Table 1:
Operationalized Definitions of Situational Awareness (SA) Error Levels
| If there were SA errors at multiple levels, code the lowest level of anesthesia SA error. |
| Level 1: Perception: What is the information? |
| Key issue: failure to gather information via history, physical exam, diagnostic tests, imaging or monitors, including absence of monitor(s) |
| • inadequate preoperative work-up (e.g. failure to question PO status or perform a more extensive cardiac evaluation) |
| • limited monitoring (e.g. equipment defect / missing, failure to place an arterial line); missing information was deleterious (e.g., missing arterial line) |
| • failure to monitor (missing ETCO2; no SpO2 reading, no arterial line; if there was no documentation that the patient was monitored, then assume the patient was not monitored (which is a level 1 error that not necessarily has to result in a level 2 or 3 error and that not necessarily has to contribute to death or brain damage) |
| • failure to check (perceive) a specific detail of the patient history / chart / test results that normally prompts a specific procedure or action (e.g. failure to consider patient name, low hemoglobin) |
| • Information was wrong (e.g. a documented value was wrong), regardless of the cause of wrong information (e.g. due to human error or other reason) |
| • non-awareness of the actions of other team members (such as the surgeon and nurses) |
| • non-awareness of equipment function (including potential problems) |
| • failure to communicate relevant information |
| • hidden information (visual barrier, e.g. drapes) |
| Level 2: Comprehension: What does the information mean? |
| Key issue: Failure to understand the significance of information obtained from history, physical exam, diagnostic tests, imaging findings, or monitors. The information was available, but it was not understood or misunderstood. If a decision (or no-decision, as illustrated by missing re-actions / non-actions) turns out wrong in face of a deteriorating event that occurred (just) in the past. |
| • failure to make the correct diagnosis |
| • failure to comprehend the cause and meaning of information (e.g. heart rate that is not within normal limits, 300–400 cc filling drains in few minutes – empty, drains continue to fill – reasonable physician would conclude patient is bleeding, likely need to draw labs, give blood, possibly return to OR) |
| • If there is information that patient is deteriorating and reasonable clinician would make diagnosis and act/react– if the physician(s) in case do not react in such a manner, conclude that this diagnosis not made/failed to comprehend |
| Level 3: Projection: What is likely to occur? |
| Key issue: Failure to forecast future events or scenarios based on a high-level understanding of the situation; failure to forecast potential outcomes based upon a chosen plan; poor planning for future events or poor/absence back-up plan. |
| If a decision turns out wrong in face of unanticipated events (e.g. well-known complications) that occur in the future: Level III.” |
| • Poor anesthetic plan (e.g. routine anesthesia plan for patient with known complex medical history or known significant comorbidities; office based anesthesia for patient with significant comorbidities; failure to plan for possible difficult airway in patient with obvious risk |
| • Proactive measures were not taken adequately although the deterioration was likely to occur or not surprising, retrospectively |
| • Failure to call for help to manage likely future complication / problems |