Current Commentary
Situational Awareness and Its Application in the Delivery Suite Leroy C. Edozien,
PhD, FRCOG
The delivery suite is a high-risk environment. Transitions between low-risk and high-risk can be swift, and sentinel events can occur without warning. The prevention of accidents in this environment rests on the vigilance of the individual practitioner at the frontline. It is, therefore, important that the individual practitioner should develop and maintain the cognitive skills to anticipate, recognize, and intercept unfolding error chains. This commentary gives an overview of a nontechnical skill that is essential for safe practice in a delivery suite: situational awareness. A basic description of situational awareness is provided, using examples of loss of situational awareness in the delivery suite and examples of simple interventions that could promote situational awareness. Involuntary automaticity readily creeps in during performance of routine tasks, and cognitive overload could deplete attentional resources that are, by nature, limited. Strategies and tactics for maintaining situational awareness include proactively seeking and managing information on unfolding events, continually updating individual and team mental models, mindful use of checklists and scoreboards, and avoidance of attentional blindness. These simple interventions require minimal financial resources but could immensely enhance clinical performance and patient safety. Situational awareness should be included in the training of obstetrician–gynecologists and other staff working in a delivery suite. (Obstet Gynecol 2015;125:65–9) DOI: 10.1097/AOG.0000000000000597
T
he delivery suite is a high-risk environment. Transitions between low-risk and high-risk can be swift, and sentinel events can occur without warning, with potentially catastrophic consequences. Even when the unit appears quiet, there could be a life-threatening emergency lurking. The price of patient safety in this environment is eternal vigilance of the practitioner at the frontline. It is, therefore, important that the individual practitioner should maintain the cognitive skills to anticipate, recognize, and intercept unfolding error chains. As an authority in patient safety research puts it, “people create safety.”1 Two observations follow from this assertion. Firstly, a system is effective in protecting safety only insofar as the persons who operate it are “safety wise.” Secondly, safety does not just happen; it has to be created. To be safety wise, clinicians should possess nontechnical as well as technical skills. Nontechnical skills are cognitive, social, and personal skills that, combined with technical proficiency, facilitate clinical safety.2 These skills include leadership, decision-making, communication, team work, and situational awareness. This commentary gives an overview of situational awareness, a nontechnical skill that is not only essential for safe practice in a delivery suite but also necessary for effective deployment of the other nontechnical skills. Without situational awareness, there can be no effective leadership, appropriate decision-making, or coherent teamwork.
WHAT IS SITUATIONAL AWARENESS AND WHY IS IT IMPORTANT? From the Manchester Academic Health Science Centre, University of Manchester, St. Mary’s Hospital, Manchester, England. Corresponding author: Leroy C. Edozien, PhD, FRCOG, Manchester Academic Health Science Centre, University of Manchester, St. Mary’s Hospital, Manchester, M13 9WL, England; e-mail: [email protected]. Financial Disclosure The author did not report any potential conflicts of interest. © 2014 by The American College of Obstetricians and Gynecologists. Published by Lippincott Williams & Wilkins. ISSN: 0029-7844/15
VOL. 125, NO. 1, JANUARY 2015
In simple terms, “situational awareness” is the cognitive state of being aware of what is happening around oneself and understanding how evolving events could affect one’s goals and objectives; it is the ability to maintain the “big picture” and think ahead. Endsley3 defines three levels of situational awareness: Level 1—perception of the environment, Level 2—comprehension of what this means, and Level 3—projection into the future. Situational awareness is critical for good decisionmaking; in its absence, poor decisions and acts of
OBSTETRICS & GYNECOLOGY
65
omission result in substandard performance, which in turn may precipitate accidents (Fig. 1). To maintain situational awareness is to be eternally vigilant. Two concepts—short-term memory and mental models— help explain how situational awareness may be maintained or lost.
