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The Big Flick

A hugely important safety feature in the aviation cockpit and in all High Reliability Organizations (HROs) is called “Situational Awareness (SA)”.  SA is just as important for us in the Operating Room and in acute care for the Drive Insafety of our patients.  SA is simply defined as ‘the big picture’ and often referred to as “The Big Flick”.  SA is a composite of two sets of information that are used to build a prediction of what is most likely to occur next. It is the accurate perception of what is going on with you, your patient, your team members and the surrounding environment 5 minutes ago, and right now.  This information is used to build a prediction of what is most likely to occur in the immediate future in order to script an effective plan to deal with all likely contingencies.

Building and maintaining good individual SA requires developing and sustaining an overall dynamic and temporal awareness of the clinical entirety based on analyzing all elements in the environment, understanding their inter-relationship and implications of each, and using this understanding to think ahead, predict, and anticipate the most likely eventualities. Forming the composite picture of SA also requires the soft skill of perception, derived from the clinical experience that comes with repetition, and develops into astute clinical judgment. Prioritizing information and actions are important aspects of situational awareness, as well as making quality and timely decisions and projecting the current situation into the future to make educated guesses as to what lies ahead so that changes in the clinical “big picture” do not come as unmanageable surprises. This requires continuous assessment and reassessment of all clinical information.

Equally important for desired clinical outcomes is group and team SA that requires all of the above skills in addition to excellent communication among all team players to share observations and plans. This requires team participation in that team members must combine all of their perceptions and experiences to form a correct “big clinical picture.” This must be shared through accurate and timely communication with others, allowing all team members to modify and reassess their clinical impressions as moment-to-moment situations change. HROs teach and diligently drill SA skills with simulation, repetition, team role-playing, and supervision and have demonstrated effectiveness of this training.

When I was a young student pilot my instructor would always tell me, “Never let this airplane take you someplace your head hasn’t already been five minutes ago”.  The same is true for me now, I try never to find myself in a clinical situation with a patient that I have haven’t already thought about.  I think about and discuss with the team what the current situation tells us is likely to happen next, I ask for the instruments, blood products or personnel to deal with that problem so that when the patient or the circumstances play out there are no surprises and no need to “wing it on the fly”.  The less urgent a clinical scenario the better the likely outcome and we have at least a little control over that urgency by building the big picture and planning for it in advance.

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Posted in High Reliability Organizations, Patient Safety, SA.

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  1. skulljockey says

    I think that your description about the importance of the team to have appropriate situational awareness cannot be over emphasized. This needs to be a shared responsibility with the team ( surgical or other) . This is critical important when things do not go as planned and the surgeon most “pause” ( see the work of Dr Carol Anne Moulton ) as the surgeon changes from thinking in a routine way to a more complex and deductive manner.
    Simulation can help teams practice the unexpected.



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