Medical error for individuals, teams and systems: Martin Bromley
Summary
TLDRこのスクリプトは、講演者が航空機のパイロットとしての経験と、医療分野での活動を通じて得た教訓を共有しています。彼は、失敗を通じて学び、システムの安全性、個人間のコミュニケーション、リーダーシップの重要性を強調します。また、医療現場における「ヒーロー」のイメージと実際の課題、そしてシステムの改善が安全に寄与する例を紹介しています。最後に、個人の物語が未来の成功に向けた価値を持つことを思い出すよう呼びかけています。
Takeaways
- 😔 脚本讲述了演讲者已故妻子Elaine的故事,她在2005年因无法插管而去世,但演讲者选择不讲述这个故事,而是分享了他在医疗领域的反思。
- 👨✈️ 演讲者是一个飞行员,他强调了在紧急情况下,真正的英雄是那些冲向危险的人,即像听众一样的医疗工作者。
- 👥 演讲者提到了三个反思领域:个人、团队合作和系统与英雄。
- 🧠 他讨论了人们倾向于简单化复杂问题的趋势,以及这在医疗决策中可能导致的问题。
- 🗣️ 演讲者强调了在医疗领域中提问和倾听的重要性,以及如何通过建立共同语言来促进这一点。
- 🙏 他提倡“自信的谦逊”这一概念,即在自信地运用技能的同时,也要意识到自己可能犯错。
- 🔍 演讲者指出,医疗系统常常通过提供复杂和易出错的工具来增加错误的可能性,而不是简化流程。
- 🏎️ 通过Sid Watkins在一级方程式赛车中的例子,演讲者强调了系统安全的重要性以及如何通过系统设计来减少事故。
- 👂 演讲者呼吁医疗领域的领导者更多地倾听前线工作者的声音,以理解他们的挑战和需求。
- 👨👧👦 演讲者分享了他的家庭生活,包括他的新妻子和孩子们,他们中的一些人也对航空和医疗领域感兴趣。
- 🤝 他最后呼吁听众帮助那些可能没有能力分享自己故事的患者和家属,因为这些故事对于未来医疗改进同样重要。
Q & A
スクリプトの主題は何ですか?
-スクリプトの主題は、医療の失敗とその教訓、そして個人、チームワーク、システムの英雄についての考え方です。
スクリプトで話されているエリンの物語とは何ですか?
-エリンの物語は、2005年に彼女が病院に入院し、喉頭マスクが合わず、最終的に人工呼吸もできず意識不明となり、13日後に亡くなるという出来事です。
スピーカーは医療分野で12年間関わってきましたが、その経験からどのような3つの分野に関する反省を提供していますか?
-スピーカーは個人、チームワーク、システムとヒーローの3つの分野に関する反省を提供しています。
スピーカーが所属する航空会社での仕事と、チャーティーの活動の違いは何ですか?
-スピーカーは航空会社の機長として50%の時間を飛行に費やし、残りの50%の時間をクリンカルヒューマンファクターズグループの活動に費やしています。
スクリプトで話されている「システムとヒーロー」とはどのような関係性を持っていますか?
-「システムとヒーロー」は、医療現場で働く人々がシステムのエラーや複雑さに直面しても、その上に立って困難に立ち向かうヒーロー的な姿勢を指しています。
スピーカーが提唱する「自信ある謙虚さ」とは何を意味していますか?
-「自信ある謙虚さ」とは、自分自身のスキルと練習に基づく自信と、自分が間違っている可能性があることを認める謙虚さをバランスさせることを意味しています。
スクリプトで話されているシド・ワトキンズの事例は何を教訓として提供していますか?
-シド・ワトキンズの事例は、システムの安全性を高めるためには、システム全体の改善が必要なことを教訓として提供しています。
スクリプトで話されている「失敗から学ぶ」とはどのような意図を持っていますか?
-「失敗から学ぶ」は、失敗を恐れるのではなく、それらから教訓を得て自分自身やシステムを改善する意図を持っています。
スピーカーが提唱するリーダーシップの姿勢とは何ですか?
-スピーカーが提唱するリーダーシップの姿勢は、リーダーが最前線の状況を理解し、その状況に基づいて人々をサポートすることです。
スクリプトの最後にスピーカーが話す家族の物語は何を意味していますか?
