Case study - Elaine Bromiley
Elaine Bromiley was a fit and healthy young woman who was admitted to hospital for routine sinus surgery. During the anaesthetic she experienced breathing problems and the anaesthetist was unable to insert a device to secure her airway. After 10 minutes, it was a situation of 'can't intubate, can't ventilate', a recognised anaesthetic emergency for which guidelines exist. For a further 15 minutes, three highly experienced consultants made numerous unsuccessful attempts to secure Elaine's airway and she suffered prolonged periods with dangerously low levels of oxygen in her bloodstream. Early on, nurses had informed the team that they had brought emergency equipment to the room and booked a bed in intensive care, but neither were utilised. Thirty-five minutes after the start of the anaesthetic, it was decided that Elaine should be allowed to wake up naturally and she was transferred to the recovery unit. When she failed to wake up, she was then transferred to the intensive care unit. Elaine never regained consciousness, and after 13 days the decision was made to withdraw the life support. Several lapses in human factors were noted:
Source: Pensar, S et al. (2021). Patient safety and healthcare Improvement at a glance, p. 12. Wiley-Blackwell.
Question:
Please read the Emily Bromiley story attached here". Please post your response to "Assess the human factors or environmental risks that contributed to the negative outcome for the patient?"