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I'm Dr Kevin Fong.

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And in the last few decades, I've
seen the operating theatre
transformed

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by revolutionary
advances in science and technology.

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They've made open-heart surgery
like this seem almost routine.

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So in unexpected emergencies, the
weakest link in the room isn't
usually the drugs,

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or the equipment...

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..it's us.

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The surgical team.

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And that's because under pressure,

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doctors and nurses, like
everyone else, make mistakes.

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In fast-moving situations,
we are horribly fallible.

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Our brains default to patterns of
behaviour that let us down

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at the crucial moment.

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And so the question becomes this -
is there anything at all that we

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can do to better prepare ourselves?

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Is there anything in those
catastrophic moments that we

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can do to give ourselves
a fighting chance?

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This is a life-or-death problem.

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Everyone in medicine realises that
avoiding mistakes

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is crucial to saving lives.

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This is University College Hospital
in London.

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It's where I work and
went to medical school.

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Since I qualified 15 years ago,
we've got much more in the way of
science

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and technology to
protect our patients.

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Over the years, our expectations of
medicine have changed dramatically.

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Things that were once fatal
are now commonly survivable.

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'But despite all of this, very
rarely, unexpected
life-and-death emergencies

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'can still occur and threaten lives.

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'And doctors are only now beginning
to understand the crucial

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'role of simple human error.

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'And there's one case that's struck
a chord with me as a doctor.

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'It's got vital lessons for all of
us in medicine about how

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'we make life and death decisions
under extreme pressure.'

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Elaine Bromiley was 37 years old

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when she came in to a private clinic
for a routine sinus operation,

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on the morning of the 29th March
2005.

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There was nothing out of the
ordinary as the anaesthetist
prepared her for surgery.

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She'll be falling asleep now.

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That's it.

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Part of this process is called
intubation,

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which involves placing a tube into
the patient's throat to allow them
to breathe.

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But out of the blue,
a severe problem arose.

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I'll have the laryngoscope, please.
And the ET tube.

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Elaine's airway - the route
through her mouth and throat to
her lungs - became blocked.

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It's an event that happens in as
few as one in 50,000 routine
anaesthetics.

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Calling in another anaesthetist
didn't help.

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No matter what they did,
they couldn't intubate her.

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Elaine couldn't breathe.

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Can you see anything?

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An ear, nose
and throat surgeon then stepped in.

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It's difficult.
Can you see anything?

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He also tried...but failed.

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25 minutes passed, and
the situation became critical.

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There was an alternative solution
which could have made a difference,

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but they just couldn't see it.

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The sats are really low.

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The pressure of the situation was
so intense...

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The sats are really low.

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..that their decision-making had
become fatally compromised.

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Inflating? Yeah, inflating. Thank
you.

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Starved of oxygen, Elaine was left
in a coma...

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and died 13 days later.

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That's very difficult to watch. And
it leaves you with mixed feelings.

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Reflexively, you want to know
what went wrong

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and how to stop it happening again.

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But as a doctor, you watch it unfold

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and it leaves you with
a sense of deep unease,

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because you think, "there, but for
the grace of God, go I".

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And it's not just me.

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Every doctor I know has asked
themselves

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how they'd cope
in the same situation.

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Working out what we can do about
this is really a human, rather than

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a medical problem, requiring
radical new ways of thinking.

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So I'm leaving the operating
theatre behind

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to find out how other professions
deal with making

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life-and-death decisions in
fast-moving emergencies.

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Come back!

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From discovering new ways the fire
service are fighting fires...

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Rotate.

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..to how a simple piece of paper
removes human error in the
high-pressure cockpit

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of our most complicated
modern passenger aircraft...

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That's er, engine two fire.

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..and getting to grips with
the ingenious strategies that
pit-crews employ

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in the fast-moving,
technically demanding,

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highly dangerous world of
Formula One.

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But my quest to deal with the
life-threatening problem

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of human error in medicine starts in
the most unlikely place - a casino.

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MUSIC: "Rocks" by McFly

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# Dealers keep dealing, thieves keep
thieving, teasers keep teasing, holy
joes are preaching... #

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I've been told that watching how the
cards fall could provide some

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unexpected insights into why
we make mistakes under pressure.

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This is Professor Nilli Lavie.

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She specialises in a field
of psychology called load theory.

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And she tells me she can change
the way

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I think about surgery by putting me
through a simple test.

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Well, let's see.

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So, Kevin. Here is the test.

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So that's two different, one
different, five different,

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'All I have to do is
tap my hand on the table

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'when I see two cards together
that are different by five.'

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Zero, one - five different.

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That's four, that's four,
that's five.

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Well done. You beat me to it.
Very well done.

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OK, I think he's ready for the
actual test.

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'It might look simple, but the speed
the cards are dealt at forces me

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'to concentrate extremely hard.

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'And while I'm counting cards...

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'..Nilli is monitoring something
else.

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'Crucially, she decides
exactly when the test is over.'

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OK. Oh, gosh!

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OK. Um...right.

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That was quite bad.

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How long do you think this took?

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Er...dunno.

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It was about 10 seconds worth
to about 15 seconds, probably.

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It actually took 25 seconds.

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What, er...I mean
I was out by almost, what?

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A factor of two, there. Yeah.

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So that's quite terrifying, really.

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'Professor Lavie has discovered
that if one part of your brain

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'is overloaded by concentrating
on a single task or activity...

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'..its capacity to accurately
monitor other things, like the
passage of time,

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'is severely compromised.

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'It's what the experts call
"losing my situational awareness".'

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So it's a zero sum game, right?

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Either I can focus on the task
or I can monitor the time,
but I can't do both.

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You can do both, but one will
be at the expense of the other.

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Right. I mean, that's pretty trivial
in this context,

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but terrifying, terrifying for
medical practice.

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'This simple card test has been
a revelation to me.

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'Until now, I just wasn't aware
that our powers of reasoning could
be so easily overloaded.'

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That's the problem.
We are wired up to fail.

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We have a finite ability to cope
with complex information.

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And avoiding the traps that come
with that is not about being smart.

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It's not about your intelligence.

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It's about accepting your
limitations

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and designing strategies
that are going to allow you to cope.

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Back!

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Fires are unpredictable
and clearly, extremely dangerous.

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Because of this, the fire service
face many of the same

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challenges that doctors do
in medicine.

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So at this huge converted
airfield in the Cotswolds,

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they run a variety of training
exercises.

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They have everything here
from motorway pile-ups

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to crashed planes

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and even derailed trains.

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And a crucial part of the training
is designed to help fire crews

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maintain their situational
awareness.

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When you think about what fire crew
do on scene, it involves

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juggling two very
different priorities.

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The first involves search
and rescue,

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pulling people
out of buildings like that.

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But the second is monitoring
the constant threat

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from the environment around you.

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Now getting that right,
switching between those two tasks,

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is far from easy.

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But to get it wrong
is to invite catastrophe.

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Because losing situational
awareness is so dangerous,

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the fire service sets up
specific exercises,

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to give commanders and
crew the skills to cope

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with fast-moving situations.

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A testing scenario
for the training crew today.

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This represents an oil platform
with a helicopter

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that's caught fire during
a refuelling accident and exploded.

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Now, over here on the ground,

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is a casualty that they're going
to have to rescue

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so there's plenty to focus on here.

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Plenty to keep the crew occupied.

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But here's the thing -
the wider picture,

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the thing that's going to take it
all out of their hands, is up here.