-家族の物語は、スピーカー自身が恵まれていると感じていること、そして彼の家族が異なる形で航空業界に関与していることを示しています。
Outlines
🎤 Kevin Fongの失敗についてのセッションの続き
スピーカーは自身の故妻エレインの話ではなく、過去12年間の医療における経験について語ることを決意。個人としての視点、チームとしての働き方、システムとヒーローの役割について反省を述べる。医療従事者をヒーローと称え、その仕事に誇りを持っていると語る。また、航空機の操縦士としての体験談も交え、失敗から学ぶ重要性を強調。
🧠 複雑な状況下での失敗と感情の反応
エレインのケースをシミュレーションした結果、多くの医療従事者が同じ過ちを犯すことが分かった。人間の単純な反応と複雑な医療現場の矛盾を指摘。感情的な反応が制御を奪い、適切な判断を妨げることを説明し、当時の決定がなぜ合理的に思えたのかを理解することの重要性を強調。
🗣️ 意見を言うことの重要性
医療現場で意見を言わないことが問題であると指摘。過去のシンプルな医療と現代の複雑な医療の違いを比較し、システム内で質問を投げかけ、意見を聴くことの重要性を強調。パイロットの例を用いて、意見を交換し理解を確認する文化を育むべきだと述べる。
🏥 システムとヒーロー
システムがエラーを引き起こす状況を作り出し、最終防衛線として働く医療従事者をヒーローと称える。しかし、システムの設計を改善し、最前線の労働者と管理者の間の理解のギャップを縮める必要があると訴える。F1のシステム安全性の例を挙げ、リーダーが現場の声に耳を傾ける重要性を強調。
👨👩👧👦 家族と学びの重要性
自身の家族の写真を見せ、失敗から学ぶことの重要性を子供たちに教えていることを共有。医療現場での個々の声がシステムの成功に繋がると強調し、声を上げることを奨励。特権的な立場から他者の声を代弁する責任を感じていると述べる。
Mindmap
Keywords
💡失敗
💡医療
💡ヒーロー
💡システム
💡人因工学
💡コミュニケーション
💡リーダーシップ
💡複雑性
💡自信の持てる謙虚
💡リスニング
Highlights
演讲者分享了其已故妻子Elaine的医疗事故经历,强调了医疗失误的严重性。
演讲者提出反思过去12年在医疗领域的经验,将从个体、团队合作和系统三个方面进行分享。
强调飞行员和医护人员在面对危机时的相似性,称赞医护人员为真正的英雄。
演讲者分享了自己作为飞行员的经验和对飞行舱复杂性的描述。
讲述了一个关于飞行员在希思罗机场的幽默故事,强调了复杂性与简单性之间的关系。
演讲者介绍了自己参与的慈善组织——临床人文因素小组,及其在医疗领域推广人文因素的工作。
分享了与政治家、决策者、学者和医疗专业人员合作的经历,以及从中获得的宝贵视角。
演讲者提到自己再婚,并且新妻子是英国国家卫生服务系统中的重要人物。
提出了三个关于如何失败的教训,包括简单思维、不发声和系统问题。
讨论了人们在面对复杂情况时倾向于采取简单化思维的问题。
强调了在医疗领域中,人们需要勇于提问和倾听,以应对复杂性。
演讲者提倡“自信的谦逊”,即在自信的同时保持开放和谦逊的态度。
讨论了医疗系统中的错误倾向,以及如何通过系统设计来减少错误。
通过F1赛车的例子,说明了系统安全的重要性和系统设计的改变如何减少事故。
演讲者呼吁医疗领域的领导者更多地倾听前线工作者的声音,以缩小管理层与前线之间的差距。
分享了演讲者的家庭故事,包括家庭成员的职业和兴趣,以及他们与医疗领域的联系。
演讲者最后呼吁听众帮助那些没有能力分享自己故事的患者,因为他们的故事同样重要。
演讲结束后,观众在社交媒体上的反馈,包括对演讲者信息的认同和对医疗错误的看法。
Transcripts
[Music]
so I'm gonna follow on from Kevin Fong
session on how to fail with the second
part and I'm gonna try and make it
personal you all know the story of what
happened to my late wife Elaine she went
into hospital in 2005 she was an ephah
ties the laryngeal mask and wouldn't fit
her jaw was too tense in the end they
started to intubate
and it didn't seem to work and it ended
up as a can't intubate can't ventilate
she remained unconscious and died 13
days later but I'm not going to talk
about Elaine's story what I'm gonna do
instead is to offer some reflections on
the last 12 years that I've been
involved in health care I'm going to
offer reflections in three areas one
relating to all of us as individuals
the second relating to how we work
together and the final one is about
systems and heroes I still fly I fly
fifty percent of my working life and and
sometimes we hear pilots being talked
about as heroes perhaps they found
themselves in a situation where they
didn't choose to be but they left having
to deal with something but particularly
over the last couple of months in the UK
we've been reminded that when really bad
things happen the real heroes are the
people who run towards danger and those
are people like you and thank you for
you do because you guys are my heroes
I'm very privileged to do what I do I'm
very proud of my profession
it looks quite complex when you look at
the flight deck of an aeroplane this is
an old picture by the way I'm now a
captain for a major UK airline but this
pictures 17 years old and the reason I
like it is because I have hair and some
of you youngsters may laugh at that but
it's very important it reminds me of a
true story many years ago at Heathrow an
American pilot was doing his welcome
onboard PA to his passengers and he made
the mistake of pressing the wrong switch
and button and he ended up transmitting
instead across the air traffic control
frequency to all the aircraft that were
on the ground at Heathrow and about
halfway through his PA he realized his
error he clearly decided it was best to
fess up so he just said on the frequency
gee guys I'm sorry there's so many
switches and buttons in this cockpit
[Applause]
as quick as a flash a British voice
comes on the radio and says yes but
there's only one knob which leads me
nicely into failure but before we do
that the other thing I want to say is
that the other 50% of my life I spend
doing this sort of thing working with my
charity the clinical human factors group
simply promoting the idea of human
factors in healthcare and I've been very
lucky I've been very privileged because
in that time I've worked with
politicians of a number of countries
I've worked with policymakers have
worked with world leading academics I've
worked with all sorts of clinicians and
allied health professionals and and it's
given me I suppose a very valuable
perspective on the whole system and I
hope I can share just a little bit of
that oh and by the way I've remarried
and the lady I've married now is one of
the most powerful people in the National
Health Service
she's a GPS receptionist so 3 lessons on
how to fail on how you can fail the
first one is to think like this when I
present Elaine's story this is the most
common comment I get at the Scottish
clinical simulation centre they used to
run a city the scenario where they
present them with the lanes story they'd
all say I wouldn't have done that and
then a week later they bring the
multidisciplinary team back in and it's
a very different scenario in the
simulator it's a knife attack victim but
it deteriorates into a can't intubate
can't ventilate and you know what most
of them go down the same route has
