INCIDENT REPORT and Example of Remedial Plan of Action

https://www.nytimes.com/2019/10/11/world/africa/soldier-death-somalia.html

Why does it take the NY Times to identify and disseminate our medical lessons learned?!

How was this not immediately circulated to all medics internally the way parachute failure incidents and military vehicle accidents are?!

Why is there not an immediate safety stand down and retraining required?!

Don’t let Dunning-Kruger fool you. Any one of us could have been the initial medic, the receiving PJ or even the patient. Incidents like this can even occur here at hole in the firat world. Have you ever watched the Elain Bromily case?

Imagine if there were a proper incident report posted in every Command hallway, everytime there were a poor outcome experienced across the enterprise?

How much easier would it be to justify training and equipment needs with the penny pinchers, bean counters and check writers who were acutely aware of the actual risk to force?

If the article is accurate, this was a catastrophe for everyone involved. The lives of the patient, the family, the team and the medics are irreversibly altered.

Our last podcast was about High Reliability Organizations. A key hallmark of an High Reliability Organization involved in life and death operations is a preoccupation with failure. We cannot continue to bury our collective failures and must focus on identifying and fixing them all from an organizational level.

Here is a sample plan of action for organizational remedial training that I would do if I were a Senior Leader with medical personnel in my unit.

I personally challenge you to actually complete the following action items this week. If we do not learn from our collective failure we will repeat it until we do.

  • There should be immediate notification, reeducation and retraining for everyone followed by an improved initial and sustainment training plan. Battalion Surgeons, PAs Instructors and Senior Medics should ensure every single medic does the following:
  • Recieve(or Demand) the incident report and AAR from the Chain of Command the way other Saftey Stand Down incident reports are disseminated. -Post it for the entire unit to read next to the parachute failure incident.
  • As a small group, read and review the report and AAR.

  • Reread the guidelines and watch the videos freely available on the DeployedMedicine App

https://deployedmedicine.com/market/11/content/158

  • Ensure everyone immediately participates in hands-on table top training with whatever you currently have available or can easily construct.

https://emcrit.org/emcrit/ultimate-cricothyrotomy-trainer/

-Be sure to discuss shortfalls and inaccuracies of your trainer.-Dont just focus on the single skill, discuss other options that could have led to a better outcome:

-‘Could different patient positioning have helped the situation?’
-‘How could the outcome have been different with various pharmacological adjuncts?’

-‘One of the things I have seen in small group training was to inject a hematoma just over the cricothyroid membrane. This makes it super messy and hard to identify landmarks which is usually a slam dunk training scar.’

-Ask Medics how well their non-Medics are trained to take care of them if it were them on that table?

  • Submit a WRITTEN request through multiple channels for proper equipment citing the article, incident report and TCCC guidelines as justification to your MEDLOG, S4, XO and anyone else who can affect the situation.

-Imagine if 10,000 requests were simultaneously submitted for similar equipment…

  • Identify training deficiencies in your immediate organization and actually make a WRITTEN request to your Command for additional remedial training to be included in future non-medical training.

-Attach the article to the request.

  • Identify equipment deficiencies and again, submit a WRITTEN request through multiple channels for proper equipment citing the article, incident report and TCCC guidelines as justification to your MEDLOG, S4, XO and anyone else who can affect the situation.

-Do you have Super Glottic Airways in every aidbag and IFAK? An Emma Capnograph would have helped identify the false passage instantly.

These are just a few things an HRO can EASILY and IMMEDIATELY accomplish. What else can you do to ensure this death of our brother is not in vain?

3 thoughts on “INCIDENT REPORT and Example of Remedial Plan of Action”

  1. Paul- I can tell you why…policy associated with the investigation. I wrote our AAR right after the event but it was sequestered until the 15-6 was released, which was just recently. Copy have been distributed widely over the last several weeks. I will be happy to send it to you directly. Thanks. Ramey

    1. Thank you Sir. I know your office has been doing good work. We need to take a tragedy like this and turn it in to an opportunity to improve organizational remediation. A response more akin to the grounding of aircraft after an incident.

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