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This is a propane store
and if it gets hot enough

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it's going to explode, take out the
liquid petroleum gas canisters here

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and incinerate everything for
the surrounding 200 or 300 metres.

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The man under the microscope
in the exercise

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is trainee
Incident Commander, Simon Collyer.

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So helicopter's coming in,
refuelling. Ignition source.

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He's in charge of all
the decision-making.

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OK, folks, listen in.
I want you to do a live attack.

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Two of you on foam,
two of you, casualties.

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Snatch rescue, please, as quickly as
possible under cover from these two.

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ASAP, hurry up.

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Naturally enough, given the
pressures of the situation,

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he's decided to rescue the casualty
hidden behind this oil drum

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as quickly as he can.

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Watching on is instructor
Gavin Roberts.

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They should be doing something
with these cylinders.

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They're getting warm now.

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Once they fail,
it can be catastrophic.

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But the Incident Commander is so
focused on rescuing the casualty

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that he's lost his situational
awareness

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and that's going to put
his whole crew in danger.

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Get back. Get back.

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When the acetylene cylinders go off,

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he has to evacuate the entire rig.

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And in the real world,
some of his crew could have been

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seriously injured or killed.

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In hindsight,
I think I got far too close in.

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Far too involved with and carried
away with the immediate threats

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I could see and I didn't observe
the big picture and the key threats.

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In hindsight, acetylene
cylinders are very unstable.

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Heat, not a good combination.

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The consequences could have
been quite bad.

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If you had a similar incident again,
would you approach it differently?

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Oh yeah, very much so.

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I think I should certainly have
made a bigger step back,

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looked at the big picture,
taken some time out

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and I think that would have really
made it much clearer to me

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about the potential risk there and I
could have taken appropriate action.

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This kind of training
goes on all year round.

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It's so successful that fire crews
from all over the world

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come here to learn
from our fire service.

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I think there's something hugely
important here.

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00:17:01,080 --> 00:17:04,640
If you were looking for a general
theory of how to deal with

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life-threatening risk, then
this would be a huge part of it.

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That thing that the fire service
teach explicitly,

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that ability to focus on a
life-saving task, all the while

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00:17:15,280 --> 00:17:20,280
maintaining an awareness of the
greater situation, is all important.

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And it's something that
in the operating theatres

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could make all the difference.

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OK, Mrs Bromiley, I'm going to
give you something to relax you.

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And then, after that, we're going
to put you to sleep.

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It all sounds simple
enough in theory...

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Just looking for the cords.

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..but in practice,
it's extremely difficult,

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as the doctors in Elaine Bromiley's
case discovered.

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I see the voice box.

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A report into her death revealed

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they had lost
their situational awareness.

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They became so focused on trying to
establish an airway

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through the mouth to allow Elaine
to breathe...

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..they might have overlooked
other possibilities.

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Still can't see anything.

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It's easy to be wise in retrospect.

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Everything looks better,
clearer, with hindsight.

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There are so many things that could
have been improved upon

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00:18:38,600 --> 00:18:42,440
in that operation, so much that
could have gone better.

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But where do you start?

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How do you go about giving yourself
a better chance in the future?

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And, as strange as it may sound,

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that process begins with a piece
of paper that looks like this.

241
00:19:05,280 --> 00:19:08,840
Surprisingly, it was in places
like this, that the power

242
00:19:08,840 --> 00:19:13,680
of a simple slip of paper helped to
improve safety in civil aviation.

243
00:19:23,680 --> 00:19:27,080
These machines are the latest
in flight simulators.

244
00:19:31,480 --> 00:19:35,040
And every commercial pilot
in the country has to undergo

245
00:19:35,040 --> 00:19:36,840
regular training in one of them.

246
00:19:45,320 --> 00:19:49,120
Guy Hirst was a senior airline pilot
for over 30 years.

247
00:19:53,160 --> 00:19:57,000
And he's used that experience
to train over 1,000 new pilots.

248
00:19:59,720 --> 00:20:03,920
So he's got unique insight
into how a simple piece of paper,

249
00:20:03,920 --> 00:20:06,560
known as a checklist,
makes flying safer.

250
00:20:10,360 --> 00:20:13,120
And it all starts on the flight deck

251
00:20:13,120 --> 00:20:15,240
before the plane
even gets into the air.

252
00:20:17,520 --> 00:20:20,520
So you agree that, Kevin,
and I would make the responses,

253
00:20:20,520 --> 00:20:23,160
so we're just confirming that
everything is in the right place

254
00:20:23,160 --> 00:20:24,200
before we take off.

255
00:20:24,200 --> 00:20:27,480
OK, I'll start from the top
and work down, so flight controls.

256
00:20:27,480 --> 00:20:30,240
They're checked. Transponder?
T-A-R-A.

257
00:20:30,240 --> 00:20:32,800
Loadsheet? That's received.

258
00:20:32,800 --> 00:20:35,560
Flaps? Flaps one set.

259
00:20:35,560 --> 00:20:37,000
It says on there.

260
00:20:37,000 --> 00:20:39,400
Trims? Are set.

261
00:20:39,400 --> 00:20:43,320
Vital data? Vital data is received.

262
00:20:43,320 --> 00:20:46,720
ECAM memo. Take off and clear.

263
00:20:46,720 --> 00:20:48,360
And that appears to be that.

264
00:20:50,240 --> 00:20:52,640
And this is the stuff within
the realms of human error?

265
00:20:52,640 --> 00:20:55,080
We could set any of these switches
to the wrong thing

266
00:20:55,080 --> 00:20:57,320
and this is our last chance to
get that right?

267
00:20:57,320 --> 00:21:00,360
Absolutely right. Correct.
That's good to know.

268
00:21:00,360 --> 00:21:02,360
Well, I think,
given that we sorted that out,

269
00:21:02,360 --> 00:21:04,400
I wouldn't mind going flying now.

270
00:21:11,360 --> 00:21:14,160
It is impressive how
realistic that view is.

271
00:21:20,480 --> 00:21:22,560
So we're clear for take off.
Here we go.

272
00:21:25,560 --> 00:21:28,600
'Even during take off,
checks are still being done.'

273
00:21:30,920 --> 00:21:32,920
Engine stable. Check.

274
00:21:34,080 --> 00:21:36,080
100 knots. Check.

275
00:21:38,040 --> 00:21:39,760
Rotate.

276
00:21:48,480 --> 00:21:51,360
Gear up. Gear up. Yeah.

277
00:21:52,560 --> 00:21:54,760
And now we're flying up.

278
00:22:09,440 --> 00:22:11,880
I'll probably put
the autopilot on now so we can talk,

279
00:22:11,880 --> 00:22:14,520
which will be that one there.

280
00:22:14,520 --> 00:22:16,000
And that's it.

281
00:22:24,440 --> 00:22:30,160
'But why bother? How do checklists
make flying safer?'

282
00:22:30,160 --> 00:22:33,000
To be blunt, we all have bad days,
when we need reminders.

283
00:22:33,000 --> 00:22:37,280
The human memory's frail and we need
things like checklists to make sure

284
00:22:37,280 --> 00:22:40,880
that the very vital things keep us
on the straight and narrow.

285
00:22:40,880 --> 00:22:42,560
CONSOLE BEEPS

286
00:22:42,560 --> 00:22:46,200
Oh dear, that's, um,
a master warning.

287
00:22:46,200 --> 00:22:47,600
Engine two fire.

