Know You’re Human

The patient declined rapidly, the arrest call went out, staff rushed into the operating room. Some helped obtain intravenous access, others drew up adrenaline, and the arrest trolley was brought in. As the patient’s cardiac output disappeared the anaesthetist asked for someone to commence cardiac compressions then turned to put the patient on 100% oxygen. On turning back he noticed compressions hadn’t started. The anaesthetist made eye contact with a nurse and asked her to start compressions – she looked behind thinking he meant someone else. The anaesthetist realised, despite having worked in the same hospital as the nurse for years, he didn’t know her name. Moments later another staff member stepped in.

Perhaps these vital few moments may have made the difference to the patient’s outcome.

Medical error has been reported as the third greatest cause of death – we can overcome this.

Knowing someone’s name allows clearer, more direct, communication – it’s a non-technical skill. Non-technical skills refer to general cognitive and social skills that allow one to, among other things, monitor a situation, make decisions, take a leadership role, communicate and co-ordinate actions within a team, in order to achieve high levels of safety and efficiency. There is growing awareness that non-technical skills are essential for competent practice and improved patient outcomes.

The World Health Organisation Team Time Out process involves staff introducing themselves providing their name and role. This step is in response to poor communication being recognised as contributory to numerous adverse events. Unfortunately, given lack of transparency with error reporting, operating theatre staff aren’t aware of the significance of this issue (see here). While this box is invariably ticked, the actual process is trivialised and rarely takes place – this is the gap that exists between work as perceived and work as performed (see here).

Knowing one another’s names instils camaraderie and improves social interaction in a workplace.

Sometimes names are written on a white board in theatre – these whiteboards obviously don’t move with the staff member. Many theatre staff work in several different operating rooms and even in different hospitals. Remembering everyone’s name in the constantly shifting workforce is an almost impossible task. Names are forgotten and staff frequently pass the stage where asking someone’s name becomes too socially awkward.

From the patient’s perspective when everyone appears the same it is extremely difficult and unsettling to discern who is who.

Policies exist in many institutions indicating that staff clearly display their name and role above waist height. These policies don’t translate well into operating theatres – badges and lanyards are viewed as an infection risk and become covered under sterile, lead or other gowns. For the most part staff in operating theatres have no visible means of identification.

A simple solution to this problem is for staff to have their names and roles written onto their surgical hats. Essentially this places no extra work onto the front line – names which would have otherwise been written on a white board, are written on the staff member instead.

So why aren’t we already doing this?

Perhaps for fear of looking ridiculous. However, as this great TED talk reveals, all movements must start somewhere:

Perhaps administrators view a label on one’s head as a message of imperfection. If we forget people’s names what else might we forget? Unfortunately this is how hospitals are invariably designed – on the premise that as doctors and nurses we shouldn’t make mistakes. However we’re just as human as everyone else, just as likely to make mistakes, yet these mistakes frequently lead to catastrophic outcomes.

We need to nurture a culture which allows us to redesign our healthcare institutions. We need to develop systems which reduce mistakes and minimise them from causing harm when they inevitably occur. For this to happen, we need to let everyone know we’re human.

Willing to let others know you’re human to improve patient safety? #knowyourhuman

You can order theatre hats with your name & role through Hunter Scrubs via this link: click here.

Hunter Scrubs ship internationally.

Please note we have no financial interest with Hunter Scrubs or anything else discussed on the PatientSafe Network.

There is no clear evidence to support use of disposable surgical hats over cotton hats from an infection perspective. This single centre trial has studied infection rates extensively: see here. We acknowledge that despite this many institutions do not allow cloth hats – we will keep you updated on a more aesthetic sticker system we are trialling.

Dr Rhys Thomas – Anaesthesia Quality & Safety Fellow brilliantly explains the importance of theatre hats imprinted with names and roles in this video: ‘What’s in a name?’

If patient safety is to improve we need frameworks which generate a safety culture (see here).

Thank you for your support.

11 Comments

  1. Ruby Ishinjerro

    Love the idea, love the photo.
    I hope this stimulates discussion.

    • patientsafe@icloud.com

      Thanks for the comment Ruby.

      It would be great to see more support for the human factors approach to patient safety.

  2. There are several ways to facilitate this practice being implemented in your institution:
    1. Forward this post to others especially the influential staff in your hospital (theatre NUMs, departmental heads etc.)
    2. Make it as easy as possible for front line staff to perform the practice: have rolls of labels and texters located by surgical caps dispensing area and next to every whiteboard in theatre.

    If you do manage to recreate an image like the one above then please do forward it to us and show your support for the human factors approach to patient safety.

  3. Robert Hackett

    Change is always difficult. To introduce this simple solution to improve a vital non-technical skill in your institution there’s a couple of steps which may help:

    1. Forward this post to others especially those with influence (theatre NUMs, anaesthetic and surgical department heads)
    2. Make it as easy as possible for front line staff to carry out the process (e.g. place label rolls & markers next to surgical hat receptacles and at every theatre white board).

    If you take a photo similar to the one above then please do forward it to us.

    Please do show your support for the human factors approach to patient safety.

  4. Brilliant piece. Love it. I’ll pass on to my SAR guys and NHS staff when I do Human Factors sessions with them.
    Thank u. Loving the new material today.

  5. patientsafe@icloud.com

    Heard this story today:
    A gynaecologist performing keyhole surgery accidentally made a hole in a patients bowel so they called the colorectal surgeon. The guy came in scrubbed up, and after about 10 minutes they found the hole. The gynaecologist then asked his colleague what his plan was. He replied – I’m sorry I’ve never done this before – you do realise I’m a medical student.
    Sometime later the colorectal surgeon came in.

  6. Just ordered my hats. One for each day. Great idea!

  7. Only lead practitioners or sisters or charge nurses have their names stitched on to navy scrubs. Think all members of staff have names viable. Wasn’t a campaign launched by the NHS called, my name is?

    • patientsafe@icloud.com

      Thanks Andy, Yes the #hellomynameis campaign was started by the amazing Kate Granger RIP.

      If there were a better place to identify our names and roles in theatre I would be completely supportive of it. Perhaps unfortunately we will look a bit daft for a while until it becomes accepted practice and then policy and then our patients will benefit tremendously. Personally I can’t wait.

      Thanks again. Rob

  8. Hats ordered. Await silly comments from colleagues. Brilliant idea!

  9. Armies have used this for hundreds of years because good communication is so important. “Want do you think Corporal?” He is identified as a corporal by his stripes and his role is on a color patch and surname on the other pocket. To transfer this to the health field is a no brainer.

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