Martin Bromiley is the founder of the Clinical Human Factors Group (CHFG), an independent organisation which promotes patient safety by encouraging the exploration and discussion of how human fallibility influences healthcare delivery. Through its advocacy efforts, including a series of open seminars, the CHFG aims to reduce catastrophic errors and incidents caused by human factors in the UK and around the world.
Bromiley, a pilot, was prompted to form the CHFG in 2007 after researching the ways the healthcare industry deals with errors caused by human factors — such as the ability to maintain situational awareness and to make decisions under stressful conditions — and comparing them with the protocols of another safety-critical industry: aviation. In fact, the tenets of the CHFG were inspired by the Royal Aeronautical Society Human Factors Group.
For Bromiley, the mission was personal more than professional. His research and the creation of the CHFG was spurred by the death of his wife, Elaine, who died as a result of medical errors made during what should have been a routine sinus surgery in 2005. Her airway collapsed minutes into the operation, and repeated but failed attempts were made to intubate her. Rather than perform a tracheotomy or rush her to the ICU, options passively suggested by nurses in the OR that day, the doctor spent precious time repeating the intubation efforts. Elaine suffered severe brain damage from the lack of oxygen and died 13 days later.
After pushing for an independent review of the incident — something the hospital might not have done without his request — Bromiley learned that neither the operating equipment nor the clinicians’ technical skills caused his wife’s medical emergency. Elaine Bromiley had died due to the failure of her medical team to effectively communicate with each other and to follow protocols during the crisis, but Bromiley recognised that it was not the clinicians themselves who had failed. The problem was the system which did not implement techniques for how clinicians could avoid fixation and maintain situational awareness under sudden duress (dangers which would be familiar to a pilot), as well as a lack of training and rehearsal with the equipment.
Bromiley’s initial assumption that Elaine’s death was an isolated event proved to be wrong. As he began to talk with healthcare clinicians and leaders, he realised that those who understood the importance of human factors in healthcare delivery were not coordinated and as such were unable to raise a united voice. He was soon making a list of industry insiders who were willing to meet for a formal discussion on the topic.
The CHFG is thus comprised of world-renowned experts in medicine and high-risk industries, as well as relatives of patients whose lives were impacted or ended by medical errors. Its mission is to improve safety and efficiency in clinical, managerial and organisational practices. One of its advantages is that it is not limited by bureaucracy, but rather uses its power to educate and inform within the many subcategories of healthcare, “from Board to Ward”.
On the CHFG website, Bromiley notes that despite a shared fundamental focus on safety and risk management, healthcare and aviation are not closely comparable. Healthcare, he said, lacks strong centralised regulation, and policies are disputed or ignored altogether. “The state of healthcare isn’t the result of carefully planned and focussed efforts driven by a need to maintain or improve safety; it’s the result of hundreds, even thousands of years of inertia, denial and vested interest which have created an organisation more akin to the teaching professions of old or the church,” he wrote.
According to the CHFG website, the group’s efforts appear to gradually influencing healthcare discussions in the UK and beyond, with invitations to speak at conferences and contribute to professional journals. The term “human factors” is beginning to appear in policy documents. Most importantly, people from varied backgrounds are brought together in its seminars to discuss human factors in healthcare.
Martin Bromiley’s blog can be found on the Health Foundation website at www.health.org.uk.
Reference: Clinical Human Factors Group (CHFG)
Image Credit: CHFG