288
00:22:47,600 --> 00:22:49,640
OK, selecting 350.

289
00:22:49,640 --> 00:22:52,080
'Flying was once a much
riskier business.'

290
00:22:52,080 --> 00:22:53,920
Confirm that's the number
two thrust lever.

291
00:22:53,920 --> 00:22:56,360
That is the number two thrust lever.
We're closing that.

292
00:22:56,360 --> 00:22:59,400
'But now, thanks in no small part to
the power of checklists,

293
00:22:59,400 --> 00:23:02,880
'it's become routine
and a lot safer.'

294
00:23:02,880 --> 00:23:06,080
And agent two squib, correct?
Correct.

295
00:23:06,080 --> 00:23:08,720
Excellent.

296
00:23:08,720 --> 00:23:12,040
'And that's helped to change our
whole experience of flying.'

297
00:23:15,040 --> 00:23:17,880
You've only got to go to one of
the major international airports

298
00:23:17,880 --> 00:23:21,120
and the number of flights happening
every hour and multiply

299
00:23:21,120 --> 00:23:24,200
that by the number of cities in the
world, it's extraordinarily safe.

300
00:23:24,200 --> 00:23:27,600
The difficult bit, the dangerous bit,
is getting to the airport.

301
00:23:29,920 --> 00:23:33,880
Well, that was fun, but the way they
use the checklists in that cockpit

302
00:23:33,880 --> 00:23:36,560
is really impressive.

303
00:23:36,560 --> 00:23:39,400
But does it tell us anything about
what we should do in healthcare?

304
00:23:39,400 --> 00:23:41,520
How it helps us in hospitals?

305
00:23:41,520 --> 00:23:44,120
To answer that question
I'm off to London to talk to

306
00:23:44,120 --> 00:23:47,320
one of the world's busiest
and most celebrated surgeons.

307
00:23:55,680 --> 00:23:57,880
This is Dr Atul Gawande.

308
00:23:59,960 --> 00:24:02,800
He's one of America's
best-known doctors

309
00:24:02,800 --> 00:24:05,440
and just after graduating from
medical school,

310
00:24:05,440 --> 00:24:08,920
he worked as Bill Clinton's
healthcare lieutenant.

311
00:24:08,920 --> 00:24:11,880
He's now a surgeon
and professor at Harvard University.

312
00:24:19,440 --> 00:24:23,920
His schedule's so crammed he could
only find time to chat with me

313
00:24:23,920 --> 00:24:27,400
in a cab as he travelled to
the House of Lords for a meeting.

314
00:24:40,120 --> 00:24:43,440
He's so busy because he's leading
a revolution in medicine

315
00:24:43,440 --> 00:24:47,120
that started with a simple
yet shocking study.

316
00:24:51,720 --> 00:24:55,840
We did a study in 28 hospitals
across the United States

317
00:24:55,840 --> 00:25:00,640
and found that the major reason
people either die or are disabled

318
00:25:00,640 --> 00:25:05,240
after surgery involved problems
that we were not ignorant of.

319
00:25:05,240 --> 00:25:09,600
We actually knew the answers
but we didn't execute on them.

320
00:25:09,600 --> 00:25:13,320
And so what we wondered,
if you looked at other industries,

321
00:25:13,320 --> 00:25:15,400
aviation, what do they do?

322
00:25:15,400 --> 00:25:17,400
Well,
they train people for a long time,

323
00:25:17,400 --> 00:25:21,960
they get very specialised technology
and they have this one other thing.

324
00:25:21,960 --> 00:25:23,400
They have checklists.

325
00:25:25,040 --> 00:25:28,200
'So with the encouragement
of the World Health Organisation,

326
00:25:28,200 --> 00:25:31,480
'he drew up a series of surgical
checklists like this one.'

327
00:25:34,880 --> 00:25:38,000
They were introduced in selected
hospitals around the world

328
00:25:38,000 --> 00:25:40,120
and the results were startling.

329
00:25:42,720 --> 00:25:45,440
So we tested across eight
cities from London here

330
00:25:45,440 --> 00:25:51,440
in St Mary's Hospital to Toronto to
New Zealand but also poor hospitals.

331
00:25:51,440 --> 00:25:56,040
Tanzania, India. In every hospital,
it cut the complications.

332
00:25:56,040 --> 00:25:58,400
The average reduction in
complications and deaths

333
00:25:58,400 --> 00:26:00,280
was more than 35%.

334
00:26:00,280 --> 00:26:04,040
I mean, it was, we didn't believe it.

335
00:26:04,040 --> 00:26:07,880
We had to go back and check
our numbers and it was real.

336
00:26:07,880 --> 00:26:10,320
People since then have replicated it.

337
00:26:10,320 --> 00:26:13,120
47% reduction in deaths
following a checklist

338
00:26:13,120 --> 00:26:15,400
approach in the Netherlands.

339
00:26:15,400 --> 00:26:18,640
18% reduction in complications
in military hospitals that

340
00:26:18,640 --> 00:26:21,480
adopted this checklist approach.

341
00:26:21,480 --> 00:26:23,760
'It covers the fundamentals.

342
00:26:23,760 --> 00:26:27,800
'Checking you've got the patient and
you're doing the right procedure.'

343
00:26:27,800 --> 00:26:30,240
And this is it. This is what we're
talking about, isn't it?

344
00:26:30,240 --> 00:26:34,120
This is a World Health Organisation
patient safety checklist. Yes.

345
00:26:34,120 --> 00:26:39,800
This is this one piece of paper,
free, cuts deaths

346
00:26:39,800 --> 00:26:42,520
and complications by more
than a third.

347
00:26:42,520 --> 00:26:45,560
And if it were a drug or a device,
I'd be a billionaire.

348
00:26:59,560 --> 00:27:02,840
What he's discovered is that the
checklist doesn't just catch

349
00:27:02,840 --> 00:27:04,360
simple human mistakes.

350
00:27:06,480 --> 00:27:09,840
It does something else that's
critical to saving lives.

351
00:27:15,600 --> 00:27:18,560
It helps to flatten
the traditional hierarchy.

352
00:27:21,840 --> 00:27:25,520
We call it an operating theatre
for a reason.

353
00:27:25,520 --> 00:27:30,040
It is the stage for the surgeon
and everybody else is just a hand.

354
00:27:33,400 --> 00:27:37,080
And changing from a belief that
that's how this thing works,

355
00:27:37,080 --> 00:27:41,160
where everybody else is to be silent,
respectful, ssh,

356
00:27:41,160 --> 00:27:45,400
to one where a crew of people,
each with separate responsibilities,

357
00:27:45,400 --> 00:27:49,240
were making sure we're on the same
page, that's the basic idea here

358
00:27:49,240 --> 00:27:51,280
and that's what becomes very powerful

359
00:27:51,280 --> 00:27:54,120
when you put words around it
like the ones on the checklist.

360
00:28:10,000 --> 00:28:14,160
At my hospital, checklists are now
part and parcel of everyday life.

361
00:28:14,160 --> 00:28:17,880
And it sounds simple, but just
the act of introducing everybody,

362
00:28:17,880 --> 00:28:20,160
just knowing everybody's name,

363
00:28:20,160 --> 00:28:24,000
fundamentally changes
the atmosphere in theatre.

364
00:28:24,000 --> 00:28:27,400
And when emergencies arise,
that can be crucial.