Memory and Attention The maintenance of situational awareness requires retention of key information in short-term memory. It also may be necessary to retrieve some information from long-term memory and retain it in short-term memory. Short-term memory, our attention capacity, is limited. In a complex and dynamic environment, this limited attention capacity can be consumed and exhausted quickly—by information overload, task complexity, and multiplicity of tasks. As more attention is paid to some elements in the delivery suite, other elements may be forgotten. Case: Dr. X, who has had a busy shift, reviews a cardiotocograph, classifies it as suspicious, and documents a plan to review the trace in 30 minutes. Subsequently, he sees a couple of new admissions, including one woman with severe preeclampsia, and is held up for the next hour. Dr. X forgets to review the trace, which since has become pathologic.
Mental Models A mental model is the internal representation of what is happening externally—what a person thinks is true, not necessarily what is actually true. Situational awareness is lost when a wrong mental model is applied. The mental model may be influenced by preconceptions, goals, and expectations such that we see what we expect to see and subconsciously reject disconfirming cues.
Case: A midwife assisting an obstetrician to administer a local anesthetic injection during repair of a perineal tear opens an ampule. She expects this to be a lidocaine injection and holds it up to the obstetrician for double witnessing. In fact, it is an ampule of bupivacaine and fentanyl injection (used for epidural analgesia), which previously had been returned to the wrong box. She had the wrong mental model.
FACTORS THAT SHAPE SITUATIONAL AWARENESS A number of factors are known to impede situational awareness (Fig. 1). These include stress, fatigue (mental and physical), task saturation, work overload, inattention, distractions, interruptions, poor communication, and automaticity—all of which are experienced commonly in maternity units.
Involuntary Automaticity Automaticity is the process of acting without conscious control. Examples in everyday life include driving and walking. In these activities, however, the person involved is aware of the automatic control and intends it to be that way—this is conscious automaticity. By reducing demands on short-term memory, this allows limited attentional resources to be conserved for other activities (such as holding a conversation while driving). On the flip side, if a task that requires close attention is performed repeatedly, automaticity could kick in without the operator’s being aware—this has been termed “involuntary automaticity.”4 When it creeps in, minimal attentional resource is devoted to the task, and, because this is a task requiring close attention, the likelihood of error is increased. This situation frequently arises when checklists are used and in protocols that require double witnessing, where
Fig. 1. Factors that shape situational awareness. Edozien. Situational Awareness in the Delivery Suite. Obstet Gynecol 2015.
66
Edozien
Situational Awareness in the Delivery Suite
OBSTETRICS & GYNECOLOGY
a task has to be double-checked by a second person. Fundamentally, checklists and double witnessing are useful safeguards against error. In practice, however, involuntary automaticity could occur when these safeguards are used repeatedly. The defense against involuntary automaticity is mindfulness. Case: After an incident of retained swab during repair of a perineal tear, it was found that the completed checklist for this operation indicated that the swab count was complete. Involuntary automaticity had occurred during its completion. Safety incidents occurring despite the use (though inadequately) of a surgical safety checklist in obstetrics include the administration of amoxicillin to a woman in the operating room who had reported having a penicillin allergy.
Complacency A consistent finding of enquiries into intrapartumrelated perinatal deaths is that they were due mainly to clinicians’ failure to recognize a problem and take appropriate action. An analysis of maternity claims undertaken by the U.K. National Health Service Litigation Authority5 found that only one in every five claims involved a high-risk pregnancy, indicating the need to keep the eye on the ball at all times; the transition from low-risk to high-risk or accident can indeed be swift.
