Woodstock in Kissimmee: IHI's National Forum Leadership Summit

In November 2000, a very pregnant woman entered a Boston teaching hospital to have her labor induced. "Suzanne" experienced a series of medical errors that resulted in the loss of her fetus and the rupture of her uterus. This required a hysterectomy and an 18-day stay in the surgical intensive care unit.

Five months later, after the insurer, Harvard's Risk Management Foundation, had settled with the family, and after the hospital's public apology, RMF approached the hospital, asking them to adapt Crew Resource Management to safeguard obstetrics. Physician leaders did so. In fact, the medical staff was so successful at bringing this form of team communication to the Obstetrics unit that the number of high-severity adverse events fell by 62%.

This is a case in point of how tragedy can sometimes ultimately lead to improved patient safety. That may not happen often, as it requires brave and dedicated leaders at the top and middle levels of a hospital, and a particular type of dedication by clinicians. Most hospitals lack leaders like Jim Reinertsen, Paul Levy, and Stephen Pratt. Their leadership was key and their receipt of the John Eisenberg Award was well deserved.


Two weeks ago, at the National Forum of the Institute for Healthcare Improvement near Orlando in Kissimmee, Florida, I had the pleasure of meeting Paul Levy and Dr. Pratt, and seeing Dr. Reinertsen again. Along with the heads of the Cautious Patient Foundation, Paul had charmed his fellow hospital CEOs into sponsoring 50 patient activists from around the country to participate in the Forum. I was one of the lucky ones who'd been chosen to attend the Leadership Summit.

For we patient advocates, it was our Woodstock, a mass intoxicating love-in that convened widely scattered like-minded young-at-hearts who are critical of the Establishment. I expect to tell many of our intense and redemptive stories in this blog over the next few months. Many of us hope to turn our tragedies into improvements as solid, life-giving, and lasting as the use of CRM in Obstetrics.

I'd like to salute the leaders of Boston's Beth Israel Deaconess Medical Center, and the doctors who joined us in the Leadership Summit, including some who have harrowing stories as patients: Carl Flatley, Julia Hallisy, Kevin Kavanagh, Gil Mileikowsky, Cari Oliver, Kavita Patel, and Stephen Pratt.

Read another crew resource management story, or read Stephen Pratt's article of Dec. 2007 in the Joint Commission Journal on Quality and Safety.

Advice from a Pilot-Widower - Choosing your surgical team: An anesthesia error

Martin Bromiley is an airplane pilot, the father of two young children. His deceased wife Elaine had long suffered from chronic sinusitis, an inflammation of the nasal passages. Then, early in 2005, one of her eye sockets had become infected. The threat of permanent damage to the optic nerve led her surgeon to recommend a minor operation to straighten the inside of the nose - a possible contributory factor.

Unfortunately, during the operation, she was deprived of oxygen. It appears that moments after being sedated, Elaine's airway collapsed, preventing adequate levels of oxygen from reaching her brain. Though potentially an emergency, the event is a recognised risk during an anaesthetic and, as such, should be manageable. Surgeons and anaesthetists are drilled to follow a series of steps at this point - beginning with a non-invasive attempt to get the patient breathing normally, and ending, as a last resort, with an emergency surgical procedure. This is usually a tracheotomy - where the surgeon cuts through the windpipe, inserting a tube directly into the airway through the throat.

At first the drill was followed impeccably. But then a problem arose: the surgical team tried to get a tube into the airway to help Elaine breathe, but encountered some kind of blockage. According to the drill, this was the time to consider doing a tracheotomy. But the three physicians appear to have made the sort of human error that is horribly common in crisis situations. They became fixated on what they were doing. They also appear to have ignored the junior staff and remained intent on finding a way to insert a tube into the airway. More than a half hour passed before adequate oxygen levels to the brain were restored. Significant brain damage resulted, and she died less than two weeks later, soon after life support was withdrawn.

As a pilot, Martin Bromiley had received the standard training in open communication in the cockpit. Indeed, he is a specialist in this "Human Factors" field. He realizes that "Fixation is a normal reaction to stress. Human Factors training teaches people that it's normal to carry on trying to take the usual action, even when it's clearly not working. But at some point, a decision has to be made to break out of that pattern of behaviour. The way to ensure that happens is for all members of the team to see it as their duty to speak out to keep the patient safe." There was no comfort in knowing that two of the nurses knew how to save his wife's life. "What they didn't know - and what Human Factors [also called in the U.S., Crew Resource Management or Crisis Resource Management] would have taught them - is how to broach the subject with their bosses."


Lesson for Caregivers: Before surgery, verify that the surgical team has been trained so that the surgeon will open-mindedly consider urgent input from nurses and junior doctors. Do this in advance by asking the Risk Manager of the hospital whether the surgical team has been trained in Crisis Resource Management, Crew Resource Management or similar candid team communication techniques. If not, consider scheduling the surgery at a different hospital.


The whole story is told by blogger John Ray, and by Jane Feinmann in the newspaper article "Blunder that Killed my Wife."