365
00:28:30,720 --> 00:28:34,920
Dr Gawande's checklists are now
used in hospitals all over Britain.

366
00:28:38,080 --> 00:28:41,240
But when Elaine Bromiley
was in surgery,

367
00:28:41,240 --> 00:28:42,880
they didn't exist.

368
00:28:48,080 --> 00:28:51,000
RESPIRATOR BEEPS

369
00:28:51,000 --> 00:28:54,880
Well, we've tried intubating her.
Both of us have tried.

370
00:28:56,040 --> 00:28:57,880
Yeah, we've tried that too.

371
00:28:57,880 --> 00:28:59,120
OK, let's just cut, OK.

372
00:29:00,960 --> 00:29:04,800
The report into her death discovered
that during the consultants'

373
00:29:04,800 --> 00:29:07,240
efforts to establish an airway...

374
00:29:07,240 --> 00:29:09,000
This is difficult.

375
00:29:09,000 --> 00:29:11,720
..a nurse came in
offering a tracheostomy kit.

376
00:29:23,520 --> 00:29:27,160
This could have been a solution to
Elaine's life-threatening problem.

377
00:29:28,640 --> 00:29:31,160
She's really blue.
She's really blue.

378
00:29:32,600 --> 00:29:35,080
Performing an emergency tracheostomy

379
00:29:35,080 --> 00:29:37,480
is a dangerous and difficult
procedure.

380
00:29:40,360 --> 00:29:44,440
And that involves cutting a hole
in the throat around about there,

381
00:29:44,440 --> 00:29:46,280
bypassing the mouth,

382
00:29:46,280 --> 00:29:49,520
giving the patient a pathway through
which they can breathe.

383
00:29:53,800 --> 00:29:56,760
But it wasn't clear who
was in charge of this emergency.

384
00:29:58,880 --> 00:30:00,880
I'm pushing as hard as I can.

385
00:30:03,320 --> 00:30:06,840
And the nurses found themselves
unable to broach the subject.

386
00:30:10,800 --> 00:30:14,240
The opportunity to perform that
procedure was lost.

387
00:30:17,760 --> 00:30:21,960
And, with it, what might have been
a chance to save Elaine's life.

388
00:30:35,840 --> 00:30:39,240
Medicine has learned hard lessons
from Elaine Bromiley's case.

389
00:30:41,720 --> 00:30:45,520
We are now much more aware of the
importance of human factors.

390
00:30:48,840 --> 00:30:53,640
In my experience, checklists help to
make operating theatres more

391
00:30:53,640 --> 00:30:57,320
cooperative, and less prone to
the errors of dictatorship.

392
00:31:04,880 --> 00:31:08,200
At University College Hospital
in London...

393
00:31:08,200 --> 00:31:10,760
How are we doing so far?

394
00:31:10,760 --> 00:31:14,640
..they've even built a simulation
suite to help train doctors

395
00:31:14,640 --> 00:31:17,840
to recognise and deal with
the perennial problem

396
00:31:17,840 --> 00:31:19,480
of human fallibility.

397
00:31:20,880 --> 00:31:22,560
Say when.

398
00:31:23,960 --> 00:31:27,400
This is like being
backstage at junior doctor's school

399
00:31:27,400 --> 00:31:30,840
and it's something that you don't
ordinarily get to see.

400
00:31:33,400 --> 00:31:37,000
Here, medics are given the chance
to experience

401
00:31:37,000 --> 00:31:39,160
tough operating theatre emergencies

402
00:31:39,160 --> 00:31:41,600
without risking the lives of
patients.

403
00:31:41,600 --> 00:31:43,600
Can I have a bit of suction, please?

404
00:31:45,720 --> 00:31:50,040
We are behind a two-way mirror so we
can see them, but they can't see us.

405
00:31:51,160 --> 00:31:53,200
Can I have the music off, please?

406
00:31:55,240 --> 00:31:58,080
Consultant anaesthetist
Sarah Chieveley-Williams

407
00:31:58,080 --> 00:32:00,920
is in charge of the programme here.

408
00:32:00,920 --> 00:32:04,640
And she just happens to be
one of the doctors who trained me.

409
00:32:04,640 --> 00:32:06,840
More suction.

410
00:32:06,840 --> 00:32:09,880
'We've realised in medical
catastrophes,

411
00:32:09,880 --> 00:32:13,480
'that it's not just learning
the medicine that's important.'

412
00:32:13,480 --> 00:32:15,280
We are teaching human factors.

413
00:32:15,280 --> 00:32:18,040
We're teaching hierarchy gradients

414
00:32:18,040 --> 00:32:20,640
and how they may
shift during an operation.

415
00:32:20,640 --> 00:32:24,720
And we're teaching how you engage
with people in order to

416
00:32:24,720 --> 00:32:28,440
maintain the safety of all
the operations that happen.

417
00:32:30,000 --> 00:32:34,760
Duncan Wagstaff is in his first year
of training as an anaesthetist.

418
00:32:34,760 --> 00:32:37,720
Let's get two units.
Can I have two units?

419
00:32:37,720 --> 00:32:41,800
And in this extremely difficult
scenario, he's working with

420
00:32:41,800 --> 00:32:45,360
a stroppy surgical consultant
in an operation

421
00:32:45,360 --> 00:32:48,280
that's about to go horribly wrong.

422
00:32:48,280 --> 00:32:50,640
Who is the...?
I'm here on my own, Mr Barrow.

423
00:32:50,680 --> 00:32:52,120
A bit more suction.

424
00:32:52,120 --> 00:32:55,600
So these are cases not to be taken
likely even under ordinary

425
00:32:55,600 --> 00:32:59,640
conditions, but you're going to
throw some curve balls in here for
Duncan?

426
00:32:59,640 --> 00:33:02,240
Yes, so we're now going to drop
the pressure a little bit.

427
00:33:04,360 --> 00:33:06,920
We should get some blood in there.

428
00:33:06,920 --> 00:33:10,360
So Duncan's slightly worried that
there may be some bleeding going on,

429
00:33:10,360 --> 00:33:13,240
that he can't quite see exactly
where it's coming from.

430
00:33:13,240 --> 00:33:15,280
Mr Barrow, I'm worried.

431
00:33:16,680 --> 00:33:20,560
So this is so much like what you'd
expect to see in real life.

432
00:33:20,560 --> 00:33:22,600
You've got some of the numbers
coming down here.

433
00:33:22,600 --> 00:33:24,520
The oxygen saturations are dumping.

434
00:33:24,520 --> 00:33:26,800
His blood pressure is coming down.

435
00:33:26,800 --> 00:33:28,400
The heart rate is coming up.

436
00:33:28,400 --> 00:33:33,760
And still, at this point,
unsure of precisely what's going on.

437
00:33:35,840 --> 00:33:39,640
Is this as high as it will go?
I think we need head down.

438
00:33:39,640 --> 00:33:41,360
Well, I can't see.

439
00:33:42,920 --> 00:33:45,960
So we're about to throw in
the major problem.

440
00:33:45,960 --> 00:33:47,960
So the patient's just had some
antibiotics...

441
00:33:47,960 --> 00:33:49,800
Antibiotics are in.

442
00:33:49,800 --> 00:33:52,640
..and the patient's going to react to
those antibiotics, which,

443
00:33:52,640 --> 00:33:56,520
I know seems a bit unfair,
but actually we're deliberately

444
00:33:56,520 --> 00:34:00,760
pushing Duncan well outside his
comfort zone, as a learning tool.

