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Situational awareness

What is going on around you?

Knowing what is going on around you

Hockey team on ice"A good hockey player plays where the puck is. A great hockey player plays where the puck is going to be."
— Wayne Gretzky

Situational awareness is considered one of the most important non-technical skills of a physician.

Situational awareness refers to a person's perception and understanding of the dynamic information that is present in their environment. It is keeping track of what is going on around you, and includes anticipating what might need to be done.

Team situational awareness is "task- and team-oriented knowledge held by everyone in the team and the collective understanding of the unfolding situation." [REF]

Parush A., Campbell C., Hunter A., Calder L., Frank J., Worthington J., Abbott, C., Situational Awareness and Patient Safety. For more information email canmeds@royalcollege.ca. (This educational project was funded by the CMPA.)

Three signs each of which states a component of situational awarenessThere are 3 components of situational awareness:

  1. getting information
  2. understanding the information
  3. thinking ahead

Much has been learned about situational awareness from the airline industry.

Side view of airplane crash

Crew management approach

Eastern Airlines flight 401

One night in 1972, Eastern Airlines flight 401 en route from New York to Miami crashed into the Florida everglades. One hundred and one passengers and flight crew died. Some survived.

The captain, first officer, and flight engineer were all highly qualified and experienced. An investigation of the crash determined the crew, while attempting to deal with a malfunctioning landing gear light, did not notice the autopilot was no longer on.

Unknown to the crew, the plane slowly descended. An air traffic controller enquired if all was well, but did not alert the crew to the plane's low altitude. By the time the crew noticed, it was too late.

An investigation indicated poor crew leadership and teamwork, likely coupled with fatigue, resulted in the crash.

The airline industry subsequently developed the "crew resource management" approach. This approach ensures cockpit crews divide the work of problem solving, tasks are delegated, and someone is always flying the aircraft.

Rear view of airplane crash

United Airlines flight 232

In another incident in 1989, United Airlines flight 232, flying from Denver to Chicago, is considered a textbook example of successful crew management approach.

The tail-mounted engine failed and fragments of metal cut all of the plane's major hydraulic lines, rendering the airplane uncontrollable conventionally.

This would previously have resulted in a crash with the likely loss of everyone on board; however the flight crew reacted to the emergency in a disciplined manner, making effective use of all of the resources available to navigate to an airfield.

Although the plane could not be slowed sufficiently and broke apart on landing, 184 of the 295 passengers survived.

The airline industry subsequently made significant safety improvements in the design of engines and control systems.

Consider the role of human factors and situational awareness in the following healthcare cases.

Case: Airway challenge in a trauma patient
Blurred image of young male on motorcycle


A 22-year-old male in a motorcycle crash suffers a severe laceration to the neck extending into his trachea.

On arrival at the hospital at 0100 hours, he is alert, oriented with vital signs HR 110, RR 20, BP 130/70, GCS 15, P02 98% on low flow oxygen.

The emergency physician pages the anesthesiologist on call, and learns that the doctor will require 20 minutes to arrive. The patient remains alert and oriented.

Background continued

The emergency physician performs a rapid sequence induction protocol (sedation and paralysis). Several attempts at intubation with c-spine control are unsuccessful. An endotracheal tube (ETT) is placed correctly after seven minutes.

The staff moves away from the patient to allow an AP chest and c-spine film to be done. During this time, the oxygen saturation decreases significantly, and the ETT is discovered to be dislodged from the trachea.

The patient has a cardiorespiratory arrest.


Although he is successfully resuscitated after several minutes, the patient suffers extensive hypoxic brain damage.

Think about it

  • Did the emergency physician sufficiently appreciate the potential difficulty in airway management?
  • Did the team remain aware of the patient's status at all times?
  • Did everyone think ahead?
  • Did the emergency physician and this healthcare team demonstrate situational awareness?

Case: 76-year-old woman suffers respiratory arrest
Blurred image of elderly female being pushed on stretcher


A 76-year-old woman dislocates her hip in a motor vehicle crash.

The treating orthopaedic team wishes to perform a closed reduction as quickly as possible. The orthopaedic fellow orders sedation with IV narcotic and benzodiazepine.

The patient quickly becomes drowsy. A nurse places the patient on oxygen and an oxygen saturation monitor.

Background continued

Two medical students decide to watch the reduction procedure as a resident assists the fellow. After two failed attempts at reduction, the fellow orders a repeat dose of the medications to further relax the patient. The fellow attempts to reduce the hip, with the resident stabilizing the pelvis.

Everyone on the team is focused on the reduction.

Several minutes later, one of the medical students looks up to the head of the stretcher and notices that the patient has stopped breathing.

Think about it

How might this have been avoided?
  • Did the team sufficiently appreciate the potential for respiratory compromise in this elderly woman?
  • Did the team monitor the patient's status at all times?
  • Did the fellow and staff perceive there was a problem with the patient's breathing?
  • Did everyone think ahead?
  • Did the fellow and healthcare team demonstrate situational awareness?