Loss of situational awareness
CMPA Good Practices Guide – TEXT CASE AND TRIGGER QUESTIONS
Loss of situational awareness
DOMAIN AND TOPIC:
Human factors > Situational awareness
situational awareness, emergency medicine, seizure, medication, infusion pump, CanMEDS Medical Expert, CanMEDS-FM Medical Expert
This text case describes an adverse event (accident
in Québec) during a young child’s visit to emergency. The trigger questions and suggestions
to faculty focus on helping students to understand situational awareness and its importance to patient safety. Students should also be familiar
with domain 2 (Teams).
A 4-year-old male arrives in an emergency department in status epilepticus. He is given several doses of a benzodiazepine and a loading dose of
phenytoin by an emergency physician. As the patient continues to seize, the physician orders a midazolam infusion. The IV, which is not labeled,
is placed on a pump to give 1ug/kg/min.
At one point the child has an episode of hypotension and bradycardia. He is given a dose of epinephrine through the only functioning IV by a second emergency physician. The midazolam infusion is taken off the pump to flush the line fol owing the dose of epinephrine.
The child continues to be unstable and has to be intubated and resuscitated. A large team of healthcare providers assists with the resuscitation. The patient remains hypotensive despite the resuscitative measures.
Ten minutes later a nurse notices that the IV bag, which was previously on the pump, is empty and realizes that the child has received the entire 75 mg dose of midazolam contained in the infusion.
1. Identify, by profession, the different team members that may have made up the resuscitation team. What roles and responsibilities
2. Describe team situational awareness and how it appears to have broken down in this scenario.
3. What factors may have contributed to a loss of team situational awareness?
4. What are some ways of improving individual mindfulness?
5. What are some ways of improving mindfulness within a team?
SUGGESTIONS TO FACULTY
Ask students to form into groups of 3 or 4 and make arrangements to research a case outside of medicine that embodies a loss of situational
awareness by an individual or team. Research content should include:
• a description of the case, including an explanation about the loss of situational awareness
• possible reasons for the loss of situational awareness
Students should be prepared to present their findings to the larger class either formally (e.g. through a PowerPoint presentation) or informally. Faculty may also decide to have students submit a written assignment as individuals or in their small groups.
Examples of questions that may be used to debrief the students as a large group, once al presentations have occurred, include:
• Discuss any themes or variability between the cases.
• What lessons can be applied to medicine from how other professions approach situational awareness?
The information contained in this learning material is for general educational purposes only and is not intended to provide specific professional medical or legal
advice, nor to constitute a “standard of care” for Canadian healthcare professionals. The use of CMPA learning resources is subject to the foregoing as wel as the CMPA’s Terms
of Use, found on the CMPA website, and the full disclaimer in the Good Practices Guide for Faculty. Brandmark of the Canadian Medical Protective Association.
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