Situational Awareness in Surgery - RACS · PDF file• Situational Awareness is a cognitive skill that includes being conscious of what is happening around you, continuously checking

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

Peter Sterling

• He was lightly built • not especially fast • 178cm tall.

Peter Sterling

• 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

• 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

• 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

• 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

• 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

• Near misses lead to caution

Danger • Fosters complacency

• Search of memory for

solution rather than problem solving

• Near misses lead to inertia

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

– 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