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

BMC Anesthesiology
Christian M SchulzKlaus J Wagner

Abstract

A 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). Two 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. SA 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. SA 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.

Associated Clinical Trials

Apr 11, 2019·Sarah Collins Rossetti

References

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Citations

Jan 4, 2018·Prehospital Emergency Care : Official Journal of the National Association of EMS Physicians and the National Association of State EMS Directors·Robert G WalkerJames M Nania
May 10, 2018·Human Factors·Meghan LeaverTom Reader
Jul 6, 2018·Acta Anaesthesiologica Scandinavica·Christopher NeuhausChristoph Lichtenstern
Mar 17, 2020·Journal of Medical Internet Research·David Werner TschollChristoph B Nöthiger
May 23, 2019·Simulation in Healthcare : Journal of the Society for Simulation in Healthcare·Nuala C WalsheJosephine M Hegarty
Jan 10, 2020·Journal of Perioperative Practice·Stefka Ilieva Koleva
Apr 4, 2017·Western Journal of Nursing Research·Sabrina B Orique, Laurel Despins
Jul 19, 2019·Journal of Medical Internet Research·Juliane PfarrDavid W Tscholl
Jun 3, 2017·Canadian Journal of Anaesthesia = Journal Canadien D'anesthésie·Julia A HaberJocelyn M Lockyer
Dec 13, 2018·BMC Anesthesiology·David W TschollChristoph B Nöthiger
Apr 22, 2021·British Journal of Anaesthesia·Tadzio R RocheDavid W Tscholl
Nov 2, 2021·Military Medicine·Danette F CruthirdsLara Varpio

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Methods Mentioned

BETA
sedation

Software Mentioned

SPSS

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