#203 Enhancing Perioperative Patient Safety through Situational Awareness
May 21, 2024
Anesthesia Patient Safety Foundation
Discover how mastering situational awareness can revolutionize your approach to perioperative patient safety in our latest podcast episode. We are joined by David Tscholl, an esteemed anesthesiologist and researcher from the University Hospital in Zurich, Switzerland who unveils critical findings from recent studies in this February 2024 APSF newsletter article. The shocking revelation that 80% of adverse events in anesthesia and critical care are due to errors in situational awareness underscores the urgency of this discussion. This enlightening conversation promises to equip you with the knowledge to enhance your decision-making skills in the high-stakes perioperative environment.
With a deep dive into the concept's origins from aviation psychology to its application in anesthesia care, we dissect the cyclical sequence of perceiving, comprehending, and projecting crucial information for maintaining situational awareness. We also highlight how experience, knowledge, and training can build this critical skill, while cautioning against the negative impacts of fatigue and excessive workload. The episode is enriched with a visual tool in the show notes, helping to illustrate this three-tiered concept and its influence on patient outcomes. Join us for an episode that promises not only to inform but also to transform the way you perceive and react to the ever-changing dynamics of anesthesia patient care.
Discover how mastering situational awareness can revolutionize your approach to perioperative patient safety in our latest podcast episode. We are joined by David Tscholl, an esteemed anesthesiologist and researcher from the University Hospital in Zurich, Switzerland who unveils critical findings from recent studies in this February 2024 APSF newsletter article. The shocking revelation that 80% of adverse events in anesthesia and critical care are due to errors in situational awareness underscores the urgency of this discussion. This enlightening conversation promises to equip you with the knowledge to enhance your decision-making skills in the high-stakes perioperative environment.
With a deep dive into the concept's origins from aviation psychology to its application in anesthesia care, we dissect the cyclical sequence of perceiving, comprehending, and projecting crucial information for maintaining situational awareness. We also highlight how experience, knowledge, and training can build this critical skill, while cautioning against the negative impacts of fatigue and excessive workload. The episode is enriched with a visual tool in the show notes, helping to illustrate this three-tiered concept and its influence on patient outcomes. Join us for an episode that promises not only to inform but also to transform the way you perceive and react to the ever-changing dynamics of anesthesia patient care.
You're listening to the Anesthesia Patient Safety Podcast, the official podcast of the Anesthesia Patient Safety Foundation. We're bringing you the very best from the APSF newsletter and website, as well as the latest information in perioperative patient safety. Thanks for joining us.
Speaker 2:
Hello and welcome back to the Anesthesia Patient Safety Podcast. My name is Allie Bechtel and I'm your host. Thank you for joining us for another show. It is almost time for the June 2024 APSF newsletter, but don't worry, there is still time to cover more articles from the February 2024 newsletter. This week we are going to be talking about situational awareness, but before we dive into the episode today, you've heard me recognize our corporate supporters on this show. But there's another supporter who is absolutely essential you. Every individual donation matters so much. Please visit APSForg and click on the Our Donors heading and consider making a tax-deductible donation to the APSF.
Speaker 2:
In the quest for improved patient safety, situational awareness breakdowns are a big obstacle. That's what our show is all about today. So let's head back to the February 2024 APSF newsletter and our featured article. Apsf newsletter and our featured article Three Quarters of Preventable Patient Harm Stems from Situational Awareness Breakdowns Recognizing and Addressing the Core Issue by David Choll and colleagues. To follow along with us, head over to APSForg and click on the newsletter heading First. One down is the current issue. Then scroll down until you get to our featured article today. I will include a link in the show notes as well To kick off the show. Today, we are going to hear from one of the authors. Here he is now.
Speaker 3:
Hello and thank you for having me on the podcast. My name is David Scholl. I'm an anesthesiologist and researcher at the University Hospital in Zurich, Switzerland. My group focuses on developing innovative technologies to enhance situation awareness in the operating room and beyond.
Speaker 2:
I asked Scholl why he wrote this article. Let's take a listen to what he had to say.
Speaker 3:
My collaborators and me wrote this article because we wanted to remind everyone that significant studies, which we cite in the article, found that in over 80% of cases, adverse events in anesthesia in critical care are caused by errors in situation awareness. These errors arose because important information either could not be recognized or the correct conclusions could not be drawn from it. Knowing this gives us a point of attack for further improving patient safety, namely by focusing on improving care providers' situation awareness.
