Thread by @TurtonsOther

Long thread coming up but I want to put my thoughts about #TheatreCapChallenge down in one last long rambling thread before I block everyone connected to it and move on

1) the logic from certain people is:

People die in theatre

Those deaths stem from errors

Those errors happen because of poor communication.

poor communication occurs through not knowing names

THEREFORE....

If we knew the names of the staff....

Communication will improve

Errors will reduce

Lives will be saved.

IF...

A hat with a name on is an example of knowing someone’s name

THEREFORE

WEARING A HAT WILL SAVE LIVES

and also...

WEARING A HAT WILL SAVE MILLIONS OF LIVES

Let’s break that logic down.

First of all, it’s missing the word SOMETIMES.

Sometimes - people die in theatre. The event rate is actually very low. Reducing it further would take a numbers needed to treat of thousands

Sometime - errors happen in theatre. Yep.....

And a lot of the time errors don’t. Many of those errors or deaths are nothing to do with communication.

Anaphylaxis?
Thio in an artery?
Wrong side phrenic nerve block?
Unexpected dead bowel?
Unexpected AAA?
Intro op PE/MI?
Being really sick knowing this is your only chance?

None of those can be rectified by improving communication. You can argue that the events AFTER can be improved by comms, but the argument has always been that comms will prevent errors, not the response to errors.

Then there’s the type of communication error.

The wrong information (its a left nephrectomy)

Not enough info (just do it!)

Ignoring certain people (St George’s....)

In the BMJ paper commonly cited, misidentification was not listed as a communication error.

So, the logical assertion is wrong. Deaths in theatre are rare, are multifactorial, and an unknown but incredibly small number are attributed to not knowing names. Even then the effect on dying is not known and likely unmeasurable. The intervention is nice but not a life saver.

“But sam, it’s not doing any harm!”

People are equating wrongly that not doing harm is the same as being beneficial.

how do we know? a surgeon who feels like a twerp for wearing it can’t perform properly. I worked in a hospital where we wore paper scrubs and felt an idiot

“But the patient’s will appreciate it!”

We have #hellomynameis for that.

I take my hat off when doing pre op and in recovery as I feel my hair humanises me. I remind them who I am in recovery. The hat won’t help.

Now let’s move on to the more sinister aspects...

“This will save millions of lives!”

No it won’t. To reduce an already low absolute death rate to an even lower one gives a huge NNT.

“I didn’t say millions you’re misinterpreting my words!”

Stop saying it then.

“Medical error is the third largest cause of death and I have a blog to prove it”

No it isnt.

“I didn’t actually say that, stop twisting me words!”

Stop saying it then.

“Is it fair to say every death in theatre could be prevented by better communication through wearing hats?”

No.

“I didn’t say that, stop twisting my words!”

Stop saying it then.

“St George’s could have been prevented by wearing hats”

They knew their names they just hated each other.

“I didn’t actually say that, you people are misinterpreting my words!”

Stop saying it then.

ARE YOU SPOTTING THE PATTERN?!

The hat company: “this has been PROVEN to save lives”.

No it hasn’t. Not even one. Stop it or I’ll call trading standards.

Also stop conflating #TheatreCapChallenge with #hellomynameis. Kate and Chris wouldn’t be trying to force this on us.

We all went mental went Jeremy Hunt went on about weekend deaths and yet we seem perfectly happy to allow these lies and misuse of stats to go unchecked.

Then there’s forceful language being used.

Be brave.
Have courage
Take up the Gillette challenge

If you don’t agree with us you’re swimming against the tide.

Why aren’t people understanding what I’m saying? THIS IS ALL YOUR FAULT.

#hellomynameis works because it’s gentle. No ones forcing me to wear a lanyard or badge. I went to a PBL school in 2003 and the first thing I learnt was to introduce myself. No ones losing their shit if I don’t wear a lanyard if I’m actually introducing myself.

#TheatreCapChallenge fails because it feels like it’s being forced upon us, which isn’t really good for morale is it?

The threats of ripples turning to waves turning into patient safety tsunamis taking out anyone in its path and being told we are the cause of death is horrible.

Finally, there’s the man himself.

The constant tweeting to people who disagree.

Reports of people coming to me and saying “Christ we won’t stop DMing me!”

The Bob Tisdall account.

The fact he never apologises for the upset he causes people.

Apparently this is entirely acceptable.

Oh one last thing.

Alternatives to names on hats exist.

Whiteboards with all the staff names on.

Introducing oneself during the WHO.

Actually just asking who your ODP is.

This reinvention of the wheel adds little.

This was a reasonable idea.

Not a great idea.

Not a game changer.

Not a saver of millions of lives

But a reasonable idea. Soiled by fake accounts, made up statistics, baseless theories and aggressive marketing.

I feel sorry for the poor midwife who’s idea has rotted away.

And that, dear friends, is a special #NHSthisweek!