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	@NHS / Scott @NHS	2 oras
	Sumasagot kay @NHS I see most of these on my average ED shift! Important to be aware of them and understand they can effect performance
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	@NHS / Scott @NHS	2 oras
	Sumasagot kay @NHS 1) Lack of Communication 2) Complacency 3) Lack of Knowledge 4) Distraction 5) Lack of Teamwork 6) Fatigue 7) Lack of Resources 8) Pressure 9) Lack of Assertiveness 10) Stress 11) Lack of Awareness 12) Norms
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	@NHS / Scott @NHS	2 oras
	Some things we can take from learning in aviation and apply to our practice do exist. A common 12 factors frequently appear and helpfully called “The Dirty Dozen”. Try and note where they appear on any of your shifts!
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	@NHS / Scott @NHS	3 oras
	This learning is important but we have to remember healthcare is not aviation. A H145 helicopter tends to behave very predictably every time an input is applied. Unwell humans don’t do this!
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	@NHS / Scott @NHS	3 oras
	Sumasagot kay @hSafetyIB The @hSafetyIB was born recently and is starting to look at some of the common incidents in healthcare to see if we can share learning throughout the health service
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	@NHS / Scott @NHS	3 oras
	So there is this huge push and desire to introduce some of this ability to learn from incidents into the health service
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	@NHS / Scott @NHS	3 oras
	Sumasagot kay @NTSB During the investigation it was found the landing gear was locked in position and would have allowed a safe landing. The light failed due to a microswitch being damaged. The crew became task focused and lost all awareness of what was going on around them
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	@NHS / Scott @NHS	3 oras
	Sumasagot kay @NTSB The plane ran out of fuel and crashed into a wooded area of the Portland suburbs. 10 people were killed including 2 from the flight deck.
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	@NHS / Scott @NHS	3 oras
	Sumasagot kay @NTSB Coming into landing at Portland Airport in Oregon the landing gear engaged light failed to illuminate along with a loud thump. The crew spent the next hour trying to diagnose the problem. During this period nobody within the cockpit noted and monitored the fuel level.
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	@NHS / Scott @NHS	3 oras
	Common themes were coming out. There were recurring themes related to cockpit management and communication. The @NTSB made formal recommendations for CRM (Crew Resource Management) training following the tragic events in 1978 of United Airlines Flight 173
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	@NHS / Scott @NHS	3 oras
	In the mid 60s pilots were given a mechanism to report incidents and protocol breaches without fear of prosecution in a confidential fashion
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	@NHS / Scott @NHS	3 oras
	Sumasagot kay @NHS Fatalities started to increase and the question of why? Often resulted in “pilot error”. Common themes started to come out and lots of the pilots not involved in the incidents recognised they had “near-misses" pic.twitter.com/eUFbjyOZxp
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	@NHS / Scott @NHS	3 oras
	In the early 60s civilian aviation was literally taking off (sorry!) and so were the number of safety critical incidents. Pilots were not reporting “near-misses” as there employer would often punish them with their jobs
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	@NHS / Scott @NHS	3 oras
	Aviation learnt quickly that systems can be engineered but the weak part of the system is always the human. The human will often behave unexpectedly compared to the mechanical systems that are very safe
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	@NHS / Scott @NHS	3 oras
	Aviation is inherently dangerous. Placing highly flammable fuel in an engine that is designed to cause the fuel to explode then fly to this over people's heads sounds dangerous but it’s not reckless as safety systems are built into the systems
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	Ni-retweet ni @NHS / Scott
	Linda Dykes @mmbangor	5 oras
	Sumasagot kay @waharrison @NHS at 3 iba pa Thanks, yes indeed, @iron_nikki16 & @LoziEvans got our Paramedic Postbox running last July. Here’s the first 6/12 of data and our resources/forms can be downloaded from cotebangor.org/downloads pic.twitter.com/qzwA3L8yBw
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	@NHS / Scott @NHS	5 oras
	I’m just heading out so will be driving for a bit. When I come back I’m going to cover some of the stuff I’ve learnt from the pilots and how I apply it to my medical practice
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	@NHS / Scott @NHS	5 oras
	Sumasagot kay @waharrison @ujwaliofficial I’m really keen to get some formal feedback arranged for our ambulance crews (if requested) to enable learning. It’s impossible to learn if you don’t get that feedback!
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	Ni-retweet ni @NHS / Scott
	Will Harrison @waharrison	5 oras
	Sumasagot kay @ujwaliofficial @NHS Equally if something can be done differently - many Paras would appreciate constructive feedback. We have very little supervision and it's easy to just carry on doing "what we've always done" because we don't know any different. all feedback is appreciated!
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	@NHS / Scott @NHS	5 oras
	When the helicopter departs it will lift backwards and upwards. The important thing to remember is do not approach the landing site it has took off from until it has clearly flown away. If an engine fails they will put it back onto the same spot with haste!
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