Description
Instructions:Read the article “Understanding situation awareness and its importance in patient safety” (attached below)Respond to two of the following prompts Identify and discuss the five most salient points of the article in your opinion. How do these relate to Medical Assistants? Be specific and detailed.Identify and describe a minimum of ten factors in ambulatory care that would promote situational awareness for new medical assistants. Explain your rationale for the order of ranking each one. Compare and contrast the three levels of cognitive processing described in the article and how these relate to medical assistants. Provide an example that is not already included in the article. You may use examples from previous MA coursework.Expectation: Your original post would be approximately the level of a two-page paper.
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CPD
CONTINUING
PROFESSIONAL
DEVELOPMENT
Understanding situation awareness
and its importance in patient safety
NS840 Gluyas H, Harris S-J (2016) Understanding situation awareness and its importance in patient safety.
Nursing Standard. 30, 34, 50-58. Date of submission: October 29 2015; date of acceptance: December 10 2015.
Aims and intended learning outcomes
Abstract
Situation awareness describes an individual’s perception, comprehension
and subsequent projection of what is going on in the environment around
them. The concept of situation awareness sits within the group of
non-technical skills that include teamwork, communication and managing
hierarchical lines of communication. The importance of non-technical
skills has been recognised in safety-critical industries such as aviation,
the military, nuclear, and oil and gas. However, health care has been slow
to embrace the role of non-technical skills such as situation awareness in
improving outcomes and minimising the risk of error. This article explores
the concept of situation awareness and the cognitive processes involved
in maintaining it. In addition, factors that lead to a loss of situation
awareness and strategies to improve situation awareness are discussed.
Authors
Heather Gluyas Associate professor, Murdoch University, Mandurah,
Australia.
Sarah-Jane Harris Co-ordinator of nursing practice and policy,
St John of God Murdoch Hospital, Perth, Australia.
Correspondence to: h.gluyas@murdoch.edu.au
Keywords
cognitive factors, communication, errors, human factors, patient safety,
situation awareness
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This article aims to inform nurses about the
importance of situation awareness and the need
to maintain it to minimise the likelihood of
errors. Situation awareness will be referred to
as SA throughout the article for ease of reading.
After reading this article and completing the
time out activities you should be able to:
Discuss the cognitive processes involved in
maintaining SA.
Identify the factors that can lead to
a loss of SA.
Describe strategies to mitigate the loss of SA.
Identify opportunities to incorporate
knowledge of SA and associated strategies
into professional practice.
Introduction
SA describes an individuals’s perception,
comprehension and subsequent projection
of what is going on in the environment
around them (Endsley 1995). In other words,
it describes people noticing what is going
on around them, working out what the
information they are noticing means, and using
that information to plan required actions or
decisions (Flin et al 2008).
Although this article describes the
significance of SA in health care, it is important
to recognise that SA is part of people’s cognitive
functioning in all contexts. For example, when
driving on a busy road people are not only
undertaking the technical and complicated
task of driving, but also will be scanning the
environment. They will be looking at the
traffic in front of them and for brake lights
or indicators so they can anticipate changing
traffic speeds or the need for evasive action.
They will be watching for other hazards, such
as small children on the pavement who might
run onto the road or people crossing the road
recklessly, which may require corrective action
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to prevent an accident. Thus SA – processing
what is happening, what it means and what
needs to be done as a result – is an important
cognitive state that helps people make decisions
and undertake tasks in relation to all aspects
of their life (Gluyas and Morrison 2013).
Complete time out activity 1
The concept of SA sits within the group of
non-technical skills that include teamwork,
communication and managing the
hierarchical lines of communication that tend
to exist in health care. Hierarchical lines of
communication lead to what is termed as an
authority gradient and arise from a perceived
professional hierarchy that results in junior
staff feeling powerless to question or challenge
senior staff (Gluyas and Morrison 2013).
Non-technical skills are studied in the broader
discipline of human factors, which examines
the relationship between humans’ thinking
and cognitive processing and the environment
(White 2012).
The importance of non-technical skills has
been recognised in safety critical industries
such as aviation, military, nuclear, and oil
and gas. Investigations into major disasters
in such industries identified that rather than
deficient technical skills, it was non-technical
skills, such as a loss of SA, that were implicated
in many incidents (Endsley and Jones 2012).
