21 - Martin Bromiley - Turning tragedy into safer healthcare with attention to human factors (DasSMACC special episode)

Are we truly making healthcare safer?

Do we adequately understand human factors in how we work in hospitals?

How would you respond if your partner died from a "routine operation"?

These are just 3 of the questions you are likely to ponder as you listen to this interview with Martin Bromiley OBE from the United Kingdom on the Mastering Intensive Care podcast.

Whilst many people that we care for in our Intensive Care Units receive excellent care, sadly there are some who end up in our ICUs after something goes unexpectedly wrong during a routine operation. Tragically some of these people die. Not due to anything they did, but from medical error.

In the final DasSMACC special episode, I speak to Martin Bromiley, who became a widower when his wife, Elaine, died in such circumstances 12 years ago. In what has been described as "the direct result of human factors and failings in non-technical skills, created by systemic failings in the healthcare system". Martin didn't blame, shame or complain. He did his best to move forward by researching the culture in healthcare around safety and human factors. And he recognised that although there were pockets of excellence the UK's National Health Service was culturally a long way behind most other high risk industries. As a result of his experiences Martin supported the making of a DVD entitled "Just a routine operation" which explored the lessons of his late wife's death, as well as a BBC Horizon programme about human factors called "How to avoid mistakes in surgery".

Professionally Martin works in aviation where he is a pilot for a major UK airline and where he has a background specialising in human factors. Therefore, Martin founded the Clinical Human Factors Group, a non profit-making charitable trust which aims to advise and promote best practice around human factors. Since then the Group has promoted human factors at the highest levels in healthcare, making a significant contribution to current thinking. More significantly though, the terms human factors and system safety are becoming much more commonly understood in healthcare, much of which is due to Martin's efforts and leadership. His work has been recognised through awards from the Royal College of Anaesthetists, the Difficult Airway Society, and the patient support group "Action Against Medical Accidents". In the 2016 New Year Honours list Martin was awarded an OBE for his work to further patient safety.

Martin was a speaker at the DasSMACC conference in Berlin back in June, and after delivering an enthralling talk entitled "How To Fail", we went to a quiet room to record an interview. We had an important conversation and touched on:

• The tragic case of Elaine and her death after a routine operation
• How Martin dealt with it
• What support Martin received in and out of the hospital
• What Martin has been doing to try to improve safety in healthcare
• What healthcare can and cannot learn from the aviation industry
• His 3 key messages about human factors
• How he uses mental rehearsal to be the best airline pilot he can be

This podcast is my quest to improve patient care, in ICUs all round the world, by inspiring all of us to bring our best selves to work to more masterfully interact with our patients, their families, ourselves and our fellow healthcare professionals so that we can achieve the most satisfactory outcomes for all. Please help me to spread the word by simply emailing your colleagues, posting on social media or rating and reviewing the podcast.

Feel free to leave a comment or a question on the LITFL episode page, on twitter using #masteringintensivecare, on the Facebook "mastering intensive care" page or by sending me an email at andrew@masteringintensivecare.com.

Please also consider making a donation to the Clinical Human Factors Group here.

Thanks for listening. Please do the very best you can for your patients.

Andrew Davies

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Links related to Martin Bromiley

Martin Bromiley

Martin Bromiley on Twitter: @MartinBromiley

Martin Bromiley on LinkedIn

Clinical Human Factors Group

Donations to Clinical Human Factors Group

Video "Just a routine operation"

Video "How to Fail…Part Two" (a talk by Martin Bromiley at DasSMACC conference)

Video "Martin Bromiley, a Patient's Perspective" (talk by Martin Bromiley at Patient Safety Movement)

Anonymous version of an Independent Report on the death of Elaine Bromiley

Article "The husbands story: from tragedy to learning and action" (authored by Martin Bromiley)

Article "Clinical Human Factors" (co-authored by Martin Bromiley)

Article 1 on Martin Bromiley

Article 2 on Martin Bromiley

Article 3 on Martin Bromiley

Article "Lessons from the Bromiley Case" (by Mike Cadogan on Life In The Fast Lane)

Links to other resources (in order of mentioning)

SMACC

TED

Book "Black Box Thinking" (by Matthew Syed)

Paper on the Safety 1 and Safety 2 model

Second paper on the Safety 1 and Safety 2 model

Third article on the Safety 1 and Safety 2 model

Jim Harlow on Twitter

Links related to Mastering Intensive Care podcast

Mastering Intensive Care podcast

Mastering Intensive Care page on Facebook

Mastering Intensive Care at Life In The Fast Lane

Andrew Davies on Twitter: @andrewdavies66

Andrew Davies on Instagram: @andrewdavies66

Andrew Davies on LinkedIn

Email Andrew Davies