The value of Human factors or non technical skills have been recognised and their use well established in aviation for over 40 years. This followed a number of airline  accidents where the root cause was found to be due to human factor related causes such as loss of situational awareness, poor communication and leadership. Consequently  HF’s training became firmly  embedded into the aviation culture and is one of the reasons why commercial  aviation has become one of the safest ways to travel.

In healthcare we have increasingly recognised the value of non technical skills and its contribution to patient safety, based on the lessons learnt from aviation. We have learnt to recognise the vulnerability of the human condition and recognising that even outstanding clinical knowledge and skills are not sufficient in itself to deliver safe patient care.

This appreciation of the value of HF’s  has been greatly aided by organisations such as the Clinical Human Factors Group (CHFG).  It is led by  Captain Martin Bromiley OBE an airline Captain whose wife Elaine sadly died in 2005 from anaesthetic and airway related causes following a routine operation. A subsequent detailed investigation found the root causes were down to HF related causes such as loss of situational awareness, poor leadership and communication. 

Following on from this Martin recognised how the lessons from aviation  where over  70% of accidents are  felt to be due to human error, could be very applicable in  helping to prevent such future tragedies occurring again in healthcare. Despite suffering such an awful loss, Martin has worked tirelessly since then  to promote the value of HF’s in healthcare and set up the CHFG to further his work.

As a result, management of the difficult airway has been greatly improved if application of these HF principles are used. Clinical skills alone may not be enough on their own  especially when the clinical situation deteriorates very quickly.  The ability to maintain situational awareness, establish clear leadership and communication and recognising and managing overload are key to dealing with a difficult airway especially when it is unexpected. 

Experience from aviation shows that understanding the “startle factor” is also  important in a fast deteriorating situation and why there can be a delay in managing a crisis. In the film  “Sully”, based on a true event, where an Airbus A320 suffers a birdstrike related dual engine failure, Captain “Sully” Sullenberger, despite being a hugely experienced and competent pilot, delayed by a few seconds the cockpit crews response. This was subsequently shown to be down to the “startle factor” where there is a brief  “brain freeze” despite extensive training and practise in cockpit crises. In managing an airway crisis especially when it occurs very quickly, it is easy to imagine how there could be initial confusion and disbelief causing a significant delay in action just as these  pilots  experienced.  

Sadly despite the recognition of the value of these skills, there are still airway related serious incidents and deaths. The recognition of an oesophageal intubation is a core skill that anaesthetists learn to recognise and deal with very early on in their training as failure to recognise it will cause serious patient harm or death very quickly. The NAP 4 study from 2011 showed 11 unrecognised oesophageal intubation with 6 deaths,  and 1 resultant brain injury. 4 of these were during routine surgery. Overall there was a 64% mortality and all were considered avoidable.

More recently the sad death of Glenda  Logsdail in 2020 following an unrecognised oesophageal intubation showed this is still an issue. Analysis of the report showed the classic HF related failures including a lack of leadership, communication and loss of situational awareness.

What is a common factor with most of these incidents is the presence of a  Consultant  Anaesthetist and often 2 or more of them. Seniority and experience alone is not always sufficient, as the airline industry found out the hard way.