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Unexplained loss of situational awareness

 

In one review that was analysed, it was found that everyone present at a difficult vaginal breech delivery failed to appreciate a pathological CTG for over 1 hour.

 

The delivery was complex and completed by the consultant as the fetal head was entrapped. In the report, the following reason was given for the failure to act on the pathological CTG findings:

 

Situation

“There was a loss of situational awareness by all members of the team who became focused on the process of the vaginal breech delivery and lost sight of the whole clinical picture, including the fetal heart rate monitoring.”

Commentary

The unspoken shared mental model across the team was that the delivery was progressin safely and that the fetal well-being was assured.The single element that was overlooked was the CTG, but the reason for this being overlooked by all involved is unclear. No information is available as to why the CTG was not taken into account, but this was a far from isolated incident.

The solution offered in this instance was comprehensive individual supervisory investigations and individual action plans for all involved.This approach – to identify human error as a cause, and to identify a course of training to prevent healthcare professionals from making errors in the future as a solution – was frequently noted in reviews.

Things you can do

There was no consideration in this case report that there could be other ways to influence human behaviour on the delivery suite. Options available might include identifying error traps, care bundles and pathways.[i]

 

A similar situation was described in another report:

 

Situation

“MW 2 and Dr 1 both exhibited poor situational awareness as neither recognised the pathology of the CTG and both enabled a 1st year midwifery student to deliver the baby under direct supervision from MW 2.”

Commentary

Within this example, the local reviewers correctly identify a loss of situational awareness. What stands out is that – in this instance and in other instances in different reports – concerns were not apparent at the time of the incident, and nobody in the team at the time noticed them.

Considering the model of situational awareness in Figure 11, it is easy to see the reviewers’ perspective (the so-called ‘retrospectoscope’) compared with that of the clinicians’ at the time of the incident.

It is clear to the reviewers what the critical factor was, with the benefit of hindsight.There is a danger that situational awareness becomes simply another way of highlighting ‘human error’ and attributing failures to ‘bad apples’.

 

 

 


 

[i] Wachter JK,Yorio PL. Human performance tools: engaging workers as the best defense against errors and error precursors. Professional Safety 2013;58(2):54–64. Available from: http://miningquiz.com/pdf/Behavior_Based_Safety/Human_Performance_Tools_Article.pdf [accessed on 6th October 2017].