Situation awareness errors in anesthesia and critical care in 200 cases of a critical incident reporting system

Abstract

BackgroundA loss of adequate Situation Awareness (SA) may play a major role in the genesis of critical incidents in anesthesia and critical care. This observational study aimed to determine the frequency of SA errors in cases of a critical incident reporting system (CIRS).MethodsTwo experts independently reviewed 200 cases from the German Anesthesia CIRS. For inclusion, reports had to be related to anesthesia or critical care for an individual patient and take place in an in-hospital setting. Based on the SA framework, the frequency of SA errors was determined. Representative cases were analyzed qualitatively to illustrate the role of SA for decision-making.ResultsSA errors were identified in 81.5 %. Predominantly, errors occurred on the levels of perception (38.0 %) and comprehension (31.5 %). Errors on the level of projection played a minor role (12.0 %). The qualitative analysis of selected cases illustrates the crucial role of SA for decision-making and performance.ConclusionsSA errors are very frequent in critical incidents reported in a CIRS. The SA taxonomy was suitable to provide mechanistic insights into the central role of SA for decision-making and thus, patient safety.

Frequency and Type of Situational Awareness Errors Contributing to Death and Brain Damage

“…The frequency of situational awareness errors in this study (74%) was consistent with the range in studies that investigated situational awareness errors in anesthesia incident reports (82%) 10 and aviation (59 – 88 %). 14 The types of errors in malpractice claims differed in relative frequency from critical incident reports where there was a risk but no actual injury.…”

“…In incident reports, perception errors were also the most frequent, but projection errors (15%) were almost twofold less frequent than in this study of malpractice claims (29%). 10 The Australian study did not analyze levels of situational awareness. 9 Different case characteristics, the voluntary character of the incident reporting system, and the subjective view of the reports significantly limit comparability.…”

“…5,7–10 Studies in surgery using observational techniques and review of operative notes suggested that complications of laparoscopic cholecystectomy (e.g., bile duct injuries) and carotid endarterectomy were associated with situational awareness errors, especially involving perception. 5,7,8 In anesthesia, investigators in Australia 9 and Germany 10 reviewed voluntary critical incidents not resulting in patient injury and found a significant number of situational awareness errors (40 and 82%, respectively). In primary care 11 and nursing 12,13 situational awareness errors were studied qualitatively, but without quantitative data.…”

Situation Awareness-Oriented Patient Monitoring with Visual Patient Technology: A Qualitative Review of the Primary Research

“…The first level of situation awareness is the perception of environmental elements; for example, in the setting of anesthesia that corresponds to noticing the status and dynamics of the patient's vital signs on the monitor. Research has found up to 80% of anesthesia adverse events result from a lack of situation awareness, with level 1 errors (perception) accounting for the largest share (42%) [12,13]. The second and third levels of situation awareness are the comprehension of these perceived elements and their projected course.…”

The extracorporeal membrane oxygenation (ECMO) high-fidelity simulator: the best complementary tool to learn the technique

“…The authors of a recent study (16) found simulation-based training to be superior to lecture-based when teaching situation awareness, primarily because of improved perception ability. The better perception performance and global situation awareness might explain the faster response of the simulation-based group described by Zakhary et al According to a recent review of critical care medicine incidents, perception-related situation-awareness errors were slightly more frequent (17). Although it has not been fully demonstrated, decision-making processes should be improved when perception is better.…”