As a vet I make mistakes, most of the time these do not cause harm, however there is potential for mistakes I make to have disastrous consequences. For me reducing the chance of a mistake happening is extremely important. This requires understanding how mistakes happen, and how as humans we are fallible.
Flying lessons
Pilots have a big focus on safety. There are checklists. Training on human factors. Crew resource management. And psychological safety. As many of you may know I am learning to fly. For me this has been a fascinating process and has taught me a lot about human factors.
Maxed out
During one of my first lessons I was held in an orbit towards the end of the runway as we had to wait for another plane to land. It was mildly windy so I was flying in an oval shape using a lake on the ground as an anchor point to ensure I did not get blown off position. To one side of this there is a power plant which has cooling towers and is restricted airspace. I was balancing between avoiding getting blown into restricted airspace, keeping my location around the lake, keeping the same altitude so not ascending or descending. And keeping a lookout for the plane coming in to land.
My instructor next to me randomly said to turn onto the course to take us in to land. Apparently there had been a radio call clearing us to do this. I had not noticed this radio call, or my instructor’s response to it. I was maxed out mentally and had lost my situational awareness.
Fatigue
My last lesson before the CAA grounded student pilots for lockdown I was flying in the circuit. This is where I’d take off, circle round the airport, land on the runway and then take off again (a touch and go). This is where you learn landing, which is one of the most important parts of flying. I made several landings unassisted with no problems, 6 or 7 taking me up to over an hours flying time. All of my lessons to this point had been around an hour in length. Circuits are busy as there is always stuff to do, there is a high level of concentration required to get the plane onto the ground.
I’d been doing fine, touching the plane down with no issues. My instructor asked if I was happy to continue to get a couple more landings in before stopping for the day. I replied I was happy to do a couple more as it was such a beautiful day and I was happy I was doing so well. My next landing I bounced the plane and my instructor took over to rescue the situation. We decided the next landing would be the last for the day. Again I bounced and had to be rescued by my instructor. I taxied the plane back to the parking place and went through the engine shutdown & parking checklists.
Trying to step out of the plane I could barely walk my body was absolutely exhausted. I had not even realised this until it had become time to move. I’d done 7 landings with no problems. Yet I’d reached a point where my mind and body was incapable of anymore. I was fatigued.
Awareness
In both of these situations I was unaware that I was a problem. In the first situation would I have just continued orbiting until my plane ran out of fuel? In the second, if I’d be alone it is likely that the nose wheel of the plane would have been damaged. Potentially I would have ended up crashing.
Human factors in veterinary medicine conference 2021
This week VetLed has run the first ever human factors conference for the veterinary audience. This 2 day conference has seen some of the biggest names in veterinary patient safety deliver an outstanding programme. The first day started with short presentations focused on specific topics including things like communication, checklists, and handovers. Something I was fascinated by was the use of immersive simulations being used by Surrey vet school. There are some companies that use this type of training however it remains rare in veterinary medicine. Often you are placed in situations you have never been in before and expected to react. Just imagine if you could have a dress rehearsal before you did CPR for the first time. Or before you walked into a room to perform your first euthanasia.
The second day focused on the science of incorporating safety into practice. What psychological safety is and how to create a culture of safety where everyone is able to speak up. For me this is such an important thing to be able to do. It can be difficult to obtain though, and several lectures today looked at ways to achieve this. The final keynote was delivered by Martin Bromiley OBE. A pilot who introduced human factors training into human healthcare back in 2005 when his wife died during a routine operation that went wrong. This has been made into a short film (Just A Routine Operation). During his keynote the statistic of the accepted preventable death number for adults in acute hospitals in England was 150 people a week. I am left wondering what this would be in veterinary medicine…