445
00:34:00,760 --> 00:34:04,040
We've got an emergency here.
Stats down to 82%.

446
00:34:04,040 --> 00:34:05,640
Pressure is very low.

447
00:34:05,640 --> 00:34:08,240
I've got an impending disaster here,
guys.

448
00:34:08,240 --> 00:34:11,480
SUPPRESSED LAUGHTER

449
00:34:14,000 --> 00:34:16,000
Brilliantly understated.

450
00:34:16,000 --> 00:34:18,280
Just check we've got a pulse there.

451
00:34:20,120 --> 00:34:23,120
FRANTIC BABBLE

452
00:34:25,200 --> 00:34:29,000
At this point, we've pushed him
probably to his limit.

453
00:34:29,000 --> 00:34:33,280
The patient was indeed deteriorating
slightly before we ended up

454
00:34:33,280 --> 00:34:36,920
throwing in the antibiotics to which
the patient has reacted to.

455
00:34:36,920 --> 00:34:40,400
He's probably not
considered that, mainly

456
00:34:40,400 --> 00:34:43,680
because he's fixated on the fact
that the patient is bleeding.

457
00:34:43,680 --> 00:34:47,280
Yeah, well, it's a pretty horrible
scenario really.

458
00:34:47,280 --> 00:34:49,920
'Thank you. That's the end of the
scenario.'

459
00:34:54,320 --> 00:34:57,600
Poor old Duncan.
I need to go and give him a hug.

460
00:34:57,600 --> 00:34:59,240
That was fun(!)

461
00:35:00,560 --> 00:35:04,720
'Human factors are now so
recognisably important in medicine

462
00:35:04,720 --> 00:35:06,400
'that in anaesthesia,

463
00:35:06,400 --> 00:35:09,440
'they're beginning to creep into
our selection criteria.'

464
00:35:09,440 --> 00:35:12,960
There are schools
in the United Kingdom that are using

465
00:35:12,960 --> 00:35:15,680
simulation as part
of their selection criteria.

466
00:35:15,680 --> 00:35:20,000
It adds a whole new spectrum and
dimension to the selection criteria.

467
00:35:20,000 --> 00:35:23,600
It's obviously very labour intensive
and difficult to implement for

468
00:35:23,600 --> 00:35:28,560
huge numbers, but, yes, potentially
in the future it could be there.

469
00:35:28,560 --> 00:35:32,960
Slightly terrifying. I'm glad
I wasn't around when I selected.

470
00:35:32,960 --> 00:35:35,000
We might have had you anyway.

471
00:35:45,800 --> 00:35:49,440
But successful surgery is about more
than the individual.

472
00:35:49,440 --> 00:35:51,240
It's about teamwork.

473
00:35:55,520 --> 00:35:59,160
But more people can make
human errors more likely.

474
00:36:11,600 --> 00:36:15,360
And medicine is learning how to deal
with the problem from another

475
00:36:15,360 --> 00:36:17,080
surprising source.

476
00:36:19,720 --> 00:36:25,640
Believe it or not, looking at how
Formula One pit crews function

477
00:36:25,640 --> 00:36:28,040
has allowed
doctors at the world-famous

478
00:36:28,040 --> 00:36:31,880
Great Ormond Street Children's
Hospital to reduce human errors.

479
00:36:33,720 --> 00:36:37,960
And six-year-old Evelyn Soles,
who's undergone open-heart surgery,

480
00:36:37,960 --> 00:36:39,880
stands to benefit from this.

481
00:36:41,840 --> 00:36:45,720
These procedures lie at the extremes
of our capabilities in medicine,

482
00:36:45,720 --> 00:36:49,200
and, even for me, it's quite
something to watch.

483
00:36:52,000 --> 00:36:54,440
It's quite helpful,
those bits of gauze.

484
00:36:54,440 --> 00:36:57,680
But it's the dangerous period
immediately after the operation

485
00:36:57,680 --> 00:36:59,720
that doctors needed to re-think.

486
00:36:59,720 --> 00:37:02,760
Just give that a clean.

487
00:37:02,760 --> 00:37:04,800
The operation is over now

488
00:37:04,800 --> 00:37:07,040
and the surgeons have effectively
handed over care to

489
00:37:07,040 --> 00:37:11,080
the anaesthetic team and Isabeau
has to coordinate what could be

490
00:37:11,080 --> 00:37:12,280
a very complicated transfer.

491
00:37:12,280 --> 00:37:13,920
She's got to take all the drugs,

492
00:37:13,920 --> 00:37:16,400
all these machines
that are supporting her patient,

493
00:37:16,400 --> 00:37:19,440
get them off the table, out
of the theatre, along the corridor

494
00:37:19,440 --> 00:37:21,840
and up to intensive care,
and that's something that,

495
00:37:21,840 --> 00:37:25,000
until recently, there wasn't
a lot of attention paid to.

496
00:37:25,000 --> 00:37:27,760
But there's a growing
awareness that this is a key

497
00:37:27,760 --> 00:37:32,600
component in what is effectively
a continuous chain of survival

498
00:37:32,600 --> 00:37:34,640
that keeps this patient alive.

499
00:37:38,760 --> 00:37:42,400
Until relatively recently, the
handover was a source of great

500
00:37:42,400 --> 00:37:46,600
concern to the man who's in charge
of the ICU, Dr Allan Goldman.

501
00:37:49,120 --> 00:37:52,880
The handover process was
terribly fragmented.

502
00:37:52,880 --> 00:37:55,400
What we saw were some of
the consultants were doing handover

503
00:37:55,400 --> 00:37:58,440
down the corridor between the ICU
and the theatre.

504
00:37:58,440 --> 00:38:02,080
Then the registrars were handing
over in another section of the ICU.

505
00:38:02,080 --> 00:38:04,600
The nurses were doing another
handover over there.

506
00:38:04,600 --> 00:38:07,560
All these simultaneous transfers
and handovers,

507
00:38:07,560 --> 00:38:11,040
and at the same time, people were
moving all the technology.

508
00:38:11,040 --> 00:38:12,880
The nurses were trying to
write down little

509
00:38:12,880 --> 00:38:15,080
bits of information on their scrubs.

510
00:38:15,080 --> 00:38:16,840
And only
when you looked at it at that point,

511
00:38:16,840 --> 00:38:19,320
you realised how chaotic this was.

512
00:38:19,320 --> 00:38:21,360
All the little things matter

513
00:38:21,360 --> 00:38:23,520
and when the little things
start going wrong,

514
00:38:23,520 --> 00:38:26,720
they start getting error cascading
and lead to a big thing going wrong.

515
00:38:28,080 --> 00:38:32,920
Dr Goldman and a colleague then had
an unusual moment of revelation

516
00:38:32,920 --> 00:38:36,600
in front of the telly
watching an F1 pit stop.

517
00:38:36,600 --> 00:38:38,440
When we looked at a pit stop,

518
00:38:38,440 --> 00:38:41,280
these were really the experts of how
teams from different

519
00:38:41,280 --> 00:38:45,160
specialties come together,
reconfigure as a single unit,

520
00:38:45,160 --> 00:38:50,400
perform a complex task under time
pressure in such an effective way.

521
00:38:55,600 --> 00:38:58,760
When they looked more closely
at F1 pit crews in action...

522
00:39:01,320 --> 00:39:04,640
..they discovered that each
individual on the team

523
00:39:04,640 --> 00:39:08,600
had a very simple but very specific,
clearly defined task.

