Situational Awareness

Question 1

Human factors encompasses

Answer 1

• An understanding of the causes of error and systems failure
• Situation awareness
• Communication in teams
• The limitations of human performance

Question 2

Individuals need

Answer 2

Own situational awareness, awareness of team - ‘big picture’ thinking ahead, keep team up to date

Question 3

Good situation awareness requires 3 conditions

Answer 3

1. Perception
2. Comprehension
3. Projection

Question 4

Good team work will have

Answer 4

• Vigilance (preoccupation with failure)
• Awareness
• Engagement (commitment)
• Trust (deference to expertise)
• Root cause (reluctance to simplify interpretation)

Question 5

Challenges in healthcare teams - communication > patient safety incidents

Answer 5

Multiple patient handovers, hierarchy, cultures that discourage challenge, stress responses, team members don’t feel they can speak up and be listened to if a situation is unsafe

Question 6

Elaine Bromiley

Answer 6

Routine operation - sinus (tunnel vision)

Question 7

Safety briefings

Answer 7

Introduce names and roles - define objective, identify major steps, check critical treatment/equipment, ask ‘what if’, check understanding, plan debrief

Question 8

Example of safety briefing

Answer 8

WHO surgical safety checklist

Question 9

Debriefing

Answer 9

How did you do? How do you feel? What wen well? What didn’t go well? What should we do next time?

Question 10

Wayne Jowett

Answer 10

Vincristine was wrongly administed intrathecally (occurred 13 times in last 15 years)

Question 11

NPSA: medicines most frequently associated with severe harm:

Answer 11

• Anticoagulants
• Antibiotics (allergies)
• Injectable sedatives
• Chemotherapy
• Opiates
• Antipsychotics
• Insulin
• Infusion fluid

Question 12

Insulin

Answer 12

Always write UNITS, prescription charts, passports for patients

Question 13

Human factors that can increase risk

Answer 13

Mental workload, distractions, physical environment, physical demands, device/product design, teamwork, process design

Question 14

Improving situational awareness

Answer 14

1. Avoid reliance on memory
2. State the obvious, avoid ambiguous words
3. Makes things visible - self and team
4. Review and simplify processes
5. Standardise common processes and procedures
6. Routinely use checklists
7. Decrease the reliance on vigilance
8. Self awareness and well being