Examples of catastrophic incidents, where a
loss of SA was a contributing factor, include
the Chernobyl and Three Mile Island nuclear
disasters in 1986 and 1979 respectively, the
Piper Alpha oil rig accident in 1988 and the
Tenerife aviation collision in 1977 (Flin et al
2008, Wachter 2012).
Health care has been slow to embrace the role
of non-technical skills such as SA in improving
outcomes and minimising the risk of error
(Bromiley 2014). Healthcare literature was
beginning to promote discussion about SA and
error from the late 1990s (Gopher and Donchin
2011). However, in 2005, the high-profile case
of Elaine Bromiley identified the crucial role of
SA in clinical care errors. The case involved the
death of a young wife and mother following
failed intubation for routine surgery (White
2012). Elaine’s husband was an airline pilot
and, during the ensuing investigation, noted
that the role of human factors and SA were
not recognised immediately in healthcare
investigations. In 2007, he established the
Clinical Human Factors Group and in so doing
helped to shift the focus on human factors and
SA in health care from the realms of academia
to the clinical area (Reid and Bromiley 2012,
Bromiley 2014).
SA is imperative for improving patient
outcomes in many aspects of clinical care
(Stubbings et al 2012). Even a simple task such
as the allocation of nurses’ meal breaks requires
a degree of SA to ensure that patient care is
not compromised. For example, the following
factors need to be considered:
The nurses going off for a break in
comparison to those remaining on the
ward (the ‘what?’).
Whether the skill mix and numbers of
those remaining on the ward are appropriate
(the ‘so what?’).
Whether this decision would be prudent
in the case of a medical emergency (the
‘what now?’).
To use another example: a nurse walks into a
patient’s room to answer a call bell and notices
that the patient’s drainage bag is full of blood.
This is the ‘what?’ stage of SA. Interpreting the
meaning of this observation may then lead the
nurse to conclude that if the drainage bag is full
of blood, the patient is possibly haemorrhaging.
This is the ‘so what?’ stage of SA. Through
this analysis, the nurse may decide that the
patient is at risk of hypovolaemic shock and,
therefore, requires urgent attention. The nurse
subsequently seeks immediate medical review.
This is the ‘what now?’ stage of SA.
Decision making is required in everyday
clinical practice, not only in specialised
environments or during crises. The aim of SA
is to prevent critical situations from developing
(Stubbings et al 2012). Therefore, it is imperative
that the factors that improve SA are included
in the training and education of healthcare
professionals if patient safety is to be improved.
Training and education programmes
to improve SA involve identifying and
understanding the role of cognitive processing
in SA. This understanding forms the basis
for being able to examine different situations
to identify the factors that will likely have a
negative effect on achieving SA. Individuals
can use this knowledge to improve SA in
similar situations.
Cognitive processing in situation
awareness
SA is not a static state but rather an ongoing
process that is normally used in relation
to dynamic situations that require tasks,
decisions and actions to be undertaken or
completed. It involves three levels or stages of
1 Consider the
following scenario from
an SA perspective:
you are preparing a meal
and your three-year-old
child comes into the
kitchen and starts
to climb onto a stool
‘to help’. You notice
that the pot handle is
facing outwards from
the top of the stove,
there is a sharp knife
on the cutting board
and there is a hot cup
of coffee on the kitchen
worktop. Answer the
following questions:
What information
will you be processing
about the situation
(perception)?
What does this
information mean
(comprehension)?
What actions are
required (projection)?
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cognitive performance (Figure 1) (Endsley and
Jones 2012):
Level 1: perception of elements in the
environment.
Level 2: comprehension of the current
situation.
Level 3: projection of future status.
Each of these levels will be discussed separately,
however it is first important to recognise the
effect of time on SA. The perception by the
individual of the amount of time available
until a decision needs to be taken will have
an effect on SA. For example, perceived
time pressures may lead to reactive decision
making (Stubbings et al 2012). If the individual
estimates that a decision is required quickly,
cues may be missed in the perception stage and
not considered in the comprehension stage,
thus leading to a flawed projection stage. In
addition, a rapidly changing situation requires
rapid changes in perception, comprehension
and projection, and can result in outdated or
inaccurate SA (Carayon 2011).
