Situational awareness is awareness of one’s surroundings including the dimension of time as measured in a functional sense.
This terminology has its roots in aviation(1), but can be applied to medical situations. It is very important for managers and designers of medical systems to understand the importance of situational awareness. In aviation, for example, the pilot must understand air speed, position of the plane relative to the ground, angle of the wings, fuel and presence of other planes . Gladwell(2) describes what happens in aviation when a pilot panics and disregards instruments or other important clues. In medicine, depending on the situation, it is the ability to integrate the condition of the patient, known facts about the patient’s medical history, guidelines for treatment, and functional roles of team members. For example, a patient with abnormal vital signs exhibiting signs of dyspnea (shortness of breath) by gasping or retracting skin in the rib area requires much more urgent intervention than a patient without these signs.
There are many factors that can affect situational awareness. Certainly fatigue can downgrade one’s situational awareness as can lack of experience or training(3).
Interruption and distraction can also detract from situational awareness. In fact, To Err is Human(4) has identified interruption as one potential cause of medical error. The nature of an interruption is one of divided or shifted attention. If one shifts from a primary task to a new task or tries to multi-task, there is degradation in attention to the primary task. A task that interrupts and requires the same cognitive process as the primary task or is longer in duration, is more likely to cause performance degradation of the primary task(5). So for instance writing prescriptions for two patients simultaneously is more likely to be error prone than if the prescriptions are written serially. Much has been written about the use of cell phones while driving as a model of distraction and safety hazard. Strayer(6) et al. have developed a model for explaining why talking on a cell phone is more dangerous (likely to cause an accident) than changing a radio station or conversing with an adult in the front seat. Factors such as the length of the disruption, the inherent risk of the situation and the cognitive and manual skills involved determine the overall risk of the disruption. Designing electronic medical records and knowledge sources in a fashion that permits easy access without diverting attention from the clinical situation are the most likely to improve safety.
Turning away from a patient to interact with a computer to enter the information is also a distraction. The more poorly the computer interface is designed, the more cumbersome the distraction and the more likely that important clinical information will be ‘lost’.
For this reason some medical groups use scribes to assist the physician in interacting with the computer. It has been demonstrated in both Emergency Departments and Urology offices that scribes can be used without a loss in productivity or satisfaction(7,8).
- Helmreich RL. On error management: lessons from aviation. BMJ. 2000 Mar 18;320(7237):781-5.
- Gladwell M, The art of failure. New Yorker 2000 Aug 21; 84-92
- Coombes ID, Stowasser DA, Coombes JA, Mitchell C.Why do interns make prescribing errors? A qualitative study. Med J Aust. 2008 Jan 21;188(2):89-94
- Institute of Medicine. To Err is Human: Building a Safer Health System. [monograph on the Internet]. 1999 [cited 2012 May 10]. Available from: http://www.nap.edu/openbook.php?isbn=0309068371
- Rivera-Rodriguez AJ, Karsh BT. Interruptions and distractions in healthcare: review and reappraisal. Qual Saf Health Care. 2010 Aug;19(4):304-12. Epub 2010 Apr 8
- Strayer DL, Watson JM & Drews FA. Cognitive Distraction While Multitasking in the Automobile. In B Ross editor. Cognitive Distraction While Multitasking in the Automobile. Burlington: Academic Press; 2011. pp.29-58
- Arya R, Salovich DM, Ohman-Strickland P, Merlin MA.Impact of scribes on performance indicators in the emergency department.Acad Emerg Med. 2010 May;17(5):490-4.
- Koshy S, Feustel PJ, Hong M, Kogan BA.Scribes in an ambulatory urology practice: patient and physician satisfaction.J Urol. 2010 Jul;184(1):258-62. Epub 2010 May 16.
- Toner ES. IOM Commissioned Paper--Creating Situational Awareness. [monograph on the Internet]. 2009 [cited 2012 Jun 2]. Available from: Institute of Medicine, Web site: http://www.iom.edu/~/media/Files/Activity%20Files/PublicHealth/MedPrep/Jun-10-11-2009-Commissioned%20Papers/Jun-10-11-2009-Commissioned-Paper-Creating-Situational-Awareness-A-Systems-Approach.pdf
Submitted by Lawrence Dardick, MD