Safety of care
Thinking ahead: The value of situational awareness
Originally published December 2013
Having situational awareness is an important clinical skill made up of many elements including continuous scanning for information in the clinical encounter, remaining alert and watchful, communicating effectively with one's team, thinking critically, and thinking ahead.1
As just one of many possible examples, recognizing when diagnosis is urgently needed and then successfully managing the situation are often dependent on maintaining situational awareness. Mishandling these situations may have serious consequences for patients.
The CMPA has identified cases in which a failure to recognize the urgency of a medical situation when ordering and interpreting diagnostic tests and when arranging referrals or patient transfers resulted in an unfavourable medico-legal outcome for physicians. Analysis revealed that physicians either failed to recognize the urgency of a situation, or once recognized, failed to make the immediacy of the situation clear to other healthcare team members. These oversights often led to delays in diagnosis and treatment. The physicians involved were mainly family physicians working in the emergency department (ED) or office settings, as well as internists, radiologists, and residents.
To make a diagnosis, a medical condition must progress to where the clinical symptoms and signs suggest the diagnosis or at least indicate the need for further investigation. Arriving at a timely diagnosis can also depend on other elements, for example knowledge and experience, cognitive factors, team communication, and effective systems and processes supporting clinical care such as the system for following up on investigative tests.
Case 1: Failure to appreciate the urgency of a situation
A 55-year-old man presents to the emergency department (ED) with a 2-week history of occipital headache and a 1-day history of nausea and vomiting. He is admitted after investigations reveal moderately severe anemia and severe thrombocytopenia. Early the next morning, the patient has a brief episode of reduced level of consciousness. A head CT scan is negative. The internist assesses the patient and incidentally learns that a sister had been diagnosed with thrombotic thrombocytopenic purpura (TTP). The internist attributes the patient's condition to the long-term effects of a non-steroidal anti-inflammatory medication, with the possibility of liver disease and occult gastrointestinal bleeding.
The next day, a gastroenterologist assumes the patient's care and assesses him that day. She is aware of his family history of TTP. Later the same day, the result of a blood smear ordered by the internist is received and indicates fragmentation hemolysis. The report includes the recommendation to rule out TTP, DIC, and hemolytic uremic syndrome. A gastroscopy and colonoscopy are performed and are normal. The gastroenterologist's entry in the medical record 2 days later references the abnormal blood smear findings.
Following discussion with a hematologist, the diagnosis is considered likely to be TTP. While making arrangements for plasmapheresis, the patient's neurologic condition suddenly deteriorates and he dies. The cause of death is attributed to complications of TTP.
A legal action follows and experts are critical of the internist for not personally tracking down the results of the blood tests while the patient was in his care. He appears not to have recognized the urgency of the investigation and treatment of TTP. The experts are also critical of the gastroenterologist's care upon transfer as she did not take urgent steps to confirm or exclude TTP or to consult a hematologist for advice earlier. Her actions suggest she did not understand the gravity of the situation. Although not named in the lawsuit, several experts commented that the pathologist should have communicated the peripheral blood smear findings more directly. A settlement is paid to the patient's estate by the CMPA on behalf of the internist and the gastroenterologist.
Case 2: Failure to convey urgency to healthcare team
A 10-year-old boy with hydrocephalus and an implanted ventriculoperitoneal (VP) shunt is brought to the ED with a 2-day history of vomiting, headache, and increased drowsiness.
The ED is extremely busy with no available beds. The ED physician feels the patient's shunt is blocked and urgent care is required. He orders a plain X-ray that confirms that the VP shunt is broken. The ED physician gives a verbal order: "Get a CT scan." When he later inquires about the test, the nurse tells him it was not done as he did not fill out the requisition. He then does so but does not mark it as "stat" and so the radiology staff assume it is not an urgent request. The scan is delayed by 4 hours. It confirms shunt malfunction and increased intracranial pressure.
The ED physician pages the neurosurgeon at the nearest children's hospital who calls back 1 hour later and accepts the transfer. The patient's condition quickly deteriorates necessitating endotracheal intubation, and he dies several hours later. The cause of death is acute hydrocephalus secondary to presumed VP shunt obstruction.
The family initiates a legal action and experts question the delay in performing the CT scan and the delay in transfer. The experts state there would have been adequate time to image and transfer the patient for surgical repair of the shunt if the immediacy of the clinical situation had been conveyed to the nurse and diagnostic imaging department. Without expert support, a shared settlement is paid to the patient's estate by the CMPA, on behalf of the ED physician, and by the hospital.
There are 3 components to situational awareness — getting the information, understanding the information, and thinking ahead.
The concepts of risk assessment and situational awareness have been identified in many of the CMPA cases including these case examples.
Situational awareness is often studied in complex environments such as the aviation industry and the military. In healthcare, it has been explored in more unpredictable situations, such as anaesthesia,2 but has also been applied to medicine in general (e.g. the diagnostic process) to better understand diagnostic error.3
In the 2 cases presented, the physicians involved failed to apply situational awareness skills.
In the first case, the internist and gastroenterologist failed to appreciate the potential severity and urgency of the condition which ultimately contributed to the patient's death. Both physicians anchored on the working diagnosis of a GI bleed and did not assimilate the new knowledge from the blood smear into their working memory of the case.
In the second case, the ED physician's lack of situational awareness was manifested by the failure to realize that a test which had been ordered urgently had not been performed in a timely manner. Other contributing factors included workload issues, (i.e. ED extremely busy that day) and communication problems (i.e. not making it clear to the nurse and the diagnostic imaging department that the CT scan was urgent).
Managing medico-legal risk by practising situational awareness
Physicians are not expected to always predict the future course of patients' illnesses. However Canadian courts will often ask the question: "Was an event reasonably foreseeable?"
Situational awareness should be consciously practised by:
- being alert to the condition of the patient
- switching to more analytical and critical thinking, when warranted
- thinking ahead and anticipating problems
Further information and case examples of situational awareness can be found online in the CMPA Good Practices Guide.
The Royal College of Physicians and Surgeons of Canada has also published slides on the topic, Situational Awareness and Patient Safety. A Physician Primer.
For more information, see Situational Awareness and Patient Safety, Royal College of Physicians and Surgeons
of Canada. Retrieved on September 23 2013 from:
- Fioratou E., Flin R., Glavin R, Patey R., "Beyond monitoring: distributed situation awareness in anaesthesia," British Journal of Anaesthesia (2010) Vol. 105, no.1 p.83–90
- Singh H., Petersen L.A., Thomas E.J., "Understanding diagnostic errors in medicine: a lesson from aviation," Quality and Safety in Health Care (2006) Vol. 15, p.159–164