Level 1: perception
The sensory systems of vision, hearing, smell,
taste and touch provide individuals with the
information to perceive what is happening in
the environment around them. For example,
nurses may use any or all of these five senses
when undertaking a physical assessment of a
patient. They may look for and feel skin turgor,
listen to respiratory patterns or a cardiac
rhythm, smell alcohol on a patient’s breath or
smoke on clothing, and hear the sounds of,
FIGURE 1
Three levels of cognitive performance involved in situation awareness
Perception of elements in the environment
Noticing what is going on in the proximate environment
Comprehension of the current situation
Processing the information to make sense of what is happening
Projection of future status
Deciding what tasks, decisions and actions need to happen
(Endsley and Jones 2012)
and see the visual display lights on, a patient
monitor. These sensory inputs are processed
selectively because, in any given situation,
there is a significant amount of information,
which is impossible for an individual to
process. Selective processing of the incoming
information relies on past experiences that are
stored in the memory. These memories provide
nurses with cues to help recognise what it is
important to notice and what can be ignored.
The memories can be stored in either working
or long-term memory stores. However, it is the
working memory (also known as short-term
memory) that has a greater role in the
perception stage of SA (Endsley 1995).
Working memory has a limited storage
capacity – it can store approximately seven
pieces of information (Flin et al 2008), and is
susceptible to losing information unless the
information is consciously and consistently
repeated. For example, if a nurse is walking to
the office to chart physiological recordings and
is interrupted by someone asking a question, it
is likely that the physiological measurements
will be lost in the working memory and will
be replaced with the information contained in
the question. This is important in the context
of SA since retaining important information
to support accurate SA can be compromised
by interruptions and distractions (Endsley and
Jones 2012).
Long-term memory is the main memory
store and holds the information from past
experiences and events. Information is retrieved
from the long-term memory store to assist in
cognitive processing at several different levels
of SA. At the perception level, information
from the long-term memory is transferred
to the short-term memory and is used to
help recognise and prioritise which sensory
information needs to be noted. Information
retrieval from long-term memory to assist
SA perception is increasingly likely if the
information has been used recently, is familiar
or is of particular interest to the individual (Flin
et al 2008).
Failure in the perception stage of SA can
occur because sensory information is not
available or difficult to notice, individuals
do not observe elements in the environment
around them, or the information that
is gathered from the environment is
misinterpreted (Endsley 1995). Accurate
perception of factors present in a given situation
or the environment is vital to guide information
processing in relation to the significance of
these factors and subsequent decision making.
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Level 2: comprehension
The comprehension stage of SA involves
processing the information that is gathered
in the perception level to work out what is
happening and what is significant in the
situation. For example, a nurse carrying out
care for a patient in a multi-bedded room is
engrossed in the task and is not perceiving
the busy ward noises, such as people talking,
trolleys being pushed past and patient call bells
ringing. However, on hearing a loud crash
and someone calling out for help, the nurse
turns, sees a patient lying on the floor and
comprehends that the loud noise and call for
help is probably related to the patient who has
fallen. The nurse will be using information
stored in the long-term memory that provides
understanding of what a loud noise, call for
help and patient on floor probably mean.
The retrieval of stored information
from long-term memory is called pattern
matching. Pattern matching uses information
gathered and stored in the long-term memory
from previous experience to interpret the
information that is gathered in the perception
stage and to inform the comprehension stage.
The stored information is known as mental
models or schema, which are groups of
cues that can mean certain things in certain
circumstances. When pattern matching, not all
the cues need to be present for the individual
to extrapolate the information to the situation
they are trying to understand (Endsley 2015).
People with less experience have fewer
mental models on which to draw from their
long-term memory to make sense of a situation
(Endsley 2015). This is obvious when observing
a nurse who has extensive experience and
advanced skills undertake the complicated
care of an acutely unwell patient. The nurse
is able to detect minute or subtle changes in
a patient’s condition and use multiple pieces
of information such as physiological signs
and symptoms, data from technological
equipment and observation of the patient’s
behaviour quickly. A novice nurse may require
the information to be overt or may spend
additional time focusing on the situation and
processing the information in the working
memory (Carayon 2011).
Failure in accurate comprehension of
the situation can occur for several reasons,
including (Flin et al 2008):
The incorrect mental model being retrieved
from the long-term memory.
The correct mental model being used, but its
elements being applied incorrectly.
