Situational awareness:

SBAR training

Outline of this presentation

• Situational awareness• Joint accountability• SBAR

These can happen to you!• After the code team was finished resuscitating,

someone found out that the patient received more than twice the maximum allowed volume of the wrong IV fluids.

• During timeout, the surgeon assumed that the right chest was to be tapped, based on the resident’s notes. The correct side was the left chest but the resident was too confused.

• An order for Fortum was illegibly written and no generic name was included. The nurse read it and encoded the order as Forgram, assuming there was no other similar sounding drug.

We can lose situational awareness!

When an unexpected event occurs, we can be thrown off balance and our attention fixed on only one thing.

We can become engrossed in solving the problem and lose sight of the overall picture.

We can hastily assume that we have understood what people meant to say even though we can be wrong.

When everyone is busy playing their individual roles, no one may be looking at the BIG PICTURE.

SITUATIONAL AWARENESS IS ABOUT THE BIG PICTURE.

What situational awareness means

• An accurate perception of the factors and conditions currently affecting the safe operation of equipment and staff

• The perception of elements in the environment within time and space

• The comprehension of their meaning and• The projection of their status in the future

(Endsley 1988)

Levels of situational awareness

• Perceiving what is going on around you (level 1)

• Understanding what this means (level 2)• Anticipating what will happen next (level 3)• Keeping ahead of the situationThe lack of situational awareness is the

major causal factor in 88% of accidents associated with human error in review of major air carrier accidents (1989-1992)

Signs that you may be losing your situational awareness

• Conflicting input – pulse oximeter is not alarming but patient’s blood is very dark due to hypoxia

• Preoccupation – during endoscopic surgery, everyone is looking at the monitor, no one is minding the patient

• Not communicating – nurse asks doctor to activate pathway, doctor tells nurse not to tell him what to do

• Confusion – name of the drug ordered does not exactly match the name of the available drug in SHAMAN, nurse guesses the drug

Signs that you may be losing your situational awareness

• Violating regulations or standard operating procedures – nurse, not surgeon, does “time out” while surgeon and staff crack jokes

• Failure to set/meet targets – no one in the surgical team speaks up that blood loss has exceeded anticipated amount

• Not addressing discrepancies – patient has a signed informed consent for right sided surgery but the surgical marking is on the left side; no one speaks up during time out

An example of loss of situational awareness

Is that the common bile duct you are holding with your forcep?

I’m not holding a

forcep. My other hand is

unsterile.

There’s one forcep on the table. Do you mean we have

two?

Is that the common

bile duct he is holding?

Good communication helps people maintain their situational awareness

Communication breakdown leads to medical errors.

Good communication is about breaking down barriers to effective interaction.

Communication/Interpersonal skills.

• A communication barrier is anything that blocks, degrades or interferes with clear exchange of ideas.

• Cultural barriers: Shyness; excessive deference to authority; keeping quiet to avoid embarrassment.

• Rank, age, position barriers: Gaps between superiors and subordinates, between doctors and non- doctors

• Failure to get attention• Failure to communicate level of concern• Failure to communicate real problem• Failure to communicate desired action• Failure to reach decision together before

communication is cut off

Communication failures that lead to loss of

situational awareness

Attitudes for overcoming communication barriers

RNMD

HK

MD RN

HK

A A

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Individual ResponsibilityJoint

Accountability!

The concept of joint accountability

• The doctor may be the captain of the ship but the ship cannot sail with the captain alone.

• If the ship sinks, EVERYONE is in trouble.

• If a sentinel event happens, the entire team is held ACCOUNTABLE.

• Therefore, team must gel together as soon as care begins.

The concept of joint accountability

SEE IT!• Be alert to anything that feels or appears

wrong.SAY IT!• SPEAK UP regardless of authority or

seniority.FIX IT!• Stop what you are doing and help your entire

team reclaim collective situational awareness.

Speaking up is everyone’s duty

• But how do we collect our thoughts quickly?

• How do we organize what we want to say so we are easily understood?

• How do we assert ourselves and overcome communication barriers?

• How can we reclaim our situational awareness?

SBAR: A communication tool to improve situational awareness

SBAR helps you to• Precisely state your observations• Make clear and concise questions• Accurately state your concerns• Specify the feedback you need• Suggest solutions

SBAR: A communication tool to improve situational awareness

When using SBAR,• Keep an open mind• Be persistent in communicating your

concerns• Be prompt in seeking help• Listen carefully to what is being

communicated to you

SBARDeveloped for US Navy

submariners who often work in stressful, time-critical environments.