Loss of Situational Awareness Level 1 situational awareness includes the obstetrician’s perception of the number and range of admissions on the delivery suite, the available workforce, and the facilities and equipment. Level 1 failures occur when data are not available or when there is failure to observe data or failure to scan the environment for data. Failure also could result when someone has misheard or misread the information. Level 2 situational awareness reflects the degree of comprehension of the perceived data, and this is a function of experience. Level 2 failures occur when an incorrect mental model is applied or when memory fails. Level 2 failure also may result from confirmation bias or various heuristics. Level 3 failure may flow from failure of level 2 situational awareness or result from failed projection of current trends. Case: A woman with uterine leiomyomas has a vaginal delivery, but the placenta is retained. The obstetrician who conducted the delivery leaves to attend another delivery (breech second twin), and the midwife takes
VOL. 125, NO. 1, JANUARY 2015
a coffee break, temporarily handing over the woman’s care to another midwife with the instruction that maternal observations need to be recorded in 15 minutes. For a few minutes during and after the handoff, the woman is unattended by a doctor or midwife. She has a massive hemorrhage and collapses. Her husband rushes out of the room and alerts staff. There was loss of level 1 situational awareness (vital signs not monitored appropriately), level 2 situational awareness (the relieving midwife had the wrong mental model, was unaware of the leiomyomas), and level 3 situational awareness (the staff did not project the history of leiomyomas, prolonged labor, instrumental delivery, and retained placenta, all risk factors for postpartum hemorrhage, and did not anticipate postpartum hemorrhage). The high-risk delivery occurring elsewhere diverted the attention of key staff away from this woman. The incident happened at night when staffing level was low and cognitive load was high.
STRATEGIES AND TACTICS FOR MAINTAINING SITUATIONAL AWARENESS Situational Assessment Strategies There are two approaches to assessing and monitoring developments in the delivery suite. Staff simply could rely on their perception and comprehension of incoming data—data on individual women and aggregate data for the unit—and make projections accordingly. This is the data-driven approach. Alternatively, they could proactively seek and manage information on unfolding events and anticipate problems—the goaldriven approach. The latter approach is more suited to the complex delivery suite environment. It could manifest, for example, as doctors undertaking periodic ward rounds and unscheduled checks rather than being in a response mode, sitting back and relying on the midwife or nurse to keep them abreast of developments. Clarity of purpose and goals also is fostered when structured communication (such as the SBAR— Situation, Background, Assessment, Recommendation—framework) is used to report assessments.6
Handoffs In military aviation, pilots say that “the briefing is the mission”; flawless execution of a flight mission relies heavily on the team’s preflight briefing.7 The hand-off meeting between shifts is akin to the pilots’ briefing. It is the opportunity to identify available resources (workforce and equipment) and threats, determine tactics and courses of action for each woman in labor, anticipate developments, and disseminate lessons learned from safety incidents.8
Edozien
Situational Awareness in the Delivery Suite
67
Use of Checklists and Scoreboards Checklists act as a “forcing function” (in safety design, a constraint that prevents an action’s being taken without prior affirmation of critical information). The World Health Organization Surgical Safety checklist has been shown in a random-allocation trial to be effective in reducing perioperative complications and has been adapted for use in maternity units.9 Checklists also can be used for reporting vaginal examinations, electronic fetal monitoring, fetal scalp blood sampling, and operative vaginal deliveries and for managing a range of conditions such as shoulder dystocia and postpartum hemorrhage.10,11 The advantage (in the context of situational awareness) of using a checklist for these processes is that data are presented in a way that facilitates level 2 (understanding) and level 3 (prediction) situational awareness. Checklists and other means of standardization also help to reduce cognitive load, thus facilitating situational awareness. The disadvantage (or limitation) of checklists is that, as shown above, automaticity could set in during their completion, resulting in false reassurance, a near-miss, or an actual incident.
Be Mindful of Fixation, Confirmation Bias, and “Inattentional Blindness” Sometimes situational awareness is lost when a clinician not only focuses all attention on one aspect of care and loses sight of other aspects, but also remains stuck in this tunnel-vision. A good example would be the accoucheur who persists in trying to achieve an operative vaginal delivery when abandonment and recourse to cesarean delivery is the safer and more appropriate option. In another situation, a surgeon performing a cesarean delivery may lose situational awareness and fail to appreciate the degree of hemorrhage that has occurred because the surgeon has evaluated information about the patient in such a way as to fit preconceived notions and beliefs (“confirmation bias”), discounting cues that suggest otherwise. This may have consequences from delay in administering blood products to hysterectomy or both. Staff in the delivery suite should also be aware of the phenomenon of “inattentional blindness,” the failure to notice a fully visible but unexpected object because attention was focused on another task, event, or object—as happened in the postpartum hemorrhage case briefly outlined above.
