Situational Awareness in Surgery
On 27th August 2006, Comair flight 5191 took off from the
wrong runway. It was early morning and still dark outside as the
captain (highly experienced and trained) was taxiing the
aeroplane to the runway. Instead of taking the right runway, he
took a wrong turn, which led the plane onto a runway that was
too short for take-off.
During take-off the cockpit is a designated quiet area to allow for
concentration. On this occasion, the captain and co-pilot were
chatting, affecting everyone’s performance. Allowing this talk
meant that the situational awareness of the captain and co-pilot
was reduced and they failed to spot that they were on the wrong
runway.
Their perception of reality was different to the actual reality.
Despite the co-pilot pointing out that there were no lights on the
runway it was another 15 seconds before the captain realised
what was happening, by which time it was too late.
They failed to stop work despite recogising a hazard (there were
no lights even though it was dark). If they had stopped work and
brought their situational awareness in line with actual reality, 49
people would still be alive today!
Hull FC
Peter Sterling
One of the all time great halfbacks
Played 18 tests for Australia
Played in 4 premierships of the ARL
Played in 13 State of Origin matches (4 times
man of the match)
• ARL Hall of Fame
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Peter Sterling
• He was lightly built
• not especially fast
• 178cm tall.
Peter Sterling
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He had control, organisational skills
He knew where everyone was on the football field
He knew what was going to happen next
He was prepared for the unexpected –
he could exploit an opportunity, respond to an
adverse occurrence
He made extraordinary decisions, repeatedly.
Definitions of Situational Awareness
• An aviation term
• Specifically derived from successful fighter
pilots.
Baron Manfred von Richthoven
(the Red Baron)
• Initially a below average pilot (crashed on his
first flight)
• 80 “kills” – the most of any WW1 pilot
• He was not spectacular or aerobatic
• He flew inferior planes
• When he took to the skies, he had a 50-50
chance (or did he?)
Baron Manfred von Richthoven
(the Red Baron)
• In July 1917, during combat he sustained a
serious head injury.
• Unconscious, free falling spin
• With partial visual loss, he managed to land
safely.
Baron Manfred von Richthoven
(the Red Baron)
• Returned to active service against medical advice
• Headaches and temperament change
• On 21st April, flying at low altitude he was shot by
ground fire
• He managed to land but died soon after
• He had violated his own rules of tactical
engagement
• Why?
Definitions of Situational Awareness
• What has happened?
• What is happening?
• What will (might) happen?
College Council and the glass of water.
Situational Awareness is
• The perception of the elements in the
environment within a volume of time and
space
• The comprehension of their meaning
• The projection of their status in the near
future and the impact of action.
Situational Awareness
• Perceive
– An active process of collecting data
• Understand
– Combining data with knowledge and experience
– Creating “mental model”
• Project
– What will happen, what could happen
Situation Awareness
Decision making
Action
Achieving goal
Situational Awareness
• The ability of an individual to retain the big
picture in a dynamically changing
environment
The supra-coeliac clamp
• Situational Awareness is a cognitive skill that
includes being conscious of what is happening
around you, continuously checking
perceptions with reality and the related flow
of information. This skill includes predicting
the immediate and future impact of your own
or the team's actions, including anticipating
complications.
Situational Awareness
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Maintaining the big picture
Thinking ahead
Discussing the expected and the unexpected
Planning for contingencies
Situational Awareness
• Recognising the potential for deviation from
the expected
• Surgery is full of moments requiring intense
focus and concentration
• How to remain alert to the “bigger picture”
without being distracted?
Situational Awareness
• Being alert to potential dangers whilst
performing a task that you perceive to be
important.
The Aorto-caval injury.
Building Situational Awareness
• SLAM TECHNIQUE
• Stop
– Engage your mind
– Think through the task ahead
• Look
– Find any hazard – real or potential.
– What is the unexpected?
• Assess
– Are you prepared for the unexpected
• Manage
Building Situational Awareness
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Set specific objectives
Set priorities
Prepare for anomalies
Ask “What if?”
Manage workloads
An operation
• Is a series of complex tasks
• Many individuals involved with specific and
overlapping responsibilities
• Things do not always go as planned
• Have you considered unexpected occurrences,
what you will require, what you will do!
The Surgeon
• Creates a mental model of the operation
• It requires constant “up-dating”
• Priorities may change
• Roles may alter
• The bigger picture must remain constant
• Is the mental model correct?
• Is what you have perceived the reality?
Maintaining Situational Awareness
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Communicate (keep everyone in the loop)
Seek information constantly
Seek validating data, cross check
Seek contradictory elements between “real
world” data and working mental model
• (Is what you perceive the situation to be really what is
happening?)
• Be prepared to readjust plan
Detecting Loss of
Situational Awareness
Is there
– Ambiguity
– Fixation, pre-occupation
– Confusion
– Unresolved discrepancies
– Poor communication
– Broken rules
– Lack of time?
The Dinner Party
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6 items required from supermarket
On the way, car phone rings.
Determined not to forget 6 items!
Half the road closed because of roadworks.
• Waved through by road worker, crossed red
light – near miss!
