Book contents
- Frontmatter
- Contents
- List of Figures and Tables
- Preface and Acknowledgment
- Acronyms and Abbreviations
- Introduction: How Teamwork Is More Important than Technical Prowess
- 1 Rethinking Normal Accidents and Human Error – A New View of Crisis Management
- 2 USS Greeneville – The Downside of Charismatic Leadership
- 3 The Hillsborough Football Disaster – Explosive Team Chemistry
- 4 American Airlines Flight 587 – Latent Failures Align
- 5 Bristol Royal Infirmary – The Price of Organizational Overreach
- 6 US Airways Flight 1549 – Thinking through Crisis
- 7 Team Resource Management
- Notes
- Bibliography
- Index
5 - Bristol Royal Infirmary – The Price of Organizational Overreach
Published online by Cambridge University Press: 05 June 2012
- Frontmatter
- Contents
- List of Figures and Tables
- Preface and Acknowledgment
- Acronyms and Abbreviations
- Introduction: How Teamwork Is More Important than Technical Prowess
- 1 Rethinking Normal Accidents and Human Error – A New View of Crisis Management
- 2 USS Greeneville – The Downside of Charismatic Leadership
- 3 The Hillsborough Football Disaster – Explosive Team Chemistry
- 4 American Airlines Flight 587 – Latent Failures Align
- 5 Bristol Royal Infirmary – The Price of Organizational Overreach
- 6 US Airways Flight 1549 – Thinking through Crisis
- 7 Team Resource Management
- Notes
- Bibliography
- Index
Summary
Nobody exactly knew what a learning curve was except for saying that whenever you start any new operation you are bound to have unfortunately high mortality … I do not think any surgeon wants to be seen as in a way practising with his patients but that is the definition of ‘learning curve.’
Dr. Janardan Dhasmana, pediatric cardiac surgeon, Bristol Royal Infirmary, United KingdomOn January 10, 1995, Amanda Evans and Robert Loveday took their sick baby, Joshua, to see cardiac surgeon Dr. Janardan Dhasmana at Bristol Royal Infirmary (BRI), a hospital in the United Kingdom. Eighteen-month-old Joshua was suffering from a rare congenital heart deformity called Transposition of the Great Arteries (TGA) in which his heart's aorta and pulmonary arteries were reversed, connected to the wrong sides of his heart. As a result of this misplacement, oxygen-rich blood circulated back to Joshua's lungs rather than to his body, while un-oxygenated blood circulated throughout his body, often turning him blue from hypoxia.
Dr. Dhasmana recommended a relatively new procedure called an Arterial Switch Operation to rectify young Joshua's problem. During this open heart surgery, Joshua's heart would be stopped and his body sustained by a heart-lung bypass machine so that Dr. Dhasmana could sever his heart's arteries and ‘switch’ them to the correct side. Although risky, the operation was an imperative for Joshua who had a life expectancy of less than seven months without the procedure.
- Type
- Chapter
- Information
- Thinking Through CrisisImproving Teamwork and Leadership in High-Risk Fields, pp. 98 - 129Publisher: Cambridge University PressPrint publication year: 2011