Jurnal keperawatan : Using the ABCs of situational awareness for patient safety

PATIENT SAFETY

Sumber: By Nancy L. Cohen, MSN, RN, CGRN, CNE

WHEN WATCHING FOOTBALL on TV, you may hear the commentator say the quarterback has excellent situational awareness. What does this mean? In this case, it means that the key player knows the availability of his teammates, the position of opposing players, and the best trajectory of the football for a safe catch. Nurses are key players in healthcare and patient safety and, like a quarterback, are constantly bombarded with distractions while trying to ensure a safe outcome.

In my school of nursing, the curriculum has been adapted to use situational awareness to teach the principles of patient safety to nursing students.Using situational awareness develops students’ intuitive thinking and perceptual awareness. This article discusses the importance of including situational awareness in nursing education and practice and explains how nurses can use a simple 60-second situational awareness tool at the beginning of each

shift to improve patient safety.

Understanding the concept

For public safety after 9/11, Americans

were encouraged to be more aware of their environment. According to the U.S. Department of Homeland Security, situational awareness is knowing and understanding what’s happening around you.1 For instance, we use situational awareness daily when we see an unattended suitcase at an airport, walk to our car at night while being alert to dangers, or enter a patient room and notice disconnected oxygen tubing.

Situational awareness includes three elements for evaluating patient safety:

·        elements in the environment, using input from all five senses

·        comprehension of the current situation

·        the ability to anticipate risks².

         Situational awareness began in aviation. The military has adapted a

medical model of situational awareness to assess and mitigate health

risks and support timely decision making.3 It’s also used in the OR and

postanesthesia care unit. The timeout in the OR forces the healthcare team

to become aware of its environment.

Nurses intercept errors

The Institute of Medicine report Keeping Patients Safe: Transforming

the Work Environment of Nurses said explicitly that nurses are the healthcare

professionals most likely to intercept errors and prevent harm to

patients: “Nurses constitute the surveillance system for early detection of complications and problems in care, and they are in the best position to

initiate actions that minimize negative outcomes for patients.” ⁴

Nurses with situational awareness anticipate patients’ needs by knowing what’s going on, why it’s happening, and what’s likely to happen next. By seeing the big picture, nurses can recognize events around them. They act correctly when things go as planned and react appropriately when they don’t.

Patient safety tool

Our hospital-based curriculum has adapted an environmental survey

tool to increase nurses’ situational awareness and improve patient safety

throughout the nursing program. ⁵ (See Performing a situational awareness

assessment.) Faculty members continually promote and reinforce situational

awareness in all clinical settings and simulation experiences. This approach can benefit both novice nurses transitioning to professional practice and experienced nurses assigned to multiple patients.

Using the ABCs

The ABCs of situational awareness for patient safety can be simplified as follows:

•         Awareness of the environment

•         Belief in your gut feelings

•         Changing what’s wrong.

Nurses can focus on the art of observation by performing a 60-second

situational assessment based on these ABCs. This exercise helps them process

the environment as they stop, look, listen, and smell to assess the situation.

Surveying the patient’s environment at the beginning of the shift helps nurses head off problems that might harm the patient. Completing a situational awareness assessment for each patient also provides data to prioritize care. All students in our nursing program begin their clinical experience with this exercise.

Awareness of the environment

includes the patients’ airway, breathing, and circulation; tubes and lines;

respiratory equipment; and a safety survey. Without touching the patient,

the nurse completes this assessment for each patient by considering each

of these sections on the tool. The nurse focuses first on airway, breathing, and circulation. What’s the

patient’s color and respiratory rate? Is the patient using oxygen? What’s

the patient’s heart rate and BP?

Next the nurse focuses on the environment. What’s out of place that captures the nurse’s attention? Is it the call light out of reach on the floor, the nasal cannula on the patient’s pillow, or the side rail that’s down? Are the patient’s I.V. solutions about to run dry? Is other bedside equipment such as suction equipment readily available and functional? Consider what data indicate the need for immediate action and why. What further assessment should be completed? Is an intervention indicated? Does a problem

need to be reported?