• Situation

• Background

• Assessment

• Recommendation

SBAR is a “must” when•Endorsing patients•Handing-off patients•Referring a patient to a MD•Responding to or calling a code•Addressing discrepant observations•Resolving a patient or family issue

Situation

State the current situation, including• Your name and unit• Patient’s name, physician and room

number• Brief statement of your concerns• Patient’s immediate problems that you

want addressed• Reason for the call or referral

SBAR script: Situation• I am ______________.• I am calling about __________________.• The patient’s status is _______________.• The problem I am calling about is _____.• I have just assessed the patient personally:

– Vital signs are: BP___, PR ___, RR ___.• I am concerned about the patient’s

– BP because it is over 200 or less than 100.– PR because it is over 140 or less than 50.– RR because it is over 40 or less than 10.

Background• Provide a brief and pertinent history of the

patient or situation, which may include:– Admission diagnosis and date of admission– Pertinent medical history– Brief summary of treatment to date– Results of clinical assessments– Recent interventions– Abnormal lab or imaging results– Status of IV fluid– Gait / fall precautions– Diet– Living situation / discharge plan– Vaccines, allergies

SBAR Script: Background

• The patient was admitted for _____ last / / .• The patient’s mental status is ___________.• The patient has been on coumadin for 3 days.• The patient has been on ____ l/min oxygen for

the past 8 hours.• The oximeter reads ___%.• The oximeter does not detect a good pulse and

is giving erratic readings.

Assessment

• State what your understanding of the problem, which may include– Your clinical impression or diagnosis– Your best calculated guess about the patient’s

problem or concern• In other words, what do you think the

problem is?

SBAR script: Assessment

• I think the problem is ________________.• The problem seems to be cardiac /

respiratory / infection / neurologic, etc.• I am not sure what the problem is but the

patient is rapidly deteriorating.• The patient seems to be unstable and may

get worse. We need to do something.

Recommendation• Give a suggested response based on the

situation, background and assessment. In other words, what do you needs to be done?

The recommendation should include• Anything that needs to be attended immediately.• Details on what the patient’s physician ahs been

told.• Anything that has been left undone.• Information on anything that could not be

finished during your shift / time with the patient.

SBAR script: RecommendationI suggest (or request) that you __________.

– Transfer the patient to critical care.– Call the rapid response team.– Come to see the patient at this time.– Talk to the patient or family about code status.– Ask the hospitalist to see the patient now.– Ask for the AP to see the patient now.

Are any tests needed? Do you need CXR, ECG?If a change in treatment is ordered, how often do

you want vital signs checked?How long do you expect this problem to last?If the patient does not get any better when would

you want us to call?

Use critical language to ensure that your recommendations are taken

seriously!• Critical words convey urgency!• “This patient needs medication now.”

•Now

•Must

•Need

•Immediately

•Critical

•Priority

•Important

•Quickly

•Requires

•At once

•Instantly

•Acute

•Fast

•Urgent

•Essential

SBAR during patient hand-offs

• Ensure that your concerns or questions about the patient’s conditions are satisfactorily addressed

• Communicate clearly the patient’s status and needs

• Communicate clearly what should NOT be done or what precautions are critical

SBAR during nurse to MD communication

• Nurses tend to describe and tell stories.• Doctors want the bottomline fast.• Nurses wait to be asked.• Doctors tend to say the final word.• SBAR gives nurses a chance to organize

their thoughts and prioritize information before talking to a physician.

• SBAR helps physicians get the facts they need.

SBAR during nurse to MD communication

Before talking to a physician, ask yourself• Why am I calling this physician?• What’s happening to the patient that

makes this call important?• What information is relevant to the

situation?• What might the information mean?• What would I need to know if I had to

make the decision?

SBAR during nurse to MD communication

Before talking to a physician, • Assess the patient.• Review the chart for the appropriate physician to

call.• Know the admitting diagnosis.• Read the most recent progress notes and the

nursing assessment.Have available when talking to the physician

- chart, allergies, meds, IVF, lab/imaging results.

SBAR during emergency response

In the chaos of an emergency response, be sure you are communicating with the other members of the team to prioritize actions and be clear about patient’s needs.

SBAR when resolving complaints

Organize your thoughts before responding and explain the situation clearly and concisely

SBAR BARRIERSHow to fix?• Acknowledge that you are

probably an average doctor, like the ones who are involved in sentinel events

• Rules are a defence barrier, you may get away with breaking them occasionally, but eventually,one day…

• Caution, what would your chairman or unit head do?How would the report read to your colleagues? Your residents?