Speaker 2:
With over 80% of cases of adverse events in anesthesia caused by errors in situational awareness. This is a high-yield topic that we are excited to feature on the show today. So here we go. The authors start things off with some background information and definitions. What is situational awareness? It will likely not come as a surprise that the concept of situational awareness first started in aviation psychology. 30 years ago, david Gaba, an anesthesiologist at Stanford University and former member of the APSF Board of Directors, brought situational awareness from aviation to anesthesia. The concept of situational awareness was further advanced by Mika Ensley, an engineer, was further advanced by Mika Ensley, an engineer, and Christian Schultz, an anesthesiologist, about 10 years ago. Now these APSF authors are highlighting the importance of situational awareness to help keep patients safe during anesthesia care.
Speaker 2:
It's time for some definitions. Situational awareness starts with a cyclical sequence of perceiving individual elements of information from the environment this is level one Then comprehending their collective meaning this is level two and finally projecting the meaning of that comprehension into the immediate future, which is level 3. One of the key considerations is that only when the relevant information is perceived can its importance then be understood and then used to predict where the situation may lead. We can think of situational awareness as the foundation of our decision-making ability. By allowing us to construct a mental model of a given situation and its near future, this provides us with the ability to predict the consequences of our actions. We can build situational awareness with experience, knowledge and training. Keep in mind that fatigue, excessive workload and system complexity can have a negative impact. This is a pretty complex topic, so the authors provide a visual representation of it in Figure 1, which depicts the three-tiered concept of situational awareness and factors that positively and negatively affect it. I will include this in the show notes as well, and we are going to review it now. This is based on Ensley's model of situational awareness, adapted to highlight the impact on patient safety.
Speaker 2:
Let's start with the situational awareness box, which includes the following three levels First, perception of data and elements in the environment. Second, comprehension of the meaning and significance of the situation. And third, projection of future states and events. If we move right out of the box, we hit the decision-making box and from here we can travel to either performance of action or deliberate inaction. Moving out of both of these boxes, we converge on the increased patient safety box that arises from situational awareness. From the graphic, we can see the influences of the task and environmental factors, including workload, stressors, system design and complexity, which negatively impact our situational awareness. We can also see the impact of individual factors that positively impact our situational awareness, including goals, preconceptions, knowledge, experience, training and abilities.
Speaker 2:
Imagine you are the anesthesia professional providing care in the operating theater and you notice a gradual decrease in the patient's blood pressure. Then you notice an increase in the volume of blood in the suction canisters, as well as an increasingly nervous surgeon. These observations fall into the first level of situational awareness. Have you ever been in this situation? I am sure that many of us had made similar observations, but we may not have known that this was the first level of situational awareness. From these observations then you gather that this is most likely a bleeding situation. This is level two situational awareness. Depending on the severity of the bleeding, the patient's comorbidities and surgical factors, you anticipate that additional help is needed. This brings us to the third level of situational awareness. You make the phone call for additional help and move on to the next steps when caring for the patient.
Speaker 2:
In this example, it is easy to see how situational awareness can improve patient safety. This cycle of observations and decision-making repeats continuously while providing patient care, with the anesthesia professional adapting to new challenges and optimizing patient safety. It is important to reduce the effort to build situational awareness during anesthesia care to promote faster and more effective patient safety decisions with reduced workload. At least 75% of errors in medicine are human errors, which are ultimately situational awareness errors, so we need to improve our situational awareness to help decrease errors and improve patient safety. One of the fundamental principles of healthcare, according to the World Health Organization, is to first do no harm. We are still striving to meet this goal. Adverse events that may lead to preventable patient harm include medication errors, unsafe surgical practices, and this includes performance of non-routine procedures by inexperienced surgeons, wrong site surgery, retained surgical instruments or anesthesia-related errors, healthcare-associated infections and incorrect diagnoses.
Speaker 2:
Let's take a look at the literature on situational awareness and adverse events in the 2016 article by Schultz and colleagues Situational Awareness Errors in Anesthesia and Critical Care in 200 Cases of a Critical Incident Reporting System. I will include the citation in the show notes as well. This was an observational study with two experts independently reviewing cases from the German critical incident reporting system. Cases were related to anesthesia or critical care for an individual patient in a hospital setting, with qualitative analysis for the role of situational awareness for decision-making. The results revealed that situational awareness errors occurred in over 80% of the cases, especially for perception about 38% and comprehension 31.5%. Projection-level errors had a lower rate of about 12%. The investigators concluded that situational awareness errors were common for these critical incidents and determining the different levels of situational awareness for critical incidents can be useful for improved decision.