The absence of a mental model in the
long-term memory that pattern matches for
the perceived situation.
A simple memory failure.
Failure to comprehend the situation accurately
can lead to delayed care or the provision
of inappropriate care and adverse patient
outcomes (Flin et al 2008).
Level 3: projection
Projection involves using the understanding
of what is going on in the situation to project
what might happen in the future and thus
what actions or decisions are required (Endsley
2000). For example, an experienced surgical
nurse may be assessing a post-operative patient
and note tachycardia, hypotension, a significant
amount of fresh blood in the drainage bag and
restlessness. Pattern matching to a mental model
gained from the nurse’s experience in caring
for many post-operative patients provides
the cues in the comprehension stage that the
possible meaning of such signs is post-operative
haemorrhage. In the projection stage, the
possibilities include patient collapse from
massive haemorrhage. Therefore, the nurse
responds by seeking review, assessing the need
to increase fluid input and further physiological
assessment of the patient.
The projection stage provides the opportunity
to anticipate and predict what might happen
and gives time to prepare and decide the best
course of action. Projection can also heighten
perception since people scan and look for
possible cues indicating that the understanding
of the situation gained in the comprehension
and projection stages is stable or changing
(Endsley 2015).
The description of the three levels or stages
of SA may appear to be linear and a slow,
laborious process. In practice, however, the
process can be almost instantaneous and
appear to be automatic, especially in skilled
individuals (Endsley 2015). The process is
also dynamic and can move to and from the
different levels (Endsley 2015). In addition,
while the individual is occupied by other
tasks or if the situation is rapidly changing,
the monitoring of the situation can result in a
fluctuating SA status (Gartenberg et al 2014).
Factors influencing situation awareness
Effective SA is influenced by several factors,
both internal and external to the individual.
These factors can be related to the context of
the situation, individual factors, task factors
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and particular cognitive processing factors
that lead to sub-optimal SA. The factors can
be thought of as ‘red flags’ identifying possible
negative effects on SA (Box 1).
Context factors include workload, busy
shifts, rapidly changing environments and
inappropriately designed or maintained
equipment (Endsley 1995). These factors can
increase stress on the individual’s working
memory capacity and result in ineffective
scanning of the environment (Endsley and
Jones 2012). For example, it is easy to imagine
the challenges involved in maintaining SA if
equipment used for monitoring a patient’s vital
signs does not have built-in safety features
such as audible alarms. To enable accurate
information gathering (perception), data
displays need to be visible and easily read from
all angles, and alarms must be audible and
distinguishable from other equipment alarms.
However, a determination of whether displayed
vital signs are normal or abnormal may require
BOX 1
Factors influencing situation awareness
Context
Workload.
Equipment.
Distractions.
Interruptions.
Inadequate teamwork, for example sub-optimal
communication, co-ordination and co-operation.
Time constraints.
Individual
Fatigue.
Level of knowledge.
Experience.
Language barriers.
Individual cognitive limitations and
tendencies, for example mind wandering
and attentional tunnelling.
Individual life events, for example anxiety
and illness.
Task
Complexity, for example multiple steps.
Novel or new task.
Routine task leading to automaticity.
Cognitive limitations and tendencies
Attentional tunnelling.
Limitation of working memory capacity.
Information overload.
Cognitive sensitivity to certain types of noise,
light and colour.
Confirmation bias.
Attribution bias.
(Reason 2004, Boakes 2009, Endsley 2012, Gluyas and
Morrison 2013)
further interpretation (comprehension) and
reliance on working memory to analyse the
information. During a busy shift, or when
clinicians are multi-tasking and attention is
diverted elsewhere, critical changes in the
patient’s vital signs may be missed. Therefore,
when the patient’s vital signs diverge from
acceptable parameters, safety features such as
audible alarms and flashing lights can assist in
maintaining SA (Drews and Doig 2014).
Distractions and interruptions are particularly
intrusive on the maintenance of SA (Thomas
et al 2015). Individuals rely on working
memory to process information at all three
levels of SA. However, the working memory
has limited storage capacity and therefore has
minimal ability to retain information. Thus,
interruptions and distractions lead to rapid
decay of information in the working memory.
