Review| Volume 58, ISSUE 4, P404-408, May 2020

Leading article: What can we do to improve individual and team situational awareness to benefit patient safety?

Published:February 27, 2020DOI:


      It is increasingly being recognised that human factors can contribute to error in complex safety systems. Healthcare, however, has a long way to go before the promotion of training in, and awareness of, human factors will catch up with other high-risk organisations. A critical component that is deemed essential both for improving clinical performance and reducing medical error is situational awareness (SA). This is dynamic and can reduce quickly or be lost entirely, particularly when the workload is heavy. Tunnel vision, in which healthcare professionals concentrate on a single aspect of a patient’s care, is just one example of reduced awareness that can be detrimental to safety. As in aviation and other high-risk organisations, a reduction in SA, if not recognised by individuals or the wider team, can lead to serious or potentially fatal outcomes. We therefore give an overview of SA and show how it can easily be reduced. We also suggest some simple but effective ways to improve it and in turn improve patient safety. We emphasise the importance of clinical teams looking out for each other, particularly in the operating theatre.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to British Journal of Oral and Maxillofacial Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Schulz C.M.
        • Endsley M.R.
        • Kochs E.F.
        • et al.
        Situational awareness in anesthesia: concept and research.
        Anesthesiology. 2013; 118: 729-742
        • Gilson R.D.
        Situation awareness — special issue preface.
        Hum Factors. 1995; 37: 3-4
        • Jensen R.S.
        The boundaries of aviation psychology, human factors, aeronautical decision making, situation awareness, and crew resource management.
        Int J Aviat Psychol. 1997; 7: 259-267
        • Panagioti M.
        • Khan K.
        • Keers R.N.
        • et al.
        Prevalence, severity, and nature of preventable patient harm across medical care settings: systematic review and meta-analysis.
        BMJ. 2019; 366: l4185
        • de Carvalho P.V.
        • Gomes J.O.
        • Huber G.J.
        • et al.
        Normal people working in normal organizations with normal equipment: system safety and cognition in a mid-air collision.
        Appl Ergon. 2009; 40: 325-340
        • O’Connor P.E.
        The nontechnical causes of diving accidents: can U.S. Navy divers learn from other industries?.
        Undersea Hyperb Med. 2007; 34: 51-59
      1. Clinical Human Factors Group. Available from URL: (Last accessed 27 January 2020).

        • Brennan P.A.
        • Davidson M.
        Improving patient safety: we need to reduce hierarchy and empower junior doctors to speak up.
        BMJ. 2019; 366: l4461
        • Reader T.W.
        • Flin R.
        • Mearns K.
        • et al.
        Team situation awareness and the anticipation of patient progress during ICU rounds.
        BMJ Qual Saf. 2011; 20: 1035-1042
        • Gillespie B.M.
        • Gwinner K.
        • Fairweather N.
        • et al.
        Building shared situational awareness in surgery through distributed dialog.
        J Multidiscip Healthcare. 2013; 20: 109-118
        • Haynes A.B.
        • Weiser T.G.
        • Berry W.R.
        • et al.
        A surgical safety checklist to reduce morbidity and mortality in a global population.
        N Engl J Med. 2009; 360: 491-499
        • Wright M.C.
        • Taekman J.M.
        • Endsley M.R.
        Objective measures of situation awareness in a simulated medical environment.
        Qual Saf Health Care. 2004; 13: i65-i71
        • Willett M.
        • Gillman O.
        • Shin E.
        • et al.
        The impact of distractions and interruptions during Cesarean Sections: a prospective study in a London teaching hospital.
        Arch Gynecol Obstet. 2018; 298: 313-318
        • Yoong W.
        • Khin A.
        • Ramlal N.
        • et al.
        Interruptions and distractions in the gynaecological operating theatre: irritating or dangerous?.
        Ergonomics. 2015; 58: 1314-1319
        • Endsley M.R.
        Measurement of situation awareness in dynamic systems.
        Hum Factors. 1995; 37: 65-84
        • Green B.
        • Mitchell D.A.
        • Stevenson P.
        • et al.
        Leading article: how can I optimise my role as a leader within the surgical team?.
        Br J Oral Maxillofac Surg. 2016; 54: 847-850
        • Brennan P.A.
        • Oeppen R.
        • Knighton J.
        • et al.
        Looking after ourselves at work: the importance of being hydrated and fed.
        BMJ. 2019; 364: l528
        • Ragau S.
        • Hitchcock R.
        • Craft J.
        • et al.
        Using the HALT model in an exploratory quality improvement initiative to reduce medication errors.
        Br J Nurs. 2018; 27: 1330-1335
        • Reynard J.
        • Reynolds J.
        • Stevenson P.
        Situation awareness.
        Practical patient safety. Oxford University Press, 2009: 201-246
        • Rasmussen J.
        • Vicente K.J.
        Coping with human errors through system design: implications for ecological interface design.
        Int J Man Mach Stud. 1989; 31: 517-534
        • Banbury S.
        • Dudfield H.
        • Hoermann H.J.
        • et al.
        FASA: development and validation of a novel measure to assess the effectiveness of commercial airline pilot situation awareness training.
        Int J Aviat Psychol. 2007; 17: 131-152
        • Graafland M.
        • Schraagen J.M.
        • Boermeester M.A.
        • et al.
        Training situational awareness to reduce surgical errors in the operating room.
        Br J Surg. 2015; 102: 16-23
        • Jung J.J.
        • Borkhoff C.M.
        • Jüni P.
        • et al.
        Non-Technical Skills for Surgeons (NOTSS): critical appraisal of its measurement properties.
        Am J Surg. 2018; 216: 990-997
        • Whittaker G.
        • Abboudi H.
        • Khan M.S.
        • et al.
        Teamwork assessment tools in modern surgical practice: a systematic review.
        Surg Res Pract. 2015; 2015494827