Continual Update of Mental Model
CONCLUSION
Staff in the delivery suite should update their mental model continually. There are various ways of doing this. The handoffs and ward rounds provide ample opportunity. Other approaches include periodic critical review of the whiteboard, health records, and care plans and practicing read back (the receiver of a message repeats the message and obtains affirmation). The central information station in the delivery suite, whether it is an electronic board or a low-tech whiteboard, should be a dynamic, rather than static, scoreboard. It is invaluable for continually assessing and reassessing priorities, ensuring that staff are deployed appropriately, and that each woman gets the attention she needs when she needs it. Ward rounds and handoffs should be used not merely for collecting and interpreting data (levels 1 and 2 situational awareness), but also for projecting downstream and anticipating events (level 3 situational awareness). A common mistake by clinicians and managers is to assume that failure to act on an abnormal cardiotocograph reflects a knowledge deficit. In this author’s experience, the failure to act is more commonly due to attention and perception deficits. The effects of fatigue, cognitive overload, and automaticity can be reduced by implementing a buddy system: at regular intervals during a woman’s labor, the cardiotocograph is assessed by a fresh pair of eyes.12
Although it is important to improve systemic defenses against accidents in the delivery suite, it is also important for the clinicians at the frontline to acquire and maintain nontechnical skills and be safety wise. Loss of situational awareness is a common but often unrecognized factor in clinical safety incidents. Situational awareness is an essential skill for staff in the delivery suite and should be included in professional training. Simple interventions, requiring minimal financial resources, could facilitate maintenance of situational awareness and protect patient safety.
68
Edozien
Situational Awareness in the Delivery Suite
REFERENCES 1. Vincent C. Patient safety. 2nd ed. Chichester (UK): WileyBlackwell; 2010. 2. Flin R, O’Connor P, Crichton M. Safety at the sharp end: a guide to non-technical skills. Aldershot (UK): Ashgate; 2008. 3. Endsley MR. Towards a theory of situation awareness. Hum Factors 1995;37:32–64. 4. Toft B, Mascie-Taylor H. Involuntary automaticity: a worksystem induced risk to safe health care. Health Serv Manage Res 2005;18:211–16. 5. National Health Service Litigation Authority. Ten years of maternity claims: an analysis of NHS litigation authority data. London (UK): NHSLA; 2012. 6. Cornthwaite K, Edwards S, Siassakos D. Reducing risk in maternity by optimising teamwork and leadership: an evidence-based approach to save mothers and babies. Best Pract Res Clin Obstet Gynaecol 2013;27:571–81.
OBSTETRICS & GYNECOLOGY
7. Murphy JD. Flawless execution. New York (NY): Harper Collins; 2008. 8. Edozien LC. Structured multidisciplinary intershift handover (SMITH): a tool for promoting safer intrapartum care. J Obstet Gynaecol 2011;31:683–6. 9. Kearns RJ, Uppal V, Bonner J, Robertson J, Daniel M, McGrady EM. The introduction of a surgical safety checklist in a tertiary referral obstetric centre. BMJ Qual Saf 2011;20: 818–22.
10. Fausett MB, Propst A, Van Doren K, Clark BT. How to develop an effective obstetric checklist. Am J Obstet Gynecol 2011;205:165–70. 11. MacEachin SR, Lopez CM, Powell KJ, Corbett NL. The fetal heart rate collaborative practice project: situational awareness in electronic fetal monitoring—a Kaiser Permanente perinatal patient safety program initiative. J Perinatal Neonatal Nurs 2009;23:314–23. 12. Fitzpatrick T, Holt L. A “buddy” approach to CTG. Midwives 2008;11:40–1.
