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Situational awareness


  • As a team member, speak up early.
  • Welcome and facilitate input from all healthcare professionals.
Situational Awareness is a cognitive skill that includes being conscious of what is happening around you, continuously checking perceptions with reality and the related flow of information. This skill includes predicting the immediate and future impact of your own or the team's actions, including anticipating complications.

It is easy to lose situational awareness, so physicians should welcome and facilitate input from all healthcare professionals.

Case: Elaine Bromiley – "Can't intubate, can't ventilate"

The following is a summary of a well-known patient safety case from the United Kingdom.

Two surgical staff working in surgery

Background

Elaine Bromiley was a 37-year-old healthy woman with chronic sinusitis, admitted to hospital for septoplasty.

After induction, the anaesthetist could not place a laryngeal mask. Based on the reasonable assumption that this resulted from light anaesthesia, the anaesthetist administered an additional small dose of anaesthetic. The laryngeal mask could still not be placed, and bag and mask ventilation remained inadequate. Further muscle relaxant was given but the larynx could not be visualized, and endotracheal intubation failed. Nevertheless three highly experienced consultants persisted in several more attempts to secure the airway by intubation for about 20 minutes. The pO2 was at or less than 40% during much of this time.

At the outset the operating room nurses informed the consultants that surgical equipment was available. A surgical airway was not attempted. It was decided the patient should be allowed to "wake up naturally" and she was transferred to the recovery unit. Ms. Bromiley never regained consciousness and life support was withdrawn many days later.

Think about it

The many physicians and nurses involved in this case were all considered to be technically competent professionals. Failure to intubate is a recognized inherent risk of anaesthesia. Guidelines for "can't intubate, can't ventilate" exist for this recognized emergency in anaesthesia.

So what went wrong?

Lessons learned

An investigation of Ms. Bromiley's care concluded the following:
  • Loss of situational awareness - The consultants, focusing on intubation, lost sight of the overall clinical condition of the patient.
  • Leadership - An overall leader was required to facilitate communication and decision-making.
  • Cognition dispositions - The team, particularly the consultants, anchored on endotracheal intubation as a solution in this stressful situation and did not consider the guideline protocol.
  • Failure to communicate assertively - Some of the nurses recognized the situation that was unfolding and made surgical airway equipment available. The operating room culture and hierarchies interfered with the nurses' voicing their warnings. They did not know how to speak up effectively.

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For more information about the Elaine Bromiley case see a video Opens in new window or watch a reenactment Opens in new window.