To instil Practitioner & Patient confidence .. Dr M Bloch Consultant Anaesthetist NHSG Plan: • Why? • How? • When & Where? Teams: • 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 work 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: Local Regional Systemic ‘Staying ahead of the game’ Aviation video Good Clinical Practice: • Human factors is not a substitute for technical proficiency. • High technical proficiency cannot guarantee patient safety. When & Where? All the Time & Everywhere! 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 resources. – Calling for help early enough.