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VOL. 125, NO. 1, JANUARY 2015
Edozien
rev 11/2014
Situational Awareness in the Delivery Suite
69
Situational Awareness and Its Application in the Delivery Suite Leroy C. Edozien,
PhD, FRCOG
The delivery suite is a high-risk environment. Transitions between low-risk and high-risk can be swift, and sentinel events can occur without warning. The prevention of accidents in this environment rests on the vigilance of the individual practitioner at the frontline. It is, therefore, important that the individual practitioner should develop and maintain the cognitive skills to anticipate, recognize, and intercept unfolding error chains. This commentary gives an overview of a nontechnical skill that is essential for safe practice in a delivery suite: situational awareness. A basic description of situational awareness is provided, using examples of loss of situational awareness in the delivery suite and examples of simple interventions that could promote situational awareness. Involuntary automaticity readily creeps in during performance of routine tasks, and cognitive overload could deplete attentional resources that are, by nature, limited. Strategies and tactics for maintaining situational awareness include proactively seeking and managing information on unfolding events, continually updating individual and team mental models, mindful use of checklists and scoreboards, and avoidance of attentional blindness. These simple interventions require minimal financial resources but could immensely enhance clinical performance and patient safety. Situational awareness should be included in the training of obstetrician–gynecologists and other staff working in a delivery suite. (Obstet Gynecol 2015;125:65–9) DOI: 10.1097/AOG.0000000000000597
T
he delivery suite is a high-risk environment. Transitions between low-risk and high-risk can be swift, and sentinel events can occur without warning, with potentially catastrophic consequences. Even when the unit appears quiet, there could be a life-threatening emergency lurking. The price of patient safety in this environment is eternal vigilance of the practitioner at the frontline. It is, therefore, important that the individual practitioner should maintain the cognitive skills to anticipate, recognize, and intercept unfolding error chains. As an authority in patient safety research puts it, “people create safety.”1 Two observations follow from this assertion. Firstly, a system is effective in protecting safety only insofar as the persons who operate it are “safety wise.” Secondly, safety does not just happen; it has to be created. To be safety wise, clinicians should possess nontechnical as well as technical skills. Nontechnical skills are cognitive, social, and personal skills that, combined with technical proficiency, facilitate clinical safety.2 These skills include leadership, decision-making, communication, team work, and situational awareness. This commentary gives an overview of situational awareness, a nontechnical skill that is not only essential for safe practice in a delivery suite but also necessary for effective deployment of the other nontechnical skills. Without situational awareness, there can be no effective leadership, appropriate decision-making, or coherent teamwork.
WHAT IS SITUATIONAL AWARENESS AND WHY IS IT IMPORTANT? From the Manchester Academic Health Science Centre, University of Manchester, St. Mary’s Hospital, Manchester, England. Corresponding author: Leroy C. Edozien, PhD, FRCOG, Manchester Academic Health Science Centre, University of Manchester, St. Mary’s Hospital, Manchester, M13 9WL, England; e-mail: [email protected]. Financial Disclosure The author did not report any potential conflicts of interest. © 2014 by The American College of Obstetricians and Gynecologists. Published by Lippincott Williams & Wilkins. ISSN: 0029-7844/15
VOL. 125, NO. 1, JANUARY 2015
In simple terms, “situational awareness” is the cognitive state of being aware of what is happening around oneself and understanding how evolving events could affect one’s goals and objectives; it is the ability to maintain the “big picture” and think ahead. Endsley3 defines three levels of situational awareness: Level 1—perception of the environment, Level 2—comprehension of what this means, and Level 3—projection into the future. Situational awareness is critical for good decisionmaking; in its absence, poor decisions and acts of
OBSTETRICS & GYNECOLOGY
65
omission result in substandard performance, which in turn may precipitate accidents (Fig. 1). To maintain situational awareness is to be eternally vigilant. Two concepts—short-term memory and mental models— help explain how situational awareness may be maintained or lost.
