In 2005 my late wife died during an attempted routine operation.
When I was told it wouldn’t be investigated I couldn’t understand, I didn’t want to blame anyone, but I couldn’t accept that a healthy young life could be lost and apparently no one would try and learn from what happened. That would be a truly wasted life.
I’ve since met many relatives of loved ones who’ve said to me, “I don’t want to get angry, I don’t want to take legal action, but I do want to make sure no one else suffers in the way I did”.
Eventually I was granted my request, an independent investigation was carried out, the final report was put on line in an anonymous form, and I spoke at a patient safety conference about what had happened. I didn’t know it at the time but what I had started to do was something almost unheard of. Here was a story of the death of a patient, and all the details of what happened were being openly published, in writing, on line, and in a conference. And later a DVD was made as well.
As an airline pilot the concept of “narrative evidence” is something that was normal to me. When I do anything as a pilot I can explain why I do it the way I do because of some accident or incident that has happened in the past. These investigations are published on a regular basis and they drive learning.
When clinicians talk about “evidence based medicine” what they often mean is some form of controlled trial, as you would undertake for a new drug for example. But the evidence that really made a difference in my professional world, narrative, was absent.
When I find myself in the air, and things start to go wrong, and the pressure is on, at almost any moment I can recall some similar incident report I’ve read, and that helps steer me in the right direction.
People don’t remember statistics. If you tell someone that following a particular protocol gives success in 79% of cases it’s unlikely to have an impact. “79%” doesn’t explain the what and why and it’s certainly not interesting, it doesn’t impact on our memory, it doesn’t create a feeling in us. But tell a story, in all its detail, now that does create a memory, not of facts and figures, but of how we felt when we heard the story, and that’s what drives us to change our behaviour.
Martin Bromiley is an airline pilot and Chair of the Clinical Human Factors Group.
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