524
00:39:13,240 --> 00:39:15,800
There's a guy to take off the tyre.

525
00:39:17,360 --> 00:39:19,240
A guy to put it on.

526
00:39:20,680 --> 00:39:23,120
Someone to take the used wheel away.

527
00:39:25,560 --> 00:39:30,760
And crucially there's one person in
charge - the man with the lollipop.

528
00:39:35,080 --> 00:39:38,800
He decides when the car is ready
to go back on the track.

529
00:39:48,280 --> 00:39:51,760
What else did you pick up from
watching how they operate?

530
00:39:51,760 --> 00:39:54,200
I think it's just a very
professional approach,

531
00:39:54,200 --> 00:39:58,280
so there's the leadership,
there's constant use of checklists.

532
00:39:58,280 --> 00:40:01,680
There's great focus on task
allocation at a pit stop

533
00:40:01,680 --> 00:40:05,800
where one person has got one or two
jobs that they're doing.

534
00:40:05,800 --> 00:40:08,280
A lot about situational awareness

535
00:40:08,280 --> 00:40:12,480
and then contingencies for things
going wrong and a definitive plan.

536
00:40:14,720 --> 00:40:17,760
So how did that affect what
they did after operations?

537
00:40:20,800 --> 00:40:23,400
I'm just going to put
the gastric tube down

538
00:40:23,400 --> 00:40:25,520
and then I'll
switch off the machine.

539
00:40:25,520 --> 00:40:27,720
Thank you.

540
00:40:27,720 --> 00:40:30,600
'We just simplified
the process into three phases.'

541
00:40:37,640 --> 00:40:41,920
'So phase one is we'd just transfer
the technology with no talking

542
00:40:41,920 --> 00:40:45,360
'so everybody knew what they were
doing, so it's exactly like theatre.'

543
00:40:55,560 --> 00:40:58,960
There is nothing connected here that
doesn't need to be connected.

544
00:40:58,960 --> 00:41:01,240
No drug, no piece of monitoring,

545
00:41:01,240 --> 00:41:03,880
no piece of life support.

546
00:41:03,880 --> 00:41:07,120
All of it's got to go over. All
of it, ALL of it has got to work.

547
00:41:13,840 --> 00:41:18,560
'Phase two is organized by the
person in charge of the transfer

548
00:41:18,560 --> 00:41:21,760
'and that person
is the anaesthetist.'

549
00:41:21,760 --> 00:41:25,400
If you just point out that potassium
is low and they need to top it up.

550
00:41:26,840 --> 00:41:29,480
They decide when
the patient can be moved.

551
00:41:29,480 --> 00:41:34,360
and that only happens after they
run through a transfer checklist

552
00:41:34,360 --> 00:41:37,120
which they call an aide-memoire
at Great Ormond Street.

553
00:41:40,640 --> 00:41:45,280
So we just hand over information
in a fixed, consistent manner.

554
00:41:45,280 --> 00:41:47,960
Right, so ready to go.

555
00:41:47,960 --> 00:41:51,760
Only when everything is checked can
the patient be moved from the

556
00:41:51,760 --> 00:41:53,840
operating table to the trolley.

557
00:41:53,840 --> 00:41:56,680
Go.

558
00:41:56,680 --> 00:41:58,480
Thank you.

559
00:41:58,480 --> 00:42:00,200
For six-year-old Evelyn Soles,

560
00:42:00,200 --> 00:42:03,680
the four-hour open-heart surgery
has been very successful.

561
00:42:08,720 --> 00:42:10,800
Before these changes were
introduced,

562
00:42:10,800 --> 00:42:13,960
there was no protocol that guided
the transfer process.

563
00:42:16,760 --> 00:42:19,080
Now, just like in F1,

564
00:42:19,080 --> 00:42:22,880
everyone around the patient
has a simple but specific role.

565
00:42:25,480 --> 00:42:28,400
Phase three is
defined by the careful

566
00:42:28,400 --> 00:42:31,840
and heavily structured
passing on of vital information

567
00:42:31,840 --> 00:42:35,240
when the patient
arrives in the intensive care unit.

568
00:42:38,520 --> 00:42:40,800
So this is Evelyn Soles.

569
00:42:40,800 --> 00:42:44,840
She had an ABSD and a coarctation
repair when she was four months old.

570
00:42:44,840 --> 00:42:47,680
She developed subaortic stenosis
and she had that resected

571
00:42:47,680 --> 00:42:49,240
when she was about four years old.

572
00:42:49,240 --> 00:42:51,520
So today she's had a Ross Procedure.

573
00:42:53,160 --> 00:42:57,800
I think our focus has been
on the extreme of difficult technical

574
00:42:57,800 --> 00:43:02,320
procedures and actually sometimes,
as you know,

575
00:43:02,320 --> 00:43:07,160
the rewards are actually in very
simple simplified processes

576
00:43:07,160 --> 00:43:09,600
between humans.

577
00:43:09,600 --> 00:43:14,840
She's had a low dose of morphine,
five ml. Last set of gases...

578
00:43:14,840 --> 00:43:17,120
And it's these procedures
that are helping to save

579
00:43:17,120 --> 00:43:20,040
the lives of critically unwell
children like Evelyn.

580
00:43:22,800 --> 00:43:27,760
Dr Goldman calculates that there's
been a 40% reduction in human error

581
00:43:27,760 --> 00:43:33,160
since he introduced these new
Formula One-inspired protocols.

582
00:43:33,160 --> 00:43:35,200
She got quite breathless...

583
00:43:44,360 --> 00:43:48,240
When you step back
and look at that process,

584
00:43:48,240 --> 00:43:51,080
without adding any drugs,

585
00:43:51,080 --> 00:43:55,680
or any extra technology,
they manage to save lives.

586
00:44:12,120 --> 00:44:14,000
Slowly but surely,

587
00:44:14,000 --> 00:44:16,800
medicine is waking up to
the experience of others.

588
00:44:27,600 --> 00:44:31,640
Improvements in engineering have had
a major impact on aviation.

589
00:44:37,600 --> 00:44:41,400
But human factors dominate training
and practice in the industry.

590
00:44:42,840 --> 00:44:44,880
And it's the same
in the fire brigade

591
00:44:44,880 --> 00:44:48,880
and even in the high-octane world
of Formula One.

592
00:45:01,320 --> 00:45:06,000
And, as a doctor, they're beginning
to change my everyday working life.

593
00:45:10,600 --> 00:45:15,720
In my experience, they're making
routine practice much safer.

594
00:45:25,920 --> 00:45:29,480
But what I'm less sure about is
the stuff that we can't plan for.

595
00:45:29,480 --> 00:45:34,640
Those routine days that become your
worst nightmare out of the blue.

596
00:45:34,640 --> 00:45:36,840
When we face emergencies
in medicine,

597
00:45:36,840 --> 00:45:39,920
they're usually messy
and they unpack in seconds,

598
00:45:39,920 --> 00:45:44,800
giving doctors only the narrowest
window before life is lost.

599
00:45:44,800 --> 00:45:48,280
And so what I want to know is,
in those extreme situations,

600
00:45:48,280 --> 00:45:52,720
is there anything at all that we can
learn from the experience of others?

601
00:46:03,280 --> 00:46:07,320
In the recent past there's one event
that stands out from all the others.