Memory and Attention The maintenance of situational awareness requires retention of key information in short-term memory. It also may be necessary to retrieve some information from long-term memory and retain it in short-term memory. Short-term memory, our attention capacity, is limited. In a complex and dynamic environment, this limited attention capacity can be consumed and exhausted quickly—by information overload, task complexity, and multiplicity of tasks. As more attention is paid to some elements in the delivery suite, other elements may be forgotten. Case: Dr. X, who has had a busy shift, reviews a cardiotocograph, classifies it as suspicious, and documents a plan to review the trace in 30 minutes. Subsequently, he sees a couple of new admissions, including one woman with severe preeclampsia, and is held up for the next hour. Dr. X forgets to review the trace, which since has become pathologic.
Mental Models A mental model is the internal representation of what is happening externally—what a person thinks is true, not necessarily what is actually true. Situational awareness is lost when a wrong mental model is applied. The mental model may be influenced by preconceptions, goals, and expectations such that we see what we expect to see and subconsciously reject disconfirming cues.
Case: A midwife assisting an obstetrician to administer a local anesthetic injection during repair of a perineal tear opens an ampule. She expects this to be a lidocaine injection and holds it up to the obstetrician for double witnessing. In fact, it is an ampule of bupivacaine and fentanyl injection (used for epidural analgesia), which previously had been returned to the wrong box. She had the wrong mental model.
FACTORS THAT SHAPE SITUATIONAL AWARENESS A number of factors are known to impede situational awareness (Fig. 1). These include stress, fatigue (mental and physical), task saturation, work overload, inattention, distractions, interruptions, poor communication, and automaticity—all of which are experienced commonly in maternity units.
Involuntary Automaticity Automaticity is the process of acting without conscious control. Examples in everyday life include driving and walking. In these activities, however, the person involved is aware of the automatic control and intends it to be that way—this is conscious automaticity. By reducing demands on short-term memory, this allows limited attentional resources to be conserved for other activities (such as holding a conversation while driving). On the flip side, if a task that requires close attention is performed repeatedly, automaticity could kick in without the operator’s being aware—this has been termed “involuntary automaticity.”4 When it creeps in, minimal attentional resource is devoted to the task, and, because this is a task requiring close attention, the likelihood of error is increased. This situation frequently arises when checklists are used and in protocols that require double witnessing, where
Fig. 1. Factors that shape situational awareness. Edozien. Situational Awareness in the Delivery Suite. Obstet Gynecol 2015.
66
Edozien
Situational Awareness in the Delivery Suite
OBSTETRICS & GYNECOLOGY
a task has to be double-checked by a second person. Fundamentally, checklists and double witnessing are useful safeguards against error. In practice, however, involuntary automaticity could occur when these safeguards are used repeatedly. The defense against involuntary automaticity is mindfulness. Case: After an incident of retained swab during repair of a perineal tear, it was found that the completed checklist for this operation indicated that the swab count was complete. Involuntary automaticity had occurred during its completion. Safety incidents occurring despite the use (though inadequately) of a surgical safety checklist in obstetrics include the administration of amoxicillin to a woman in the operating room who had reported having a penicillin allergy.
Complacency A consistent finding of enquiries into intrapartumrelated perinatal deaths is that they were due mainly to clinicians’ failure to recognize a problem and take appropriate action. An analysis of maternity claims undertaken by the U.K. National Health Service Litigation Authority5 found that only one in every five claims involved a high-risk pregnancy, indicating the need to keep the eye on the ball at all times; the transition from low-risk to high-risk or accident can indeed be swift.
