Tag Archives: human error

Story#20 Dirty Dozen, Titanic and Mr Bean

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Reading time 5 minutes   

Background

Human factors are commonly found to be the underlying reasons behind most aviation accidents and are famous as dirty dozen. As an ED and pre-hospital physician, we interact and work in flash teams all the time in extremely high risk circumstances. But can we train our selves to minimise these risks? Lets watch how Bean copes with stressful situations.

Bean = You(just assume)

Going Downstairs = Procedure

Lady = Check list

 

Elderly Man = Complication

Story

Its 0645 and only 15 minute to handover. What has been a very challenging shift for resus staff, they just have to sort one last patient out.

It is a 71 year old bradycardiac man with a heart rate of 30/min. Except feeling light headed on standing up, he is otherwise asymptomatic. His BP is 144/77, SpO2 98% on air & RR 18/min. His PMhx includes hypertension and ischaemic heart disease for which he had CABG 2 years back.

The ECG shows Mobitz type 1 heart block. While awaiting cardiology review, doctor decides to give 0.5 mg of atropine to record the response. While the nurse is getting atropine out, she notices patient goes pale and unresponsive. ECG shows asystole.

Call for help is given and the team starts CPR. The doctor leading the arrest says to  the nurse  ” What took you forever to give atropine”. He then tells her to give adrenaline 1 mg. A bit shaken, she carries on giving the drug.

ALS is carried for 2 minutes. On next rhythm check, patient is still in asystole. CPR is resumed. Doctor asks the nurse again to prepare adrenaline for the next cycle.

On the next rhythm check, patient has an organised rhythm and a pulse of 28. Blood pressure is 110/60. The doctor says to the nurse in rather impudent tone ” now give it(atropine) before he arrests again”. She gives 10 ml of 1:10000 adrenaline instead. The patient arrests and CPR is unsuccessful.

The nurse later tells that she knew doctor meant atropine but in a rush gave the mini jet of adrenaline that was in her hand.

The doctor said he had issues with this nurse as she was not prompt and he had to carry out most of the treatment himself for the patient. He couldn’t remember if he wasn’t clear enough in asking for atropine post ROSC/

Other team members felt there was no coordination in team. They also felt that busy shift meant they couldn’t get their breaks properly and everyone was tired. They also had few sicknesses which led to current staffing level being dangerously low.

Do you smell dirty dozen? 

 

Moral

Here is a 2 min clip from Titanic about all 12 factors in dirty dozen.

 

And now watch the true story of Elaine Bromiley who died as a result of attempted routine sinus operation that when horribly wrong..

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