There will be few perioperative students (nursing, ODP) or surgical and anaesthetic trainees, who will not have heard of the tragic case of Mrs Elaine Bromiley. A 37 year old mother of two, admitted for an elective endoscopic sinus surgery and septoplasty, Elaine suffered major complications during the induction of general anaesthesia that resulted in her death due to hypoxic brain damage (Harmer 2005).
As a student ODP, watching the DVD of the reconstruction of the events that contributed to Elaine's death, I am conscious of the profound impact it had on me and the key learning points for practice.
Association of Anaesthetists of Great Britain and Ireland2002Immediate postanaesthetic recoveryLondon, AAGBI
3.
Association of Anaesthetists of Great Britain and Ireland2005Catastrophes in anaesthetic practice –dealing with the aftermathLondon, AAGBI
4.
Association of Anaesthetists of Great Britain and Ireland2007Recommendations for standards of monitoring during anaesthesia and recoveryLondon, AAGBI
5.
Association of Anaesthetists of Great Britain and Ireland2010Safety guideline: preoperative assessment and patient preparation. The role of the anaesthetistLondon, AAGBI
6.
BarakaA.2010‘Routine’ preoxygenation before induction of and recovery from anesthesiaMiddle East Journal of Anesthesiology20(6) 769–71
7.
BerlandA., NatvigG.K., GundersenD.2008Patient safety and job-related stress: A focus group studyIntensive and Critical Care Nursing3490–7
8.
CantR.P., CooperS.J.2011The benefits of debriefing as formative feedback in nurse educationAustralian Journal of Advanced Nursing29(1) 37–47
9.
CooperN., ForrestK., CrampP.2006Essential guide to acute careOxford, Blackwell Publishing Ltd
Critical Incidence Stress Debriefing Service1997Resource guide for critical incident stress and debriefing in human service agenciesMelbourne, Critical Incidence Stress Debriefing Service
12.
Difficult Airway Society2004DAS guidelines flow-chart 2004London, DAS
FioratouE., FlinR., GlavinR.2010a No simple fix for fixation errors: cognitive processes and their clinical applicationsAnaesthesia6561–9
15.
FioratouE., FlinR., GlavinR., PateyR.2010b Beyond monitoring: distributed situation awareness in anaesthesiaBritish Journal of Anaesthesia105(1) 83–90
16.
FrancisR.2013Mid-Staffordshire NHS Foundation Trust public inquiry (HC 947) Available from: www.midstaffspublicinquiry.com/report [Accessed December 2013]
HatfieldA., TronsonM.2009The complete recovery room bookOxford, Oxford University Press
21.
HealeyA.N., UndreS., VincentC.A.2006Defining the technical skills of teamwork in surgeryBritish Medical Journal (15) 231–4
22.
Health Care Professions Council2012Standards of proficiency of operating department practitionersLondon, HCPC
23.
HellabyM.2013What can other industries teach us about safety?Technic4(3) 18
24.
HendersonJ.J., PopatM.T., LattoI.P., PearceA.C.2004Difficult Airway Society guidelines for management of the unanticipated difficult intubationAnaesthesia (59) 675–94
25.
Nursing and Midwifery Council2008The code: Standards of conduct, performance and ethics for nurses and midwifesLondon, NMC
PinnockC., LinT., SmithT.2003Fundamentals of anaesthesiaLondon, Greenwich Medical Media Ltd
28.
ReasonJ.1995Understanding adverse events: human factorsQuality Health Care480–9
29.
ReidJ., BromileyM.2012Clinical human factors: the need to speak up to improve patient safetyNursing Standard26(35) 35–40
30.
ReidJ., ClarkeJ.2009Progressing safer surgeryBritish Journal of Perioperative Nursing19(10) 336–41
31.
Royal College of Anaesthetists & Association of Anaesthetists of Great Britain and Ireland2010The good anaesthetist standards of practice for career grade anaesthetistsLondon, RCA and AAGBI
32.
SeoS.H., LeeJ.G., YuS.B.2012Predictors of difficult intubation defined by the intubation difficulty scale (IDS): predictive value of 7 airway assessment factorsKorean Journal of Anesthesiology63(6) 491–7
SmithG., NielsenM.1999ABC of intensive care: criteria for admissionBritish Medical Journal318(7197) 1544–7
35.
TakrouriM.S., El-BakryA.A., El-DawlatlyA.A.2003Management of unpredicted difficult tracheal intubation due to soft tissue swelling: a report of five casesInternet Journal of Anesthesiology7(1)
36.
VatsA., NagpalK., MoorthyK.2009Surgery: a risky businessBritish Journal of Perioperative Nursing19(10) 330–4
