To instil Practitioner
& Patient confidence ..
Dr M Bloch
Consultant Anaesthetist
• Why?
• How?
• When & Where?
• Different equipment.
• Different education and training.
• Different perspective, pressures and pitfalls.
100,000 Americans die each year as a result of
medical errors
43,458 - motor vehicle accidents
42,297 - breast cancer
16,516 - AIDS
equivalent to a full Jumbo Jet crashing each day
over a full year
Good patient outcome by luck alone is no
longer acceptable:
It is important for the appropriate process to occur
in all interactions, including those between:
 patient and staff
 staff and staff
 the individual and the ‘systems’ within which they
How: Crisis evolution / avoidance:
active / latent factors:
• environmental
• organisational
• cultural
• individual
• team
• patient
Shared Mental Model:
Communicate appropriately & effectively
voice modulation & non-verbal communication
direct specific instructions
close communication loop
open exchange of information
• Try see others perspective when
communicating with them:
Situation Awareness:
Know what is going on around you:
‘Staying ahead of the game’
Aviation video
Good Clinical Practice:
• Human factors is not a substitute for technical
• High technical proficiency cannot guarantee
patient safety.
When & Where?
All the Time &
Conclusion: Systematic approach
• Knowledge, skill and understanding is
required to make the appropriate clinical
judgement decisions.
• Non-technical skills are also required to
optimise patient outcome including:
– Anticipating and planning.
– Appropriate team leadership.
– Effective communication & sharing
mental models.
– Maintaining situation awareness and
utilising appropriate personnel and
– Calling for help early enough.

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