had been left on the ramp overnight and not de-iced before take-off was attempted.

Airframes, engines and aircraft systems have continually become stronger and more reliable, but as these improved the aircraft could also fly faster, perform a greater variety of tasks, and operate in worse weather conditions.

As the machinery became more reliable it caused less accidents. The role of the human became the focus of those who would improve aviation safety, really staring in the 1970s covering both on-board crew and maintenance.

Cockpit or flightdeck ergonomics started to improve in the 1960s, and really stepped up in the 1980's when cathode ray tube instrument displays (later replaced by liquid crystal displays) started to appear. This provided opportunities to improve crew situational awareness because data regarding performance and navigation could be integrated rather than being displayed as disparate pieces of data. This not only reduced the potential for individual confusion, but provided both pilots with the same picture of what was going on rather than allowing each to develop their own pictures that may not be identical.

In the 1970s KLM invented the concept of crew resource management (CRM) with the objective of improving the way crew communicated and worked together. This is now officially accepted globally as a critical part of multi-crew pilot training.

Technology alone has rarely eliminated a serious risk, but since the mid-1990s real progress has been made in reducing what had been the worst killer accident category - controlled flight into terrain. The ground proximity warning system (GPWS) has been replaced by Enhanced GPWS (EGPWS) which provides pilots with a graphic picture of their position and height relative to terrain, plus audio alerts. It is stated that there have been no incidents of controlled flight into terrain involving aircraft fitted EGPWS, but 5% of the world's big jet airline fleet that do not have it.

The windshear alert was developed in the late 1980s after meteorologists improved their understanding of phenomena such as windshear and micro­bursts associated with storm cells, and how these can affect aircraft close to the ground just after take-off and on approach. Pilots' awareness of the risk has also been improved.

Information technology has allowed company and global databases of safety data to be developed. Downloading data from aircraft allows engineers to recognise where operational best practice has been breached and to spot the technical signs of impending equipment failure.

In addition, the adoption of safety management systems and global auditing of airlines has made its contribution. But it may be argued that liberalisation of the market has allowed greater competition and therefore greater passenger choice. Where there is a choice of another airline to fly with, a carrier that has suffered an accident also suffers commercially.

Andy Brazier

Formula 1's virtual reality

Article from by Joe Saward on 14 January 2009

Apparently Formula 1 has been using simulators for sometime for testing technical components and this will become more useful now that circuit testing has been banned in a bid to save the teams money. Highly-advanced rolling-road wind tunnels, transient dynos, seven-post rigs, Computational Fluid Dynamics (CFD) and computers to "crunch away to work out every conceivable race strategy" are being used along with "driver-in-the-loop simulators" where the F1 drivers sit in "virtual" F1 cars and drive them.

It is suggested that use of simulator technologies in Formula 1 started when teams recognised that they could make money by working with computer gaming companies to create entertainment for the public. The first racing computer game was Gran Trak 10released by Atari in 1974.

The article gives an interesting summary of the history of simulation.

"Modern simulation techniques can be traced back to the 1920s when an American engineer called Edwin Link, who had begun his career as a builder of organs and nickelodeons, used his knowledge of pneumatic pumps and valves to create the first flight simulator" He developed a device which became known as the Blue Box. It was an aircraft cockpit that the pilot sat in and was able to 'fly' using instruments alone - until this time learning to fly in cloud was done in the air and was known to be rather dangerous. The Blue Box produced pitch, roll and yaw motions which were controlled by the pilot. The Army Airforce made the first purchases in 1934 after a number of trainee pilot fatalities, and in the end 10,000 were sold with more than half a million aircrew from different nations using them to train.

The boom in civil aviation after World War II created a greater need and pneumatics were replaced by hydraulics in simulators by the 1960s. They incorporated "six degrees of freedom", which meant that the platforms on which the cockpits were mounted were able to generate roll, pitch, yaw motion plus surge (longitudinal), heave (vertical) and sway (lateral). Visuals were introduced, with the earliest versions using cameras that filmed models of the ground. By the 1970s wide-angled screens with film footage came in, to be followed by curved mirrors and ultimately plasma screens with virtual imagery.

Other uses of simulator included army ground vehicles and automotive simulators use to understand how drivers behaved in different situations. Today there are reckoned to be 1200 professional flight simulators in the world.

Back in Formula 1: McLaren is believed to have spent as much as $40m on its system using technology developed for the Eurofighter aircraft. The driver sits in a full-size F1 monocoque, in front of a large, curved plasma screen. The whole device is mounted on a hexapod which moves around an area about the size of a professional basketball court, in response to the driver's steering and pedal input. Conversely Williams have used a fixed simulator which has been "amazingly cost-effective, with a budget of probably a tenth of what has been spent at McLaren." Apparently Williams can download data from practice sessions on the track to the simulator to try out different set-ups, which can then be tried to ensure the cars have the optimum set-ups

Andy Brazier

Surgical checklist 'saves lives'

Article on BBC website 14 January 2009.

A one-page checklist devised by the World Health Organization (WHO) has been tested in eight cities around the globe (Seattle, Toronto, London, Auckland, Amman, New Delhi, Manila and Ifakara, Tanzania). It focuses on basic good practice before anaesthesia is administered, before a patient is cut open, and before a patient is removed from the operating theatre, and is designed to promote effective teamwork and prevent problems such as infection and unnecessary blood loss.

Data was collected from 7,688 patients, 3,733 before the checklist was implemented, and 3,955 afterwards. The rate of major complications fell from 11% to 7%, and the rate of inpatient deaths following surgery fell more than 40% from 1.5% to 0.8%. Findings were similar across all the hospitals in the study.

Dr Alex Haynes, who led the study, said the checklist had a significant impact at every hospital site in the study. "Even many clinicians who were initially sceptical of the idea became advocates once they saw the benefits to safety and consistency of care."

Dr Kevin Cleary, NPSA medical director, said: "The results of the study give clear evidence that a simple intervention leads to dramatic improvement in outcome for patients undergoing surgery."

UK Health Minister Lord Darzi is quoted as saying "The beauty of the surgical safety checklist is its simplicity" and "Operating theatres are high-risk environments. By using the checklist for every operation we are improving team communication, saving lives and helping ensure the highest standard of care for our patients."

The checklist is already in use in Scotland and the National Patient Safety Agency (NPSA) has ordered all hospitals in England and Wales to use it across the board by February 2010.

I'm a strong advocate of checklists for certain tasks, although their overuse can be counter-productive. What I don't understand is why it will take so long to get this implemented. The checklist is readily available for use. You can download it from the BBC website.

Andy Brazier

Monday, January 12, 2009

Take a Nap! Change your Life

A very interesting book by Sara Mednick. Available from Amazon

The book talks about how napping during the day to supplement night-time sleep is part of human nature. It makes specific reference to health and safety, including the role of fatigue in the Exxon Valdez accident.

A few snippets.

* In 1950's studies were done where subjects were kept in small flats without windows or clocks. After a short transitional phase people would sleep six to seven hours at a time that would represent night and roughly 12 hours later would return to bed for a shorter time. It is suggested that this is a natural sleep pattern.

* Before the light bulb was invented adults would typically get as much as 10 hours rest during the average weeknight. Today the average (in USA I presume) is 6.7 hours.

The book explains when to nap and for how long, but the basic message I take from it is napping can have great benefits, with small naps greatly reducing fatigue. I would not say I would follow detailed advice particularly, but it has encouraged me to take more naps whereas in the past I may have felt it a slightly silly thing to do. Also, it backs up advice I have given in the past for shift workers to have the opportunity to take short naps at works, especially when working nights.

Andy Brazier