Loss of Situational Awareness Level 1 situational awareness includes the obstetrician’s perception of the number and range of admissions on the delivery suite, the available workforce, and the facilities and equipment. Level 1 failures occur when data are not available or when there is failure to observe data or failure to scan the environment for data. Failure also could result when someone has misheard or misread the information. Level 2 situational awareness reflects the degree of comprehension of the perceived data, and this is a function of experience. Level 2 failures occur when an incorrect mental model is applied or when memory fails. Level 2 failure also may result from confirmation bias or various heuristics. Level 3 failure may flow from failure of level 2 situational awareness or result from failed projection of current trends. Case: A woman with uterine leiomyomas has a vaginal delivery, but the placenta is retained. The obstetrician who conducted the delivery leaves to attend another delivery (breech second twin), and the midwife takes
VOL. 125, NO. 1, JANUARY 2015
a coffee break, temporarily handing over the woman’s care to another midwife with the instruction that maternal observations need to be recorded in 15 minutes. For a few minutes during and after the handoff, the woman is unattended by a doctor or midwife. She has a massive hemorrhage and collapses. Her husband rushes out of the room and alerts staff. There was loss of level 1 situational awareness (vital signs not monitored appropriately), level 2 situational awareness (the relieving midwife had the wrong mental model, was unaware of the leiomyomas), and level 3 situational awareness (the staff did not project the history of leiomyomas, prolonged labor, instrumental delivery, and retained placenta, all risk factors for postpartum hemorrhage, and did not anticipate postpartum hemorrhage). The high-risk delivery occurring elsewhere diverted the attention of key staff away from this woman. The incident happened at night when staffing level was low and cognitive load was high.
STRATEGIES AND TACTICS FOR MAINTAINING SITUATIONAL AWARENESS Situational Assessment Strategies There are two approaches to assessing and monitoring developments in the delivery suite. Staff simply could rely on their perception and comprehension of incoming data—data on individual women and aggregate data for the unit—and make projections accordingly. This is the data-driven approach. Alternatively, they could proactively seek and manage information on unfolding events and anticipate problems—the goaldriven approach. The latter approach is more suited to the complex delivery suite environment. It could manifest, for example, as doctors undertaking periodic ward rounds and unscheduled checks rather than being in a response mode, sitting back and relying on the midwife or nurse to keep them abreast of developments. Clarity of purpose and goals also is fostered when structured communication (such as the SBAR— Situation, Background, Assessment, Recommendation—framework) is used to report assessments.6
Handoffs In military aviation, pilots say that “the briefing is the mission”; flawless execution of a flight mission relies heavily on the team’s preflight briefing.7 The hand-off meeting between shifts is akin to the pilots’ briefing. It is the opportunity to identify available resources (workforce and equipment) and threats, determine tactics and courses of action for each woman in labor, anticipate developments, and disseminate lessons learned from safety incidents.8
Edozien
Situational Awareness in the Delivery Suite
67
Use of Checklists and Scoreboards Checklists act as a “forcing function” (in safety design, a constraint that prevents an action’s being taken without prior affirmation of critical information). The World Health Organization Surgical Safety checklist has been shown in a random-allocation trial to be effective in reducing perioperative complications and has been adapted for use in maternity units.9 Checklists also can be used for reporting vaginal examinations, electronic fetal monitoring, fetal scalp blood sampling, and operative vaginal deliveries and for managing a range of conditions such as shoulder dystocia and postpartum hemorrhage.10,11 The advantage (in the context of situational awareness) of using a checklist for these processes is that data are presented in a way that facilitates level 2 (understanding) and level 3 (prediction) situational awareness. Checklists and other means of standardization also help to reduce cognitive load, thus facilitating situational awareness. The disadvantage (or limitation) of checklists is that, as shown above, automaticity could set in during their completion, resulting in false reassurance, a near-miss, or an actual incident.
Be Mindful of Fixation, Confirmation Bias, and “Inattentional Blindness” Sometimes situational awareness is lost when a clinician not only focuses all attention on one aspect of care and loses sight of other aspects, but also remains stuck in this tunnel-vision. A good example would be the accoucheur who persists in trying to achieve an operative vaginal delivery when abandonment and recourse to cesarean delivery is the safer and more appropriate option. In another situation, a surgeon performing a cesarean delivery may lose situational awareness and fail to appreciate the degree of hemorrhage that has occurred because the surgeon has evaluated information about the patient in such a way as to fit preconceived notions and beliefs (“confirmation bias”), discounting cues that suggest otherwise. This may have consequences from delay in administering blood products to hysterectomy or both. Staff in the delivery suite should also be aware of the phenomenon of “inattentional blindness,” the failure to notice a fully visible but unexpected object because attention was focused on another task, event, or object—as happened in the postpartum hemorrhage case briefly outlined above.