That information is replaced with the sensory
information that has captured attention
from the distraction or interruption (Thomas
et al 2015). Of particular importance is the
distraction of the mind, mind wandering or,
as it is commonly called, day dreaming. This
is when individuals are distracted by their
inner thoughts, to the detriment of the task or
actions being undertaken. Mind wandering
occurs when an individual is undertaking tasks
automatically, for example when the tasks are
familiar and do not require conscious attention.
However, automaticity that allows the mind to
wander is also detrimental to noticing cues in the
surrounding environment and therefore can lead
to a loss of accurate SA (Endsley 2015).
Ineffective teamwork is another context factor
that can result in inadequate SA. If individuals
in a team are not working towards a common
goal because each has a different perception,
comprehension and projection of the situation,
ineffective communication, co-operation
and co-ordination in the team are likely to
result (St Pierre et al 2010). The case discussed
previously of the death of Elaine Bromiley
provides an example of ineffective teamwork
and sub-optimal team SA. In this case, the
anaesthetists were cognitively fixated (attentional
tunnelling) on establishing the patient’s airway
and did not notice the passage of time and the
patient’s decreasing oxygen saturation levels. The
nurses were focused on trying to raise the issue
of patient deterioration and the need to consider
a tracheostomy, but were inhibited by the
authority gradient. There was no clear leadership
for effective communication, co-operation
and co-ordination among team members.
These factors combined and led to a situation
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of inadequate SA of the severity of the clinical
situation and ultimately the death of the patient
(Walker 2008, Gluyas 2015).
Individual factors such as anxiety, illness,
fatigue and negative life events can also affect
working memory capacity. Studies have shown
that fatigue is responsible for a multitude of
errors in health care, for example omissions
and needlestick injuries (Rogers 2008, 2011,
Hewitt 2010, Mahlmeister 2010). Referring to
the previous example of the drainage bag full of
blood, a nurse who is fatigued at the end of a busy
12-hour shift may have a diminished working
memory and find it difficult to process additional
information. The nurse’s environmental
scanning may be impaired as a result of the
amount of pre-existing information being
processed and consequently the blood in the
drainage bag may not be noticed. Conversely, a
graduate nurse may see the blood in the drainage
bag but not comprehend its significance through
lack of experience and knowledge and therefore
may be unable to respond appropriately.
The experience and skill of the individual
has a direct effect on the mental models
that are available for pattern matching in
the comprehension stage, and the ability to
predict what might happen in the future in the
projection stage. Given the synergy of these
factors within a complex, dynamic environment
such as health care, it is easy to understand how
challenging yet vital it is to preserve SA.
Task factors that can affect SA may be related
to the complexity of the task. If a situation
requires the individual to undertake a new
or novel task, depending on the difficulty
associated with the task and/or the experience of
the individual, the cognitive load requirements
may result in the individual focusing on the task
to the exclusion of other tasks that need to be
completed. Conversely, a task that is routine and
can be undertaken with a level of automaticity
may result in slips or lapses, where steps in the
task are done in the incorrect order or left out
completely (Gluyas and Morrison 2013).
From a cognitive perspective, accurate SA
relies on the individual being able cognitively
to juggle many different pieces of information
at the same time, which can result in (Simons
2010, Endsley 2012):
Problems with cognitive processing,
including attentional tunnelling where the
individual focuses on one particular aspect
of the situation and ignores other aspects of
the situation.
Limitations of working memory capacity in
terms of storage.
Information overload in terms of cognitive
processing ability.
Sensitivity to certain types of noise, light
and colour, which can lead to erroneous
perception, comprehension and projection of
the cues in the environment.
Complete time out activity 2
Humans have cognitive biases, which help
individuals manage the load of sensory
information to be processed. However, in a
negative sense, cognitive biases can lead to
incorrect SA. Examples of such biases include
confirmation bias where an individual ignores
information that might challenge the SA mental
model and only focuses on information that
confirms the mental model. Fundamental
attribution bias is where the individual relies
on a mental model that is seen as typical of all
similar circumstances; however, this can lead
to incorrect comprehension, projection and SA
(Mannion and Thompson 2014).
Complete time out activity 3
Strategies to mitigate loss
of situation awareness
The first step in improving SA is to raise
the individual’s awareness of the effect of
personal factors on SA. A tool that has been
adopted by the NHS is the Foresight training
programme (Norris 2012). This is based
on the ‘three bucket’ model (Reason 2004),
which encourages individuals to step back and
examine the three aspects of self, context and
task, which potentially could have a negative
effect on SA and increase the likelihood of
errors. Using this model helps individuals
to identify red flags within themselves,
the context and the task that might have a
detrimental effect on their SA.