• Came home with 5 items
• “There is no such thing as a simple operation”
Losing Situational Awareness
• Perception
– Tunnel vision
– Complacency
– High workload
– Interruptions or distractions
– Deficient observation
Losing Situational Awareness
• Understanding
– Poor knowledge or experience
– Wrong or inappropriate mental model
– Confirmation Bias (seeing what you expect to see
rather than what is actually happening, based
upon misperception)
Losing Situational Awareness
• Projecting
– over-reliance on the mental model by failing to
realise that the mental model needs to change in
a dynamic environment.
Losing the “bigger” picture
• The blinking warning light
Losing the bigger picture
• Becoming too focused
– “Impervious” to the dynamic flow of information
– Losing awareness of what others are doing
– Failure to consider options
– Failure to question perceptions
• Being distracted
A clinical problem
• The operation is proceeding as planned
• Suddenly the anaesthetist exclaims “what
have you done? I have lost blood pressure!”
• Your mental model of the operation is in
tatters
• How do you proceed?
Recovering
Situational Awareness
Follow rules, procedures
Create time
Ask for help
Go back to the last thing that you were sure of
Expand your focus, recover the big picture
Manage distractions
Why is situational awareness an issue?
Why is situational awareness an issue?
• Operating theatres are highly complex
environments
• It is a dynamic environment
• Multiple people are involved
• Technical skills are at extremely high level
If at first you don’t succeed …..
If at first you don’t succeed …..
- sky jumping (parachuting) is not for you!
• Situational awareness assists in confronting a
“first time “ event.
Wrong site or side procedures.
• Estimated occurrence = 1 in 100,000 operations
• How many operations does a surgeon perform in a
lifetime?
• This “never” event is not avoided by experience
alone.
The size of the problem.
The Quality in Australian Healthcare Study
Wilson, Runciman et al
Med J Aust 1995
16.6% of hospital admissions experienced an adverse event
51% of these were potentially avoidable
13.7% experienced permanent disability
4.9% died
The size of the problem.
To Err is Human – building a safer health system
Institute of Medicine
1999
98,000 preventable deaths annually in US hospitals.
The size of the problem.
Society of Actuaries, US Dec 2010
• 7% of all inpatients experience medical injury
• Total cost $19.5 billion
The size of the problem.
In Hospital Avoidable Medical Error
- the eighth leading cause of death, surpassing MCA deaths,
AIDs, and breast cancer.
“Avoidable medical error is a greater public health hazard than
malaria!”
- WHO
The size of the problem.
World Healthcare Organisation 2008
“One person in 10 receiving healthcare will suffer preventable
harm”
The size of the problem.
One patient in 10 suffering an avoidable event will occur if the
hospital care provided is 99.97% correct.
The size of the problem.
Average length of stay of “multi-day” surgical patient = 3 days
Average number of interventions per day = 100
The size of the problem.
One patient in 10 suffering an avoidable event will occur if the
hospital care provided is 99.97% correct.
How can we improve on this?
To date, we have not been able to.
The problem
• One patient in ten will suffer avoidable medical
harm in hospital.
• 5% of these will die, 50% will have morbidity
• More then 20% of these will occur in the
operating theatre
• Of these,, more than 50% are due to teamwork
(communication) failure.
Communication failure
• Lack of empowerment
• Different perceptions of the situation
Lessons for Consideration
• Communication – am I hearing or just
listening?
• Are things progressing as expected?
• What is the most important thing?
• Am I too focused?
• Am I being distracted?
• Do I need help?
Summary
Situational Awareness for the Surgeon
• Is about planning ahead? Anticipating potential
problems before they occur
• Is dynamic, constant data inflow
• Beware of seeing what you expect to see
• Is about “receptive concentration” to the exclusion of
distractions.
• Is about retaining the bigger picture
• Is continually questioning the mental model, looking
from variations from the expected.
• Involves communication, leadership
What is the difference between
• Situational awareness
• Experience
• Intuition
• Horizon scanning?
Experience
Both beneficial and dangerous
Benefit
• Helps to create the mental
model
• Awareness of deviations
Danger
• Fosters complacency
• Near misses lead to caution
• Near misses lead to inertia
• Search of memory for
solution rather than
problem solving
Why is communication important?
• Analysis of 2455 sentinel events (Joint
Commission) – primary root cause was
communication failure.
What is the difference between
• Situational awareness
• Experience
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Knowledge, understanding the way things should be
Aids SA
Cannot be relied upon to the exclusion of SA
Aids in mental model, but risks are complacency and attempting to
solve problems by recall rather than thinking
• Intuition
– Subconscious
• Horizon scanning?
– SA is near future and dynamic
The case for structured
communication
• S - “Dr. Grigg, I am calling about Mr. Smith who is having
trouble breathing”
• B - “He was admitted with chronic lung disease and now is
acutely worse”
• A – “There are no breath sounds on the right side. I think he
has a pneumothorax.”
• R – “ I need you to see him right now. He may need an urgent
chest tube.”
The case for structured
communication
• SBAR (should it be taught?)
– Situation
– Background
– Assessment
– Recommendation