happened in my late wife's case we're
very simple creatures and we've already
talked and heard about the amygdala and
our emotional response you know caveman
chased by woolly mammoth
and that fight-or-flight response comes
in the emotional brain takes control a
quick simple response the problem is the
world is very complex it's very messy in
all sorts of ways the world that you
work in a very messy the decisions you
have to take aren't simple when people
talk about my late wife's case they say
yeah well it was a can't intubate can't
ventilate we know what to do but the
people involved didn't know that they
were just struggling with a laryngeal
mask and some more propofol and they
were struggling and then he decided to
intubate why wouldn't you and that
becomes difficult and they they're
trying to work out what's happening
instead of saying that as an accident
investigator said to me some time ago
what people should be saying is why did
it make sense at the time
there is another brilliant way to fail
I'll let you read that
what can you say this was a colleague of
mine speaking to a group of consultants
yeah you know what this is a massive
problem people don't speak up and again
it's kind of about that the simple and
complex you know you know in Victorian
times in the 1800's health care
I would suggest was pretty simple you
had a patient you had a physician the
patient had a problem the physician
dispensed some form of intervention and
and it was probably not particularly
effective but it probably wasn't
particularly dangerous either and anyway
nobody was going to challenge the
physician the patient might have died
but that's just how it was these days
again healthcare is very complex it's
very messy you understand the fairly
complex comorbidities you you know you
dispense things to your patients which
are highly effective but probably highly
dangerous and and your patient and you
are operating in a system that you don't
really understand a colleague of mine
did a study and found that junior
doctors on their placements spent about
half their time just trying to learn to
be better doctors and about half their
time just trying to understand how the
hell things were done around here there
are so many unintended consequences of
the things you do and what we need more
than ever at the moment is people who
are prepared to ask questions and to
listen as a pilot when things go wrong
on my flight deck the first thing I want
to do is to check my understanding is to
check my thought process to turn my
colleague and say what do you think
what's happening now I might have a good
idea but maybe they've got a better idea
and actually maybe I'm wrong a colleague
of mine captain Jim Harlow spoke at a
conference last week and he came up with
this term
confident humility confidence that you
have the skills that you've practiced
and you're as good as anybody at those
but humble enough to know that you could
be wrong I was at a school last week I
was with sorry i was with some school
teachers last week and one school
teacher was describing to me his inner
city school and the challenges they had
and he said you know a lot of our
children don't have the confidence to
speak up in class so we give them
certain stop phrases to use for example
i partly agree with you but now the
value of those stock phrases was that
when a student started saying that the
other students knew that they might be
struggling to say something the teachers
have learned these phrases as well the
parents have learned these phrases it's
created a common language which has
allowed people to speak up when they
need to but we still need to see so much
more of that in health care we need to
see people listening at all levels
whether whether you're leading a million
people or whether you're leading one
person setting the example is so
essential if we're to understand this
complex messy world that we're now in
health care has a third way to help you
fail and the good news is is that the
system is fantastic at doing this
we give you systems tools processes we
give you drugs that do different things
in similar packaging and we just hand it
to you and expect you to get on with it
we give you things that make it hard to
get it right and easy to get it wrong
and this is where we get the problem
about kind of systems and heroes because
you're you are heroes in what you do and
you will you know you you can cope you
can deal with all this stuff it doesn't
matter how busy how tense it is you're
still going to go and grab those drugs
from the cupboard or whatever and just
get on with a job but the problem is
you're at the tip of that triangle all
the time by doing that and then what we
do is we give you all these tools and we
say be careful double-check don't get it
wrong we give you the error prone
situation and we expect you to act as
the line of defense
you should really only be the final line
of defense and when it comes to thinking
about systems the best example I can
think of is Professor Sid Watkins
he was the chief medical officer of
Formula One he's passed away now but I
was very lucky a few years ago to spend
some time with him and chatting to him
and listening to his reflections on the
death of Ayrton Senna his great friend