Speaker 2:
The rate of situational awareness errors is similar in aviation as well, at about 80-85%. Did you know that the three worst airline accidents in the past 20 years were due to errors in situational awareness? This includes the Asiana Airlines Flight 214 in San Francisco, airlines Flight 214 in San Francisco, the Colgan Air Flight 3407 in Buffalo, new York, and the ComAir Flight 5191 in Lexington, kentucky. Before we define the concept of situational awareness, experts in aviation recognized that the machines were too complex for humans to operate safely without checklists. The aviation industry has maintained a high safety standard with improved technology and training, using standard operating procedures and increasing awareness to optimize situational awareness.
Speaker 2:
From the study by Schultz and colleagues, errors in perception were the most common for the in-hospital critical incidence. This is when healthcare professionals do not perceive information available to them in their environment. An example is when an anesthesia professional does not notice the change in blood pressure while setting the parameters on the ventilator after induction and intubation. The second most common error is misinterpretation of the perceived information. And the third most common error is incorrect projection of the situation into the near future. The authors highlight an important consideration for improved anesthesia patient safety is to use situational awareness optimization to address the APSF's top 10 perioperative patient safety priorities. We have emphasized the role of errors in situational awareness leading to adverse events during anesthesia care.
Speaker 2:
So what can we do to improve situational awareness and, ultimately, patient safety? The first step is understanding the fundamentals of situational awareness To efficiently transfer goal-relevant information to the decision makers, thus allowing the decision makers to make informed and timely management decisions with minimal cognitive effort. Let's review several points to consider for systems that are optimized for situational awareness. According to the book Designing for Situational Awareness by Mika Ensley, these can be applied to healthcare systems as well. First, organizing and displaying relevant information around the healthcare professional's main goals to facilitate perception and understanding of the most important data. An example of this is incorporating checklists or intuitive visualization techniques. Second, enabling critical cues to be easily identifiable through signals that attract our attention through changes in color, form or frequency. This helps healthcare professionals to be able to make efficient decisions while maintaining a comprehensive understanding of complex situations. This can be accomplished using our parallel processing abilities and optimizing informational delivery with the principles of human visual information processing. And third, use of new technologies based on predictive algorithms to support level 3 situational awareness projections. We need to optimize situational awareness for any patient safety initiatives going forward, keeping in mind the impact of the task, environmental factors and individual factors.
Speaker 2:
We made it to the end of the article. The authors report that when comparing situational awareness in medicine and aviation, a patient would need daily anesthesia for 548 years to see the 1 in 200,000 mortality risk that is estimated for a healthy patient, risk that is estimated for a healthy patient. In aviation, a pilot would need to fly daily for 25,000 years to face a fatal plane crash, based on data from the International Air Transport Association Safety Performance Report of 2023. These are very uncommon events, but non-lethal critical incidents happen much more frequently and are often due to errors in situational awareness. Using situational awareness-oriented design can improve patient safety going forward. Before we wrap up for today, we are going to hear from Chol again. I also asked him what do you envision for the future with regards to this topic? Let's take a listen to what he had to say.
Speaker 3:
I hope that this underlying cause of reduced patient safety receives the attention it deserves. I would like to advocate the importance of situation awareness and to keep this topic in mind as we further develop our field. How can we ensure that all team members achieve the highest possible level of situation awareness? We provide some ideas for this in our article, but of course, it's only just the beginning and we all should continue to focus on this important issue.
Speaker 2:
Thank you so much to Joel for contributing to the show today. We are looking forward to learning more about increasing perioperative situational awareness for healthcare professionals going forward. Do you work in an institution that has a situation awareness-oriented design to facilitate perception, interpretation and projection? Do you have any ideas for helping to improve situational awareness during anesthesia care? Let us know by sending an email to podcast at apsforg, or you can tag us on X at apsforg and we can feature your innovation right here on the podcast. If you have any questions or comments from today's show, please email us at podcast at APSForg. Please keep in mind that the information in this show is provided for informational purposes only and does not constitute medical or legal advice. We hope that you will visit APSForg for detailed information and check out the show notes to links to all the topics we discussed today.
Speaker 2:
Have you seen the original APSF Prevention and Management of Operating Room Fires video, which was released in February 2010? Well, the APSF has an exciting announcement we have an all-new video and resource page dedicated to Surgical Fires, a Preventable Problem. The new video is an exciting tool for helping to keep patients safe. It is called Preventing Surgical Fires. It is about five minutes long and filled with information to help prevent this serious event. Plus, it will be available in multiple languages. Other resources include commentaries for the anesthesia professional and the ENT surgeon to put the recommendations in the video into the context of current practice, as well as printable posters and visual aids. You can use the video and supplemental information to lead a fire safety session at your institution. We hope that you will check it out and share it with your colleagues. I will include a link to the page in the show notes as well. Until next time, stay vigilant so that no one shall be harmed by anesthesia care.