Using this model, the first aspect the
individual considers is events that may be
happening in their life, such as fatigue, stress
and illness. The second consideration is the
context in which the individual is working,
where factors such as workload, light, noise,
teamwork and the possibility of interruptions
and distractions are contemplated. The third
aspect is the task being undertaken, for example
in terms of difficulty, complexity and criticality,
as well as the resources (equipment and human)
available. Moreover, the skill, knowledge,
understanding and support required to
complete the task are important aspects in
evaluating the stresses that will affect cognitive
processing. It must be remembered that stress
2 Watch The Monkey
Business Illusion at:
tinyurl.com/27h9ufx.
Follow the instructions
provided at the start of
the clip.
3 Review the list
of factors influencing
SA provided in Box 1.
Make a list of scenarios,
preferably clinical
situations, where
these factors may have
influenced negatively
your perception,
comprehension and
projection of the
situations.
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decreases scanning of the environment and the
cognitive capacity to hold information in the
working memory (Endsley 2012).
As people evaluate each of the aspects of
self, context and task, they mentally add them
to one of the three buckets representing each
aspect. The fuller the buckets or the more red
flags identified, the higher the likelihood that
there will be inadequate SA and errors as a
result of compromised cognitive load (Reason
2004, Boakes 2009, Gluyas and Morrison
2013). This strategy is particularly valuable
since it can be used by anyone in any situation
and requires no external tools. Raising
conscious awareness of the effect of stressors
and cognitive overload on the potential loss
of SA and increased risk of errors, prompts
individuals to use strategies to maintain SA
(Gluyas and Morrison 2013).
Having identified previously that working
memory has limited capacity to retain
information, it is important that individuals
adopt strategies to minimise interruptions and
distractions where possible. To some degree,
interruptions can be controlled. Individuals,
when undertaking critical or error-prone tasks
such as the administration of medication, can
verbalise to those around them the need for
uninterrupted or protected time. However,
there will always be times when the individual
is interrupted. Flin et al (2008) suggested that
when people resume the task or duties they
were undertaking before the interruption, they
should take the time to establish consciously
where they were in the task sequence. This will
reduce the likelihood of slips and lapses.
Checklists and checking protocols are useful
for overcoming distractions and interruptions
(Thomassen et al 2011). These strategies
provide a formal means of breaking tasks down
into steps or a sequence of steps. People can then
cue cognitively where they are in the sequence
of steps required to complete a task correctly
(Colligan and Bass 2012). However, checklists
and checking protocols require mindful
checking. If checking is done automatically
TABLE 1
Strategies to improve situation awareness
Situation awareness strategy
Description
Application
Self, context, task stressor evaluation,
also known as the ‘three bucket’ model
or Foresight training.
The individual assesses possible stressors within
the categories of self, context and task that
might negatively affect cognitive functioning.
Individual.
Re-evaluating task sequence after
interruptions or distractions.
The individual evaluates consciously where
they were in the task sequence or action before
resuming the task or action.
Individual.
Checklists and checking protocols.
Individuals check formally each stage against a
list of sequenced steps in a task or procedure.
Individual and team.
Updating current mental model.
The individual reviews consciously and questions
the current mental model to ensure that what
should be happening is and, if not, why not?
Individual.
Self-monitoring for mind wandering.
The individual monitors for cues or situations
where mind wandering is likely to occur.
Individual.
‘Sterile cockpit rule’.
Alerting others with visible warnings that
certain high error or critical procedures are
non-interruptible.
Team and organisational.
Checking in with other team members.
The individual verbalises their current mental
model of the situation and their intended actions
to other team members.
Individual.
Huddles.
The team gathers for a quick review of actions,
outcomes and decisions, and plans future
actions accordingly.
Team.
Simulation.
Individuals and the team practise developing
and maintaining situation awareness in realistic
simulated clinical environments.
Individual, team, organisational.
(Reason 2004, Flin et al 2008, Boakes 2009, Gluyas and Morrison 2013)
56 april
20 :: volfrom
30 no
34 :: 2016
STANDARD
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