and great racing driver Senna died
almost 25 years ago in a Formula one
crash in the 25 years previous prior to
that an average of one driver a year had
died in an accident in Formula One after
Senna's death in the almost 25 years
since only one person has died I believe
in a Formula one related accident that's
an amazing achievement what Sid didn't
do
was he didn't go to the racing drivers
and say hey you're heroes so just take
it easy be a bit more careful slow down
he knew that wouldn't work what he did
do though was he started to campaign for
subtle changes in track design campaign
for subtle changes in car design he
started to look at the rules that the
governing body had and he started to
standardize the medical facilities of
Formula one tracks that's a lesson in
system safety brought you not from a
pilot but from a doctor and this picture
by the way reminds us of another dilemma
that you know in Formula One people like
Sid when he was doing this and the team
principals and the manufacturers you
know they have a really good
understanding of what work is like at
the front line they understand what
their drivers are going through if you
like workers done and workers imagined
by the leaders there is negligible
difference but in health care with the
complex ways that health care is
developed we have a massive gap between
what things are like at the frontline
for you and how things are a managed
imagined workers imagined and we need to
reduce that gap and it comes back to
this listening we need our leaders to
listen not to comment but to listen and
understand and that's something all of
you can do more of and it's something I
desperately want our leaders to do more
of and I will continue to work for that
yeah this does the rounds on social
media every so often doesn't it and and
I don't know where it came from but I
love it it's true you know my life is
like that right hand side to you that's
real life when you see success it's not
being easy we all fail but we can learn
from it they're the things that that
make us better at what we
do and I try and teach my children this
I started with the family portrait I'm
going to end with one if the slide works
so yep there's Jane my my now wife Adam
is at the front he's now 16 years old
passionate about flying and of course
computers Victoria is now 18 and she's
also passionate about flying in fact she
starts a job in a few months with a
major UK airline working on the ground
and she's just passed a driving test and
I've inherited two stepchildren through
Jane as well Jacob at the back he's
training to be an accountant but you
know but he he really sees these lessons
he's working in the head office of
another major UK airline and the other
person at the back my stepdaughter Megan
she's at the end of her first year
training to be a student nurse training
to be nurse not training to be a student
and she's taken a real interest in
critical care next year she's got a
placement being offered to her in a
helicopter emergency medicine so it's
funny how things go isn't it but you
know I this picture reminds me of the
fact that I have been very lucky I've
been very privileged and you know I
never forget that that I've been able to
do something with my late wife's story
but what I want you to remember as well
when you go away from here is that there
are thousands and thousands of patients
and relatives have harmed patients who
don't have the voice that I have who
maybe they are disadvantaged in some way
through perhaps some form of mental
health issue or some form of social
situation they're in and they
not been able to share their story and
all I would ask is if you meet anybody
like that please help them please
encourage them because their stories are
just as valuable to achieving success in
the future thank you very much
thank you
once again a great privilege for us to
hear Martin speak and we're going to go
over to Twitter to see if we've got any
opinion outrage questions thoughts
certainly Noah raged lots of opinion
loss of support for the message I'll
survive for a lot of admiration for how
it was delivered thank you very much one
tweet reads are all paraphrase when a
senior consultant makes a mistake it's
inevitable and when a junior does it's a
mistake do we have the tendency to judge
the inevitability of error differently
depending on the person who's at the
center of them I I think we probably do
and that's really sad I think you know
very experienced people experts still
screw up but they usually have a lot
better excuses for it because they've
had years to think about it and you
haven't Minoo is so fundamental I when I
debrief in the flight deck at the end of
a flight if I've made a particular
mistake I'll always turn to my colleague
and say anything on that flights debrief
and before they get a chance to say
anything I always say by the way I know
I screwed up on this and this is what I
did and I'm very very careful I will
always take responsibility for my errors
and some of my colleagues would tell me
that's quite a lot actually but I always
do and I think that's so important we
need to use the word I when we're
talking about what we have done
[Applause]
[Music]
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