Theatre Cap Challenge

Student midwife Alison Brindle discovered a way to introduce #humanfactors into #healthcare with her #TheatreCapChallenge The repercussions could save hundreds of thousands of lives - please read the attached post. Thank You to Alison Brindle.


Theatre Cap Challenge

By the 'repercussions' the post itself, when you read it, implies that the initiative will help drive human factors understanding and interventions into healthcare.

There is a big problem with patient safety. Medical error has been reported as the third greatest cause of death with hundreds of thousands of deaths per year in the US (see http://www.bmj.com/content/353/bmj.i2139). Human factors input is crucial to address this.

Names on caps and the #TheatreCapChallenge can help deal with one latent safety threat and hopefully raise consciousness & provide a springboard to try and address others.

Healthcare often relies upon people focussed interventions for patient safety. Human factors experts understand how these are relatively less effective than system interventions.

These are some issues I'm working on. I've little doubt here are many many more.

As far as displaying names and roles itself goes as a human factors solution:

It's obvious that people displaying names and roles will improve recollection of names and roles. It's also obvious that the WHO was sufficiently concerned about the impact of an inability for staff to know names and roles to put this on the the surgical safety checklist.

There are good studies which describe human limitation particularly when it comes to remembering names.

Many of us don't like accepting our own human limitation - this in itself can have significant impact on patient safety.

Further there are good studies indicating those with the greatest influence may be the worst for accepting tools to improve communication in theatre. https://www.radionz.co.nz/news/national/315615/surgeons-more-resistant-to-improving-teamwork-study

Perhaps a good way to approach this scenario is to flip it. If we were already displaying our names and roles what evidence would be required for us to stop doing this.

I'm putting together a collaborative group to quantify the effect of staff identification - if interested your input will be gratefully received.

Displaying your name and role is not going to be worse for patient care. It will be better. It takes no effort on your behalf - in doing so it sends a strong message to others - I am prepared to change and support an environment and culture which welcomes positive change for patient safety. This culture won't appear on its own.

Patients are dying from medical error. We can reverse this and you can help.

I accept that change is difficult, and many of my colleagues will be perturbed by what I am doing - some understandably find it offensive. Who would dare say to their healthcare colleagues that they aren't prepared to provide the best environment for patient care. Each time we make a change we pretty much go through this process. Wearing a hat with and role on does just that. Having been sat in a room and threatened with expulsion and bullied by senior staff for trying to drive other obvious patient safety initiatives I'm acutely aware of how hierarchies will go to extreme lengths to stifle change.

There are many many more changes required for safety to improve - in current healthcare culture we struggle to welcome even the simplest.

I hope you will see that my intentions are honourable and solely in the interest of patient safety. I also hope you might consider doing what is intuitively best for patient care.

Semmelweis didn't have access to the internet and social media, nor was it obvious who had washed their hands. When you support this change for patient safety it's obvious - for those who do you have my utmost respect because I can see what it has the potential to lead to.


Source: Rob Hackett, www.psnetwork.org


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The Operating Theatre Journal, OTJ, is published monthly and distributed to every hospital operating theatre department in the UK. The distribution includes both the National Health Service and the Private Sector.

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