HUMAN FACTORS: SITUATIONAL AWARENESS The human factors topic highlighted in this month's edition is Situational Awareness, as this was identified as a major contributing human factor from the latest thematic analysis of Serious Adverse Event Reviews in NSLHD.
People often ignore warning signs as they lose situational awareness and don’t look at the bigger picture.
According to experts in human factors in healthcare, Global Air Training , Situational Awareness can be described in simple terms as knowing what is going on around you, or having a ‘helicopter view’ of the situation in front of you, as well as what other factors could impact the current situation. It is clear to see how this would be beneficial to the delivery of safe and effective healthcare. What is Situational Awareness? The short video Just a Routine Operation is a compelling example where a loss of situational awareness was seen as one of the predominant causes that led to serious harm. In this case, the clinical team were so focused on dealing with the emergency in front of them that they lost sight of the fact that the patient has been deprived of oxygen for a significant period of time. The film is a reenactment of an actual event, where the patient's husband talks about his experience of losing his wife during an apparently routine procedure and his hopes for making a change to practice in healthcare.
Picture Ref: Daily Mail Australia, 12 June 2018
Endangering colleagues working around you Endangering yourself Forgetting information (due to distraction or interruption) Misinterpreting information (assumption!) Missing information Not passing on all information Not requesting information Hazards associated with lack of situational awareness: Avoid confirmation bias Be assertive, don’t keep concerns inside... Speak Up for Safety Communicate openly & ensure everybody is in the loop If you feel your situational awareness is being lost, say something Interpret the facts, not what you want to see Take time, don’t be rushed Think ahead, plan ahead, review a course of action Try to remain alert and vigilant Recovering or maintaining situational awareness You can practice being more situationally aware using this short model (Endsley, 2005) 1.
Just a Routine Operation Human Factors in Patient Safety YouTube | 13min 55sec
Increasingly “a loss of situational awareness” is identified when reviewing safety incidents internationally. Investigators should first begin to understand why situational awareness may have been lost or not maintained, before considering appropriate measures to reduce the risk of recurrence in the future.
Perception of elements within the environment around you (picking up cues, noticing) Comprehension - understanding the current situation, and Projecting what might happen next (planning ahead
2.
3.
Distractions Execution of improper procedure Fatigue High workload Lack of communication Lack of experience Conditions that contribute to loss of situational awareness:
Made with FlippingBook - professional solution for displaying marketing and sales documents online