Medical error…an unbelievable story

This past year (2012) was apparently aviation’s safest year ever!

I’m not sure the same can be said for medicine. I don’t know if we have similar global data as aviation but my guess is that we haven’t made the impressive strides our pilot friends have made.  While considerable efforts are being made to improve patient safety, medical errors continue and often despite identified solutions.

I wanted to share this amazing & shocking video (see below), narrated by Martin Bromiley who is the husband of a woman (Elaine Bromiley) who died as a result of medical error during a routine surgery in the UK (around 2007). Martin is a commercial pilot and using his experience with crisis resource management, teamwork and critical decision making he sought to determine what factors lead to his wife’s death. More impressively, he developed efforts and programs within the NHS based around human factors.  Listening to Martin speak is quite remarkable and for a man who has suffered a such devastating loss, he has made an amazing effort to make medicine safer. His efforts should be congratulated and shared. Watching this video provides powerful evidence that educators must incorporate simulation that elicits stress among the participants. In medicine, we should practice scenarios where clinicians must function and make decisions in a high-stress environment. This must be implemented with caution however, as there is some emerging evidence (and another study) that when stress levels are too high, trainees may experience cognitive overload that actually inhibits learning.

2 thoughts on “Medical error…an unbelievable story

  1. Great post Andrew – very interesting and thanks also for the shout out regarding our cognitive load research!

    Martin and Elaine Bromiley’s story is a very interesting (and unfortunate one) and I think it does scream for better training. Simulation IS probably the way to go for this. What I think our research is starting to show is that by pushing a learner to the point of cognitive overload (through any of several mechanisms such as increased stress, negative emotions, too much or too difficult content) you can interfere with learning new material (i.e. encoding it in long term memory).

    I think your bottom line is correct – we need to put health care professionals in these types of situations so that they know what to do when they come up! The only tweak I would have though is to make sure we’re creating a learning environment without SO much stress that they can actually learn.

    There are lots of ways to help manage cognitive load in medical education. One paper I feel is a particularly good overview of the topic and very practical in its recommendations on ways to move forward is van Merriënboer, J. J. G., & Sweller, J. (2010). Cognitive load theory in health professional education: design principles and strategies. Medical Education, 44(1), 85–93. doi:10.1111/j.1365-2923.2009.03498.x

    I wonder if there’s an effect at the opposite end of the spectrum? i.e. can the cognitive load be so light that people aren’t activated and they don’t learn because they don’t become engaged? There is a bit of data on that from the aviation industry in the 1970’s but nothing I can find in the medical education literature! I can definitely think of some lectures I was present for that I nearly slept through because they didn’t seem challenging enough. Maybe I missed out on some learning!!

    Again, great post – really enjoying your blog! Keep up the great work!

    • Thanks for that post! I think it’s a fascinating area of study (of which I know very little). But your research brings up some interesting points – how should we best manage a high cognitive load for trainees? Is it always a good thing? Maybe it’s not…We need to know more about how trainees learn and acknowledge that may not all simulation is beneficial. Definitely stuff we don’t often consider. This is why we need this research. Can’t wait to see more of your findings, thanks James.

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