602
00:46:12,400 --> 00:46:14,120
In airports across America,

603
00:46:14,120 --> 00:46:18,920
15th January 2009
was a day like any other.

604
00:46:22,160 --> 00:46:25,480
Until just before three
in the afternoon on the east coast.

605
00:46:30,520 --> 00:46:34,920
US Airways Flight 1549 was cleared
for take off from La Guardia,

606
00:46:34,920 --> 00:46:36,880
New York's local airfield...

607
00:46:39,040 --> 00:46:42,040
..and bound for Charlotte,
North Carolina.

608
00:46:45,720 --> 00:46:49,240
Captain Chesley "Sully"
Sullenburger barely had time to get

609
00:46:49,240 --> 00:46:52,400
settled into his chair
before disaster struck.

610
00:46:54,720 --> 00:46:57,160
His plane hit a flock of birds.

611
00:47:02,160 --> 00:47:05,480
And his day flipped from routine
into the worst of all

612
00:47:05,480 --> 00:47:08,240
possible emergencies
in the blink of an eye.

613
00:47:10,120 --> 00:47:13,240
The birds filled the windscreen as
if it were a Hitchcock film.

614
00:47:13,240 --> 00:47:16,560
I could feel and hear the thumps
and thuds as we struck them.

615
00:47:18,280 --> 00:47:20,600
At least two birds had gone
through the right engine

616
00:47:20,600 --> 00:47:24,160
and one or two through the left.
I felt severe vibrations.

617
00:47:24,160 --> 00:47:26,480
I heard terrible noises as
they engines were being damaged

618
00:47:26,480 --> 00:47:28,600
that I'd never
heard in an aeroplane before

619
00:47:28,600 --> 00:47:33,600
and then the thrust loss was sudden,
complete, bilaterally symmetrical.

620
00:47:33,600 --> 00:47:36,120
Both engines at once.

621
00:47:36,120 --> 00:47:39,160
I knew this was going to be
an ultimate challenge of a lifetime,

622
00:47:39,160 --> 00:47:42,280
unlike anything I'd ever
experienced before.

623
00:47:47,080 --> 00:47:50,120
Losing both engines in a bird strike
was something that

624
00:47:50,120 --> 00:47:53,400
Captain Sullenburger had never
experienced.

625
00:47:53,400 --> 00:47:56,400
An event so rare that he hadn't even
trained for it.

626
00:47:58,080 --> 00:48:01,560
I could feel my blood pressure,
my pulse, shoot up. Spike.

627
00:48:01,560 --> 00:48:04,560
I sensed my perceptual field
narrow in a kind of tunnel vision

628
00:48:04,560 --> 00:48:07,800
because of this sudden stress.
It was marginally debilitating.

629
00:48:07,800 --> 00:48:10,640
It absolutely impaired my ability to
process what was happening.

630
00:48:15,040 --> 00:48:19,160
What happened next has become
the stuff of legend.

631
00:48:19,160 --> 00:48:23,840
With no engine power his aircraft,
with 155 passengers on board,

632
00:48:23,840 --> 00:48:26,880
had become little more
than a clumsy glider.

633
00:48:31,560 --> 00:48:34,400
He started going
through his emergency checklist

634
00:48:34,400 --> 00:48:36,440
and let the local air
traffic control

635
00:48:36,440 --> 00:48:39,040
know about his desperate problem.

636
00:48:53,520 --> 00:48:57,120
His voice sounds measured and calm
but that's not how he felt.

637
00:48:58,440 --> 00:49:01,400
Listening to it now
I can hear the slight raspiness,

638
00:49:01,400 --> 00:49:04,040
the slight higher pitch in my voice.

639
00:49:04,040 --> 00:49:05,600
I know you're under stress.

640
00:49:11,840 --> 00:49:13,840
His options were limited.

641
00:49:13,840 --> 00:49:17,440
He couldn't get back to La Guardia
or to any other local airport.

642
00:49:26,200 --> 00:49:31,680
So he took the momentous decision to
land the plane on the Hudson River,

643
00:49:31,680 --> 00:49:34,120
right in the heart of Manhattan.

644
00:49:42,680 --> 00:49:45,160
I never thought
I was going to die that day.

645
00:49:45,160 --> 00:49:48,920
I was confident that, based
upon my training and my experience,

646
00:49:48,920 --> 00:49:50,720
I could find a way to solve
this problem

647
00:49:50,720 --> 00:49:53,440
and if I could find a way to
deliver the aircraft to

648
00:49:53,440 --> 00:49:56,640
the surface intact, it would float
long enough for us to be rescued.

649
00:50:18,560 --> 00:50:21,000
Not a single person died that day

650
00:50:21,000 --> 00:50:23,840
and there were no major injures.

651
00:50:25,480 --> 00:50:28,120
Sullenburger was hailed as a hero.

652
00:50:30,640 --> 00:50:34,120
But for him, this was
more about training than heroism.

653
00:50:36,880 --> 00:50:40,680
Over many decades, thousands
of people in aviation had worked

654
00:50:40,680 --> 00:50:44,200
very hard to create a robust,
resilient safety

655
00:50:44,200 --> 00:50:48,480
system in which we operate
and that formed the firm foundation

656
00:50:48,480 --> 00:50:53,160
on which we could innovate,
improvise to solve this crisis.

657
00:50:53,160 --> 00:50:57,800
We set the tone, created a shared
sense of responsibility,

658
00:50:57,800 --> 00:51:00,760
flattened the hierarchy,
opened channels of communication

659
00:51:00,760 --> 00:51:04,720
and we have teams trained
in the consistent application

660
00:51:04,720 --> 00:51:07,960
of best practices with well-learned,
well-defined roles

661
00:51:07,960 --> 00:51:11,120
and responsibilities to each other
and to the passengers.

662
00:51:11,120 --> 00:51:14,400
In other words, I took what
we did know, applied it in a new way

663
00:51:14,400 --> 00:51:18,400
to solve in 208 seconds this problem
we'd never seen before.

664
00:51:23,640 --> 00:51:26,760
There's a bunch of stuff that
I never fully appreciated

665
00:51:26,760 --> 00:51:29,600
about Flight 1549
until that conversation.

666
00:51:29,600 --> 00:51:32,360
The first thing is that Sully's
first response,

667
00:51:32,360 --> 00:51:36,240
when things start to go wrong,
is to be scared.

668
00:51:36,240 --> 00:51:38,640
Fear's a natural experience.

669
00:51:38,640 --> 00:51:41,920
In medicine, when things go wrong
the first thing you feel is scared,

670
00:51:41,920 --> 00:51:45,120
but what gets them through that
is following the protocols.

671
00:51:45,120 --> 00:51:46,440
He sticks to the procedures.

672
00:51:46,440 --> 00:51:47,800
He starts the checklist even

673
00:51:47,800 --> 00:51:50,840
though he knows he's not going to
have time to finish reading them.

674
00:51:50,840 --> 00:51:53,280
And it's that, the idea
that you standardise

675
00:51:53,280 --> 00:51:55,520
until you absolutely have to
improvise,

676
00:51:55,520 --> 00:51:58,800
that makes everything better
and allows them to survive.

677
00:52:03,320 --> 00:52:06,480
But Captain Sullenburger
had one big advantage

678
00:52:06,480 --> 00:52:10,040
in surviving this
unprecedented emergency

679
00:52:10,040 --> 00:52:12,560
and that is locked away
in his brain.

