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Tuesday, January 8, 2008

I had failed my first test of leadership: Tracheotomy error

Dr. Gerald Healy's story
When I was a young surgeon, one of my patients nearly died and I was responsible. The incident had nothing to do with my surgical skills and everything to do with my lack of leadership.

The patient's airway was obstructed by a massive tumor and he needed an emergency tracheotomy. Flush with confidence from five years of surgical training and two years in the military, I could foresee no problems that I couldn't handle. Why bother going over my plan of care with the nurses or the anesthesiologist?

Just as the patient was being prepped for surgery, he went into cardiac arrest. The anesthesiologist, inexperienced in the procedure, was helpless to reestablish an airway. The regular nurses were unavailable, and their hastily selected replacements had never worked together in the operation suite on this procedure. I found myself marooned, shouting a flurry of commands at a team too paralyzed to act.

In the end, I was able to open an airway by performing a tricky and dangerous throat operation, and then restore our patient’s heart function. I helped save him but I was no "hero." The untenable situation I had faced was largely of my own making. I had neglected to evaluate the skills of my team, prepare the team members, and plan for contingencies. I had failed my first test of leadership.

Medical errors are often caused by a lack of communication, inattention to details, poorly coordinated resources, and inadequate planning. While we surgeons are trained to be outstanding technicians, little has been done to teach us effective leadership and communication skills.

Commercial airlines excel in safety. Flight crews have learned to make fewer errors, due to a leadership and team training approach called "crew resource management."

Dr. Healy is otolaryngologist in chief at Children's Hospital in Boston, professor of otology and laryngology at Harvard Medical School, and President of the American College of Surgeons.

Browse for related stories in the index at the very bottom of this page, or read a sadder story by a crew resource management expert.

Thanks to Dr. Healy for the source article in today's Boston Globe.

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