Leading article: What can we do to improve individual and team situational awareness to benefit patient safety?

被引:40
作者
Brennan, P. A. [1 ]
Holden, C. [2 ]
Shaw, G. [2 ]
Morris, S. [3 ]
Oeppen, R. S. [4 ]
机构
[1] Queen Alexandra Hosp, Dept Oral & Maxillofacial Surg, Portsmouth PO6 3LY, Hants, England
[2] Heathrow Airport, Hounslow TW6 1EW, Middx, England
[3] RAF Scampton, Red Arrows Acrobat Team, Red 5, Scampton LN1 2ST, Lincs, England
[4] Univ Hosp, Dept Clin Radiol, Southampton SO16 6YD, Hants, England
关键词
Human factors situational awareness; patient safety; medical error; tunnel vision; team working; ERRORS;
D O I
10.1016/j.bjoms.2020.01.030
中图分类号
R78 [口腔科学];
学科分类号
1003 ;
摘要
It is increasingly being recognised that human factors can contribute to error in complex safety systems. Healthcare, however, has a long way to go before the promotion of training in, and awareness of, human factors will catch up with other high-risk organisations. A critical component that is deemed essential both for improving clinical performance and reducing medical error is situational awareness (SA). This is dynamic and can reduce quickly or be lost entirely, particularly when the workload is heavy. Tunnel vision, in which healthcare professionals concentrate on a single aspect of a patient's care, is just one example of reduced awareness that can be detrimental to safety. As in aviation and other high-risk organisations, a reduction in SA, if not recognised by individuals or the wider team, can lead to serious or potentially fatal outcomes. We therefore give an overview of SA and show how it can easily be reduced. We also suggest some simple but effective ways to improve it and in turn improve patient safety. We emphasise the importance of clinical teams looking out for each other, particularly in the operating theatre. (C) 2020 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
引用
收藏
页码:404 / 408
页数:5
相关论文
共 23 条
[11]   The boundaries of aviation psychology, human factors, aeronautical decision making, situation awareness, and crew resource management [J].
Jensen, RS .
INTERNATIONAL JOURNAL OF AVIATION PSYCHOLOGY, 1997, 7 (04) :259-267
[12]   Non-Technical Skills for Surgeons (NOTSS): Critical appraisal of its measurement properties [J].
Jung, James J. ;
Borkhoff, Cornelia M. ;
Juni, Peter ;
Grantcharov, Teodor P. .
AMERICAN JOURNAL OF SURGERY, 2018, 216 (05) :990-997
[13]  
O'Connor PE, 2007, UNDERSEA HYPERBAR M, V34, P51
[14]   Prevalence, severity, and nature of preventable patient harm across medical care settings: systematic review and meta-analysis [J].
Panagioti, Maria ;
Khan, Kanza ;
Keers, Richard N. ;
Abuzour, Aseel ;
Phipps, Denham ;
Kontopantelis, Evangelos ;
Bower, Peter ;
Campbell, Stephen ;
Haneef, Razaan ;
Avery, Anthony J. ;
Ashcroft, Darren M. .
BMJ-BRITISH MEDICAL JOURNAL, 2019, 366
[15]  
Ragau Sharon, 2018, Br J Nurs, V27, P1330, DOI 10.12968/bjon.2018.27.22.1330
[16]   COPING WITH HUMAN ERRORS THROUGH SYSTEM-DESIGN - IMPLICATIONS FOR ECOLOGICAL INTERFACE DESIGN [J].
RASMUSSEN, J ;
VICENTE, KJ .
INTERNATIONAL JOURNAL OF MAN-MACHINE STUDIES, 1989, 31 (05) :517-534
[17]   Team situation awareness and the anticipation of patient progress during ICU rounds [J].
Reader, Tom W. ;
Flin, Rhona ;
Mearns, Kathryn ;
Cuthbertson, Brian H. .
BMJ QUALITY & SAFETY, 2011, 20 (12) :1035-1042
[18]  
Reynard J, 2009, PRACTICAL PATIENT SA, P201
[19]   Normal people working in normal organizations with normal equipment: System safety and cognition in a mid-air collision [J].
Rodrigues de Carvalho, Paulo Victor ;
Gomes, Jose Orlando ;
Huber, Gilbert Jacob ;
Vidal, Mario Cesar .
APPLIED ERGONOMICS, 2009, 40 (03) :325-340
[20]   Situation Awareness in Anesthesia Concept and Research [J].
Schulz, Christian M. ;
Endsley, Mica R. ;
Kochs, Eberhard F. ;
Gelb, Adrian W. ;
Wagner, Klaus J. .
ANESTHESIOLOGY, 2013, 118 (03) :729-742