The Case

A 40-year-old woman with a history of cirrhosis and known esophageal varices was admitted to the hospital with one day of bloody stools. Blood transfusion and IV proton pump inhibitor therapy were initiated. Gastroenterology was consulted to assess and treat the source of her GI bleeding.

On the same evening, a 50-year-old man with a history of antiphospholipid antibody syndrome, complicated by recurrent blood clots and heparin-induced thrombocytopenia, was admitted to the next room with a new pulmonary embolus. Given his known adverse reaction to heparin, IV argatroban was ordered for anticoagulation.

The following morning, while pre-rounding on the woman with the GI bleed, an astute intern noticed that one of the medications hanging from her IV pole was labeled as argatroban—but the name on the label matched that of the patient with the pulmonary embolus. The intern immediately notified the nurse that argatroban had been administered to the wrong patient and disclosed this error to the patient. The argatroban infusion was stopped. Fortunately, the patient did not experience any adverse effects.

The Commentary

by Jeanne M. Farnan, MD, MHPE

Although many of us consider ourselves to be highly observant individuals, our powers of perception are not infallible and we sometimes miss the obvious. Psychologists at Harvard created the Invisible Gorilla experiment to prove exactly that.(1) Participants were asked to watch a short video of six people passing around a basketball and to count how many times those in white shirts passed ball. Nearly half failed to recognize a seventh individual, dressed in a gorilla costume, walking through the scene as they focused on counting the number of passes. The authors concluded that we miss "a lot of what goes on around us, and we have no idea that we are missing so much."(1) Yet, the phenomenon of inattentional blindness applies not only to casual observers but also to expert clinicians. Medical expertise and clinical training do not ensure perfect attention and perception. When 24 radiologists were asked in one study to assess a series of CT scans for the presence of a lung nodule (a common task in their clinical practice), 83% of participants failed to notice a picture of a gorilla—48 times larger than the average lung nodule—inserted into the last case in the set of images.(2) Using eye-tracking, the study found that "the majority of those who missed the gorilla looked directly at the location of the gorilla."(2) This experiment demonstrates that even the most expert of observers can sometimes miss what is directly in from of them.

By teaching trainees to critically examine what they see every day on rounds and at the bedside, we can make patients safer. However, we practice in a health care delivery system that prioritizes efficiency and applauds residents for rushing around in an effort to get more done. The constant emphasis on productivity passively perpetuates their inattentional blindness, or psychological lack of attention, to the hazards of hospitalization in in plain sight.(3)

The case presented above provides the opportunity to discuss potential errors and adverse events related to a lack of situational awareness. Situational awareness is the "perception of the elements in the environment within a volume of space and time, the comprehension of their meaning and the projection of their status in the near future."(4) First described and embraced in military history, situational awareness has more recently been adapted to the field of human factors analysis and has seen widespread application from aviation to anesthesiology. Three levels of situational awareness have been described: perception, understanding, and prediction.(5) Perception, identified as the first level of awareness, is the simple recognition of objects, events, and people within an environment. The next level, understanding or comprehension, integrates these perceived elements and their relationships with one another. Prediction, the third stage, involves the ability to project, or predict, future actions of these elements within the environment.

Before attempting to define situational awareness for any type of clinical practice, it is first critical to understand what it is about a situation that the physician must be aware of.(6) In fact, even more critical is ensuring the physical presence of the physician in the situation of interest—in this case, the patient's room. Literature suggests that after recent duty-hour changes, internal medicine interns spend only 12% of their time performing direct patient care activities. Arguably the bedside is the most important situation for the physician to perceive and understand. Workflow must be redesigned to ensure adequate time for bedside assessments. As is illustrated in the case, the intern's awareness of the error was intimately linked to her presence at the patient's bedside. When employed with a specific focus on the hazards of inpatient hospitalization, bedside rounding has routinely been shown to decrease length of stay and improve performance on quality metrics and patient satisfaction.(7-9) Immersion into the situation of interest is the first step in recognizing what might be wrong with the situation, and it supports the ability to anticipate what may go wrong in the future.

Situational awareness in a patient's room can undoubtedly improve the quality and safety of care delivered. The hazards of hospitalization (10), including reactions to therapeutic drugs and hospital-acquired infections, affect nearly 20% of hospitalized adults. This case scenario exemplifies how a common safety issue—medication error—could be thwarted by proactive bedside observation. In fact, many of the issues that threaten the safety of hospitalized patients, including catheter–associated urinary tract infections, hand hygiene, medication errors, and inappropriate restraints, are visible, observable, tangible errors. When trained and primed to hunt for these errors, graduate medical trainees endorse an increased awareness of patient safety and error reporting.(11)

Immersive, experiential curricula and assessments make the situations in which errors occur tangible for trainees and can vastly improve the patient safety education experience. Prior work has demonstrated that learners—both residents and students—desire a skills-based approach to patient safety education rather than a didactic one.(12) Creating patient safety "rooms of horrors" (13-14)—low-fidelity and low-cost simulated patient rooms containing potential threats to patient safety—challenges trainees to identify as many errors as possible in the simulated environment through a patient safety scavenger hunt. This model is an example of one successful educational methodology, and it is easily replicable, adaptable, and universally well received by learners.

Systematizing situational awareness requires integration into electronic systems and cultural change at the institutional level. Electronic health record–based solutions (15), such as safety-focused checklists, are well described and often successful, but they would need to be available at the bedside in mobile form to better facilitate addressing safety issues that might be identified by observation in a patient's room. Most important and challenging are the cultural and economic changes required to allow providers sufficient time at the bedside. Rounding procedures must be restructured to become more patient-centered.

Potential threats to patient safety at the bedside need to be identified, addressed, and discussed, but doing so requires balancing the tension between efficiency and situational awareness.

Take-Home Points

• Situational awareness involves the careful and deliberate perception, understanding, and prediction of events in an environment of interest.
• Cultural changes that prioritize efficiency and remove trainees from the bedside environment contribute to inattentional blindness to hazards of hospitalization that are in plain sight.
• Issues that threaten safety of hospitalized patients, including catheter–associated urinary tract infections, hand hygiene, and medication errors, are often visible and tangible errors, which are ideal for situational assessment.
• Experiential and active learner-centered strategies, such as simulated patient safety scavenger hunts, have been successful in increasing recognition and reporting of errors.

Jeanne M. Farnan, MD, MHPE Associate Professor, Section of Hospital Medicine Assistant Dean, Curricular Development and Evaluation Director, Clinical Skills Education Medical Director, Clinical Performance Center The University of Chicago Pritzker School of Medicine Chicago, IL

References

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