Continual Update of Mental Model
CONCLUSION
Staff in the delivery suite should update their mental model continually. There are various ways of doing this. The handoffs and ward rounds provide ample opportunity. Other approaches include periodic critical review of the whiteboard, health records, and care plans and practicing read back (the receiver of a message repeats the message and obtains affirmation). The central information station in the delivery suite, whether it is an electronic board or a low-tech whiteboard, should be a dynamic, rather than static, scoreboard. It is invaluable for continually assessing and reassessing priorities, ensuring that staff are deployed appropriately, and that each woman gets the attention she needs when she needs it. Ward rounds and handoffs should be used not merely for collecting and interpreting data (levels 1 and 2 situational awareness), but also for projecting downstream and anticipating events (level 3 situational awareness). A common mistake by clinicians and managers is to assume that failure to act on an abnormal cardiotocograph reflects a knowledge deficit. In this author’s experience, the failure to act is more commonly due to attention and perception deficits. The effects of fatigue, cognitive overload, and automaticity can be reduced by implementing a buddy system: at regular intervals during a woman’s labor, the cardiotocograph is assessed by a fresh pair of eyes.12
Although it is important to improve systemic defenses against accidents in the delivery suite, it is also important for the clinicians at the frontline to acquire and maintain nontechnical skills and be safety wise. Loss of situational awareness is a common but often unrecognized factor in clinical safety incidents. Situational awareness is an essential skill for staff in the delivery suite and should be included in professional training. Simple interventions, requiring minimal financial resources, could facilitate maintenance of situational awareness and protect patient safety.
68
Edozien
Situational Awareness in the Delivery Suite
REFERENCES 1. Vincent C. Patient safety. 2nd ed. Chichester (UK): WileyBlackwell; 2010. 2. Flin R, O’Connor P, Crichton M. Safety at the sharp end: a guide to non-technical skills. Aldershot (UK): Ashgate; 2008. 3. Endsley MR. Towards a theory of situation awareness. Hum Factors 1995;37:32–64. 4. Toft B, Mascie-Taylor H. Involuntary automaticity: a worksystem induced risk to safe health care. Health Serv Manage Res 2005;18:211–16. 5. National Health Service Litigation Authority. Ten years of maternity claims: an analysis of NHS litigation authority data. London (UK): NHSLA; 2012. 6. Cornthwaite K, Edwards S, Siassakos D. Reducing risk in maternity by optimising teamwork and leadership: an evidence-based approach to save mothers and babies. Best Pract Res Clin Obstet Gynaecol 2013;27:571–81.
OBSTETRICS & GYNECOLOGY
7. Murphy JD. Flawless execution. New York (NY): Harper Collins; 2008. 8. Edozien LC. Structured multidisciplinary intershift handover (SMITH): a tool for promoting safer intrapartum care. J Obstet Gynaecol 2011;31:683–6. 9. Kearns RJ, Uppal V, Bonner J, Robertson J, Daniel M, McGrady EM. The introduction of a surgical safety checklist in a tertiary referral obstetric centre. BMJ Qual Saf 2011;20: 818–22.
10. Fausett MB, Propst A, Van Doren K, Clark BT. How to develop an effective obstetric checklist. Am J Obstet Gynecol 2011;205:165–70. 11. MacEachin SR, Lopez CM, Powell KJ, Corbett NL. The fetal heart rate collaborative practice project: situational awareness in electronic fetal monitoring—a Kaiser Permanente perinatal patient safety program initiative. J Perinatal Neonatal Nurs 2009;23:314–23. 12. Fitzpatrick T, Holt L. A “buddy” approach to CTG. Midwives 2008;11:40–1.
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VOL. 125, NO. 1, JANUARY 2015
Edozien
rev 11/2014
Situational Awareness in the Delivery Suite
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