Pilot, an Airline Safety Expert, Seeks to Improve Patient Safety after the Death of his Wife

This is a dramatization of the medical error that caused the death of this Pilot’s wife, in what should have been a simple routine surgery. This is a great presentation on patient safety and team work problems that contribute to patient care errors.  In this re-enactment of a real event, the physicians are fixated on intubating a patient, and despite the nurses’ clinical grasp that a tracheostomy is needed, the nurses fail to command the attention and action of the physicians.  This is a great consciousness-raising video on the danger of silence and lack of patient advocacy for the patient’s safety. Students should look up the current safety protocol on intubation, where limits are set on number of trials before tracheostomy is recommended. Have the students observe the nurses’ ineffective attempt to get the physicians to move on to perform a Tracheostomy by bringing in a tray. It was the right thing to do in the situation, but the nurses remained silent, only gesturing to the tray and what needed to be done. How could the nurses’ intervention been more effective in this situation?


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