Belief in your gut feelings.

Nurses frequently share experiences about patients who made them feel uncomfortable. Intuitively, something didn’t seem right but they couldn’t articulate why. The 60-second situational awareness exercise encourages nurses

to develop intuitive thinking. When your gut tells you something isn’t right, check it out.

Changing what’s wrong.

 Because the patient is the immediate priority, evaluating the patient’s airway,

breathing, and circulation should be done first. Reattach disconnected oxygen tubing to avoid a drop in oxygen saturation. If the call light is out of place, move it so the patient can reach it. Clear a pathway to the bathroom to prevent a patient fall. Request assistance when you’re not sure about an unknown smell or a disconnected tube or drain.

According to a study conducted in 2003, as many as 37% of errors made by novice nurses are related to a delay in patient care. Failure to

recognize and failure to intervene in patient care were noted.6 Implementing

situational awareness supports prevention of errors through early detection and intervention. ■

Performing a situational awareness assessment

Purpose: This exercise is designed to help the nurse develop situational awareness. In the patient-care area, situational awareness focuses on the art of patient observation. This includes routine use of a general survey (observation) of the patient, family, and environment during every incidental encounter and periodically at planned intervals throughout the day. Situational awareness promotes a safer patient-care environment and helps the nurse develop care priorities and attention to clinical detail.

Directions: Enter the patient’s room and observe the patient, family, and environment for up to 60 seconds, while reviewing the following questions in your mind.

ABC (without touching the patient):

•         What data lead you to suspect a problem with airway, breathing, or circulation?

•         Is the problem urgent or nonurgent?

•         What clinical data would indicate that the situation needs immediate action and why?

•         If the patient is using oxygen, what would you need to continue to monitor?

•         How would you know respiratory equipment is functioning properly?

•         Who needs to be contacted?

•         Do you have any suggestions or recommendations?

Tubes and lines:

•         Does the patient have any tubes or I.V. access?

•         Is the I.V. solution the correct one at the correct rate?

•         Does the patient need these tubes, and if so, why?

•         Do you note any complications?

•         What further assessment is needed?

Patient safety survey:

•         What are your safety concerns with this patient?

•         Do you need to report this problem and to whom?

Environmental survey:

•         What about the environment could lead to a problem for the patient?

•         How would you manage the problem?

Sensory:

•         What are your senses telling you?

•         Do you hear, smell, see, or feel something that needs to be explored?

•         Does the patient’s situation seem “right?”

•         What additional information would be helpful for further clarification of the situation?

•         What questions are unanswered, and what answers are unquestioned?

Postconference:

•         After review of each student’s patient, which one would you focus on first? Why?

Source: Struth D. TCAB in the curriculum: creating a safer environment through nursing education. Am J Nurs.

2009;109(suppl 11):55-58.

REFERENCES

•      ESRI. Public Safety and Homeland Security Situational Awareness. ESRI White Paper 2008. http://www.esri.com/library/whitepapers/pdfs/ situational-awareness.pdf.
•     McIlvaine WB. Situational awareness in the operating room: a primer for the anesthesiologist. Semin Anesth Perioper Med Pain. 2007;26(3):167-172.
•    DeFraites RF, Chambers WC. Gaining experience with military medical situational awareness and geographic information systems in a simulated infl uenza epidemic. Mil Med. 2007;172(10):1071-1076.
•     Aiken LH, Clarke SP, Cheung RB, Sloane DM, Silber JH. Educational levels of hospital nurses and surgical patient mortality. JAMA. 2003;290(12): 1617-1623.
•    Struth D. TCAB in the curriculum: creating a safer environment through nursing education. Am J Nurs. 2009;109(suppl 11):55-58.
•    Saintsing D, Gibson LM, Pennington AW. The novice nurse and clinical decision-making: how to avoid errors. J Nurs Manag. 2011;19(3):354-359. Nancy L. Cohen is a nursing instructor I at UPMC Shadyside School of Nursing in Pittsburgh, Pa. The author has disclosed that she has no fi nancial relationships related to this article. DOI-10.1097/01.NURSE.0000428332.23978.82