680
00:52:20,760 --> 00:52:22,520
He's not even aware of it

681
00:52:22,520 --> 00:52:25,360
because it's a brand new
scientific discovery.

682
00:52:27,600 --> 00:52:31,200
And the good news is that
we can all access it.

683
00:52:34,040 --> 00:52:36,240
Uncovering exactly what it is

684
00:52:36,240 --> 00:52:39,240
means travelling to
Michigan State University

685
00:52:39,240 --> 00:52:42,800
and the labs of psychology
professor Jason Moser.

686
00:52:47,680 --> 00:52:52,160
It also involves agreeing to wear
some less than flattering headgear.

687
00:52:56,160 --> 00:52:59,880
'These electrodes allow Jason to
measure the electrical activity

688
00:52:59,880 --> 00:53:04,120
'inside my brain, and look at what
happens when I make a mistake.'

689
00:53:05,560 --> 00:53:09,040
What are you hoping to read off
me today?

690
00:53:09,040 --> 00:53:13,520
What we really want to see is how
quickly your brain reacts to

691
00:53:13,520 --> 00:53:19,600
mistakes and how well it responds
and bounces back from mistakes.

692
00:53:19,600 --> 00:53:25,280
We really want to
look at what are the neurobiological

693
00:53:25,280 --> 00:53:29,160
underpinnings of decision-making
and mistake-making.

694
00:53:31,360 --> 00:53:34,200
I'm all wired up and ready to go.

695
00:53:41,920 --> 00:53:45,160
In this line of onscreen letters,
all I have to do

696
00:53:45,160 --> 00:53:48,640
is press the left button
if the middle letter is an 'N'

697
00:53:48,640 --> 00:53:51,040
and the right button if it's an 'M'.

698
00:54:01,800 --> 00:54:05,280
It sounds simple but I'm still
making mistakes.

699
00:54:07,480 --> 00:54:09,560
It's a pretty straightforward task.

700
00:54:09,560 --> 00:54:11,760
You feel like you really
shouldn't make a mistake.

701
00:54:11,760 --> 00:54:13,680
'M' is right, 'N' is left.

702
00:54:16,120 --> 00:54:19,360
I feel like there shouldn't be any
excuse for getting this test wrong.

703
00:54:22,360 --> 00:54:26,160
Jason, meanwhile, directs everything
from a control suite next door,

704
00:54:26,160 --> 00:54:28,800
watching as my brain ticks away.

705
00:54:31,280 --> 00:54:33,280
So how did I do?

706
00:54:36,160 --> 00:54:39,760
All right, Kev, so what you're
looking at here on this left screen,

707
00:54:39,760 --> 00:54:43,080
we're looking at these two responses
that your brain puts out

708
00:54:43,080 --> 00:54:44,720
when you make a mistake.

709
00:54:44,720 --> 00:54:48,960
This first response is the,
"Oh no, something's wrong" response.

710
00:54:48,960 --> 00:54:51,800
You can see that in these cold
blue colours here.

711
00:54:51,800 --> 00:54:56,680
That's basically the brain saying,
"Something's gone awry. What's up?"

712
00:54:56,680 --> 00:54:59,760
And within just a few hundred
milliseconds as we kind of

713
00:54:59,760 --> 00:55:06,320
crawl across time here, you can
see that this next brain blip,

714
00:55:06,320 --> 00:55:09,680
that hot red is telling us,
"Now I'm paying attention.

715
00:55:09,680 --> 00:55:12,480
"I see that I've made a mistake.
That's what's wrong

716
00:55:12,480 --> 00:55:14,760
"and now I'm going to do something
about it."

717
00:55:16,400 --> 00:55:19,480
'The faster your brain
goes from blue to red,

718
00:55:19,480 --> 00:55:22,480
'the more positive your attitude is
to making mistakes.'

719
00:55:24,360 --> 00:55:26,720
'And that's vital.'

720
00:55:26,720 --> 00:55:30,000
So you're correcting your mistake
in that moment

721
00:55:30,000 --> 00:55:33,040
right after your brain tunes in and
says, "Whoops, I've made a mistake.

722
00:55:33,040 --> 00:55:35,080
"Let's zone in on it, let's fix it."

723
00:55:35,080 --> 00:55:38,320
You're correcting that response
right away and following that,

724
00:55:38,320 --> 00:55:41,800
when you see the next set of letters,
you're not only correcting that

725
00:55:41,800 --> 00:55:43,400
response that you just made wrong,

726
00:55:43,400 --> 00:55:47,880
but on the next set of letters
you're perfectly accurate.

727
00:55:47,880 --> 00:55:51,560
100% of the time you bounce right
back after making a mistake

728
00:55:51,560 --> 00:55:53,800
and you get that next one
right every time.

729
00:55:55,520 --> 00:56:01,080
'And, in a crisis, being positive
about errors is all essential.

730
00:56:01,080 --> 00:56:04,120
'If you have a negative attitude
to mistakes,

731
00:56:04,120 --> 00:56:06,480
'you not only take
longer to correct them,

732
00:56:06,480 --> 00:56:10,120
'but Jason's research has shown that
you end up making more of them.'

733
00:56:26,640 --> 00:56:30,320
Learning from mistakes is something
that runs deep in the DNA

734
00:56:30,320 --> 00:56:32,200
of the airline industry.

735
00:56:34,160 --> 00:56:37,640
Every pilot,
including Captain Sullenburger,

736
00:56:37,640 --> 00:56:41,040
is brought up with a positive
attitude to errors.

737
00:56:43,360 --> 00:56:47,360
In the end, it's that which makes
flying so much safer.

738
00:56:52,240 --> 00:56:54,920
Everything we know in aviation,

739
00:56:54,920 --> 00:56:58,680
every rule in the rule book,
every procedure we have,

740
00:56:58,680 --> 00:57:02,600
we know because someone somewhere
died, or many people died.

741
00:57:02,600 --> 00:57:05,200
So we have purchased at great cost,

742
00:57:05,200 --> 00:57:09,560
lessons literally bought with
blood that we have to preserve

743
00:57:09,560 --> 00:57:13,200
as institutional knowledge and pass
on to succeeding generations.

744
00:57:13,200 --> 00:57:17,880
We cannot have the moral
failure of forgetting these lessons

745
00:57:17,880 --> 00:57:19,880
and have to relearn them.

746
00:57:28,840 --> 00:57:33,080
And the airlines are already
learning from Flight 1549.

747
00:57:35,600 --> 00:57:39,160
There are now new procedures in
place for a double bird strike.

748
00:57:42,040 --> 00:57:45,440
It's a search for progress,
rather than for someone to blame.

749
00:57:47,080 --> 00:57:49,320
And it's a lesson
medicine needs to learn.

750
00:57:50,760 --> 00:57:54,440
Human error is always going
to be with us.

751
00:57:54,440 --> 00:57:57,440
It's how we deal with that
that really matters.

752
00:58:06,360 --> 00:58:09,840
I've spent my whole career
looking for ways we can wrap science

753
00:58:09,840 --> 00:58:13,920
and technology around fragile
physiology to protect it.

754
00:58:13,920 --> 00:58:17,000
And it is a genuine
revelation to me that we

755
00:58:17,000 --> 00:58:22,040
might do the same for psychology,
making ourselves less fallible,

756
00:58:22,040 --> 00:58:26,360
giving ourselves in that moment
the best possible chance.

757
00:58:54,840 --> 00:58:58,800
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