What strikes you from watching the video? 
What parts of this event could have been prevented with a knowledge of human factors? Did you make the following connections as highlighted in  https://drive.google.com/file//0B4dbLgB56hptZDFROU14dHdJRjg/view?
Loss of situational awareness – the stress of the situation meant that the consultants involved became highly focussed on repeated attempts to insert the breathing tube. As a result of this they lost sight of the bigger picture i.e. how long these attempts had been taking. This ‘tunnel vision’ meant they had no sense of time passing or the severity of the situation
Perception and cognition - actions were not in line with the emergency protocol. In the pressure of the moment many options were being considered but they were not necessarily the options that made the most sense in hindsight
Teamwork – there was no clear leader. The consultants in the room were all providing help and support but no one person was seen to be in charge throughout. This led to a breakdown in the decision making process and communication between the three consultants
Culture – Nurses who sensed the urgency early on brought the emergency kit to the room, and then alerted the intensive care unit. They stated that these were available but did not raise their concerns aloud when they were not utilised. Other nurses whowere aware of what was happening did not know how to broach the subject. The hierarchy of the team made assertiveness difficult despite the severity of the situation.

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