Non-technical Skills (NTS) are a set of generic cognitive and social skills, exhibited by individuals and teams, that support technical skills when performing complex tasks. Typical NTS training topics include performance shaping factors, planning and preparation for complex tasks, situation awareness, perception of risk, decision-making, communication, teamwork and leadership. This chapter provides a framework for understanding these skills in theory and practice, how they interact, and how they have been applied in healthcare, as well as avenues for future research.

We describe the successful use of cannula cricothyroidotomy and the Rapid-O2™ oxygen insufflation device (Meditech Systems Ltd, Dorset, UK) for rescue of a can't intubate/can't oxygenate (CICO) scenario in a patient with severe airway haemorrhage post-debridement of laryngeal amyloidosis. This case highlights the practical utility of a cannula technique for CICO rescue when appropriate equipment is used and when institutional measures are taken to prepare for this rare anaesthetic crisis.

Purpose of review The purpose is to show the advantages of a Bowtie diagram as a versatile tool for displaying and understanding the evolvement and management of critical incidents. Recent findings The Bowtie diagram has been used recently in anesthesia to depict critical incidents having been used in high-risk industries for several decades. This diagram displays the progression from latent factors to potential harm in five steps. Summary The Bowtie diagram combines the features of a fault tree and an event tree with the adverse event, known as the Top Event separating the two sections. The fault tree is similar in concept to a Swiss Cheese diagram and the event tree similar in concept to an emergency management algorithm. Preventive barriers and escalation measures are used to detect and trap abnormal states. If these fail, the event proceeds to a crisis, leading to the Top Event, a time for making decisions. A recovery state follows, which depicts an emergency state mandating immediate life or limb-saving management to recover from the crisis. Finally, in the aftermath state, a time for reflection and learning, ultimate outcomes are shown in the right-hand column. Video abstract The Bowtie Diagram. Designed and created by Yasmin Endlich, Martin D. Culwick and Stavros N. Prineas.

In the absence of upper airway patency, supraglottic methods of oxygen delivery become ineffective. We present two semi-elective difficult airway cases where oxygenation via the supraglottic route was deemed impractical due to upper airway obstruction. In order to facilitate safe airway management, apnoeic oxygenation was delivered via a narrow bore transtracheal cannula using a flow-regulated oxygen insufflator. The potential for safely prolonging apnoea time with this technique in both elective and emergency settings is discussed.

Drug errors amongst anaesthetists are common. Although there has been previous work on the system factors involved with drug error, there has been little research on the sequelae of a drug error from the anaesthetist's perspective. To clarify this issue, we surveyed anaesthetists regarding their most memorable drug error to identify associated factors and personal sequelae regarding their professional practice after the event. An online survey was sent anonymously to 989 Australian and New Zealand College of Anaesthetists (ANZCA) Fellows in March 2016 and the results were collected over the following two months. There were 295 completed surveys (29.8% response). The majority of respondents were male consultants, aged over 45 years. Reported drug errors occurred most frequently during normal working hours, and the most common drugs involved were non-depolarising muscle relaxants. In 34% of the errors, another anaesthetist was present, and their presence was felt to have contributed in 40.7% of these cases. About 20% of respondents reported that they did not receive adequate support after the event. Sleep patterns were affected in 14.4% of respondents, although very few found that the error had affected their capacity to function at work. These findings suggest that memorable drug errors can be significant enough to have adverse sequelae to anaesthetists, even if no patient harm occurs.

In Chapter 1 we highlighted an example of failed handover in a tragic case report. This example underscores the difficulty that doctors, as a craft group, often have when we try to talk about communication problems. When trying to explain why an adverse event has occurred, we frequently invoke ‘poor communication’ as a contributing factor. Deeper discussion, however, often proves to be a woollier beast, and we often retreat to the comforting realm of the technical, where the landscape is reassuringly familiar and the outlines are, for us, more clearly defined. Unfortunately the mammoth in the room cannot be ignored; under systematic scrutiny, ‘communication failure’ consistently represents one of the lead contributors to serious adverse events. Most recently, analysis of AIMS report data in an Australian area health service revealed that communication problems were the largest single contributing factor to severe and/or life-threatening clinical incidents over a 2-year period (2007–2009). Perhaps if we develop a better vocabulary of the types of communication errors that occur commonly in the workplace, we can be more articulate about them and develop more focused strategies to overcome them. Communication can be defined as the transfer of meaning from one person to another. For the purposes of developing practical communication tools, communication can be broken down into a package of signals sent from one person—the transmitter— to another—the receiver. These signals are both verbal and non-verbal. It is essential to realize that as social beings we are all constantly ‘transmitting’ signals—not just in the content of our words, but the types of words we use, the tone of our voice, our facial expressions, our body language, our physical proximity to others, the way we dress, the material possessions we display, etc. At any one time most of us are only partly conscious of the total package of what we are ‘saying’ to others. At the same time we are constantly receiving signals and, to a greater or lesser extent, trying to read meaning into and ‘make sense’ of these perceptions. Again often we are only partly conscious of the meaning of the ‘vibes’ we receive; yet they can have a profound impact on what we hear from others.

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