Major bad attitudes• Invulnerability or denial -

it can’t happen to me• Macho attitude – risk

taking to impress others• Anti – authority – no

respect for rules / rule makers

• Can do attitude – “press-on-it”

Summary• Situational awareness is about perceiving what is going

on around you, understanding what this means, anticipating what will happen next and keeping ahead of the situation

• The loss of situational awareness of team members precedes most medical errors and adverse events.

• You and your team are jointly accountable for your patient’s safety.

• Communicating with your team using the SBAR (Situation / background / assessment / recommendations) tool helps maintain situational awareness and joint accountability.

Do you have situational awareness?

1. You come in just as the anesthesiologist has finished anesthetic induction. You have two more procedures after this breast biopsy and your patients are piling up in your clinic. What is the first thing you should do?

a. Conduct a time outb. Introduce yourself to your team and ask them to introduce themselves.c. Brief your team about the procedure to be performed.d. Check that you are in the right room with the right patient. Answer?2. You see the surgical marking on the right breast. You know your patient has

bilateral breast masses. What should you do?a. Begin operating on the right breast.b. Palpate both breasts to remind yourself which breast to operate on.c. Check the informed consent: which side did she wanted biopsied?d. Check your admitting SOAP: which side did you tell the patient you will

biopsy?Answer?

Do you have situational awareness?

3. One hour into the procedure, you are still dissecting deeply after encountering significant bleeding. The anesthesiologist asked if you are going to take longer. What should you do?

a. Ask the anesthesiologist to explain her concern using SBAR.b. Tell the anesthesiologist that you will try to make up for lost time.c. Ask the nurse for an estimate of blood loss.d. Stop. Check your surgical field and get your bearings.Answer?4. The anesthesiologist tells you that your patient had already lost 400 cc of

blood and her pre-operative hemoglobin was 11. Which part/s of SBAR is/are still missing?

a. Situationb. Backgroundc. Assessmentd. RecommendationAnswer?

Do you have situational awareness?

5. You order ceftazidime IV on the patient’s chart and give the chart back to the nurse. What do you do next?

a. You tell the nurse to note the antibiotic order before leaving the station.b. You ask the nurse to read back the order to you and then you confirm it.c. You tell the nurse to just contact the RIC if she has any questions. d. You ask the nurse if she can read your order. Answer?6. After 1 hour, you find out that one doctor on the team rounded the patient,

noted that the patient is already receiving two other antibiotics and told the nurse to defer ceftazidime. How will you settle this problem?

a. You will tell the nurse to ask the other MD to decide on the antibiotics.b. You will review ALL current medications and problems of the patient c. You will assess which of the 3 antibiotics should be given. d. You will call the other MD and use SBAR to communicate your

Recommendations based on your medication reconciliation and agree on the antibiotic choice.

Answer?

Do you have situational awareness?

7. You admit a 78/F for dizziness and heart failure. She has cataracts and insomnia. How will you help prevent accidental falls?

a. You will review the falls risk assessment of the nurse on the Patient Assessment Form and the falls prevention protocol for her.

b. You will go over the falls prevention protocol with the Nurse in Charge.c. You will go over the falls prevention protocol with the patient.d. You will communicate your concerns with the Nurse in Charge and the

patient using SBAR.Answer?8. Your patient has an unclear history of allergies and needs a stat CT scan

with contrast. How will you deal with this problem?a. You will clearly write the indication and precautions on the chart.b. You will ask your RIC to just accompany your patient to CT scan.c. You will use SBAR to communicate your concerns to the patient and NIC. d. You will use SBAR in conferring with the radiologist on the choice of

imaging procedure and precautions,Answer?

Now check your answers:

1. ABCD2. CD3. ABD4. CD5. B6. BCD7. ABCD8. ACD

Do you have situational awareness?

8 out of 8 – you are a team player and role model of patient safety!

6 or 7 out of 8 – your situational awareness is good but can be improved

5 or 6 out of 8 – you should use SBAR when talking to your team

3 or 4 out of 8 – please start talking to your team; they will appreciate it*

<3 out of 8 – practice, practice,practice** Please go over the slides again.

This SIM Card certifies that______(please overwrite with your name, thank you)__, MD

has successfully completed the Self Instructional Module on

Situational Awareness for MDs.

(Sgd) Dr Alfredo Bengzon (Sgd) Dr Jose AcuinPresident and CEO Director, Medical Quality Improvement