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Table of Contents    
Year : 2020  |  Volume : 68  |  Issue : 5  |  Page : 1166-1169

“Being Aware!” – Situational Awareness and Its Importance in Safety and Quality Assurance in Neurosurgery

Department of Neurosciences, Kokilaben Dhirubhai Ambani Hospital, Mumbai, Maharashtra, India

Date of Web Publication27-Oct-2020

Correspondence Address:
Dr. Hrishikesh Sarkar
Kokilaben Dhirubhai Ambani Hospital, Mumbai, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0028-3886.294552

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 » Abstract 

Situational awareness (SA) is a cognitive skill that is crucial in crisis resource management. Its importance has been known extensively in aviation; however, no methodical training and structured evaluation of SA exist in Neurosurgery. Like aviation, Neurosurgery is a complex and dynamic field where the stakes are high and the permissible errors are nil or negligible. This article describes the concept of SA, by illustrating two common clinical scenarios. On the foundation of these clinical vignettes, the author builds up a strong case for incorporating SA training at all levels of seniority to prevent surgical errors. The author also proposes a safety loop that can be recalled by the surgeon when faced with an adverse surgical event.

Keywords: Neurosurgery, patient safety, quality assurance, situational awareness
Key Message: There is a dire need to incorporate non technical, “soft” skill such as situational awareness during the residency and as a part of continuing medical education for Neurosurgeons. In a crisis situation, having an ability to perform swiftly, appropriately and with a calm demeanour is vital for ensuring delivery of the best case scenario thereby enhancing patient safety.

How to cite this article:
Sarkar H. “Being Aware!” – Situational Awareness and Its Importance in Safety and Quality Assurance in Neurosurgery. Neurol India 2020;68:1166-9

How to cite this URL:
Sarkar H. “Being Aware!” – Situational Awareness and Its Importance in Safety and Quality Assurance in Neurosurgery. Neurol India [serial online] 2020 [cited 2022 Jan 23];68:1166-9. Available from:

Situation awareness is defined as a person's perception of the elements in the environment within a volume of space and time, the comprehension of their meaning, and the projection of their status in near future.[1],[2] In simple words what it essentially means is, to have an understanding of what's going on? And what is likely to happen next? What steps can be taken? Unfortunately, in surgery, a great deal of emphasis is placed on executing technical skills, however, so-called “soft skills” such as SA more so remain neglected. The consequence of keeping a blind eye to SA could be catastrophic and that would fail our patients who warrant the highest level of safety standards, similar to fields such as nuclear power stations or aviation where SA training is a norm.

 » “The Ace Factor” Top

Douglas Aircraft company during the first world war employed SA as a research tool to reduce mental workload and fatigue.[3] However, it was only in the early eighties, after the Korean and Vietnam conflict that this concept became widespread. Having been engaged in innumerable intense dogfights, good SA was identified as the decisive factor in air combat engagements - “The ace factor.”[3] Since then SA has been recognized as an extremely important concept with far-reaching applications where stakes are high, time-limited, and permissible error nil/negligible such as air traffic control, nuclear power plant, and surgery. For a pilot, SA means having a mental picture of the existing interrelationship of location, flight conditions, configuration, and energy state of the aircraft and maintaining those in adverse scenarios such as loss of control, wake vortex turbulence, and strong headwinds. Similarly, for a surgeon, it means maintaining a clear and complete mental picture of patient's preoperative and intraoperative data, physiological and pathological parameters, the existing state of men (self, patient, and rest of medical/non-medical staff in), and material (technology) in Operating Room (OR) and ability to maintain this equilibrium in an adverse event such as catastrophic blood loss and severe brain swelling.

 » “Catastrophe” Top

Following two clinical examples in Neurosurgery will illustrate the concept of SA.

Scenario 1

A 74-year-old patient is brought to emergency in a comatose situation with a large chronic subdural hematoma. History, examination, and relevant medical details were noted by the casualty medical officer and passed on to the resident on call. Promptly, the patient was taken up for an emergency surgery. While the burr hole was being made, the drill malfunctions. Anesthetist notices momentary bradycardia and immediately informs the chief resident neurosurgeon. At that instance, the junior surgeon realizes that the patient had been on Aspirin for a while. Having found him-selves in catch 22 situation, sensing the so-called “urgency,” he decides to use a handheld Hudson Brace, which he had never used before. The standalone mechanized drill which he was used to was unsterile. Unfortunately, while the Hudson brace is being used, the drill plunges injuring the brain. The postoperative scan shows a large intracerebral hematoma leading to a poor outcome.

Scenario 2

A very senior surgeon of accomplished technical skills is operating on a large planum sphenoidale meningioma. It is late in the noon and it is his third case today. In order to have a quick lunch, he asks his resident and OR technician to put skull clamps and position. After having a quick confirmation with the position visually, he proceeds with surgery. As he is nearing the (ACOM) artery complex and plane of the tumor, the patient violently coughs thereby slippage of the head. There is damage to ACOM complex with resultant unfavorable outcome. Just prior to this event, anesthetist had been texting and coordinating a CME meet due that late evening.

The two scenarios describe, that, the surgical errors can happen despite the level of experience and technical skills of the surgeon. Whenever there is a loss of situational awareness, which is a common theme missing in the illustrated cases, can lead to catastrophic consequences. Such unfortunate instances cannot be attributed to “work of destiny” or “non determinate cause”.

Having gone through both the clinical scenarios, let's have a basic understanding of the SA model. Then, we would analyze both the scenarios through the eye of this model and try to reason out, where things went wrong.

 » “The Analysis” Top

Endsley's situational model proposes three levels of SA [Figure 1].[1],[2]
Figure 1: Endsley's situational model proposes three levels of situational awareness

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Level 1 SA involves the perception of information and cues from the environment. No interpretation of data occurs at this stage. Translating to medicine what SA means “What are the current facts relevant to the case.” In medicine, it is primarily the process of getting information via history, physical examination, and diagnostic tests prior to any intervention.

Level 2 is a comprehension of the situation and the way an individual combines, interprets, stores and retains information. It leads to the development of an accurate picture of “What's going on?” and the ability to make judgments about the patient.

Level 3 is the ability to forecast future events. What is most likely to happen if?”

Let's go back and Analyse Scenario 1 in this framework. Not being aware of the fact that the elderly patient was on Aspirin, not being aware of how to handle the Hudson brace led to basic error level 1 - not knowing the facts correctly. In addition, the distraction provided by the possible false alarm raised by the junior anesthetist, compounded this issue, which led to failure in the comprehension of the entire situation which is a level 2 error and subsequently having chosen a wrong instrument which is level 3 error. In addition, in the so-called and perceived “urgent” scenario, looking at the broader picture, the resident could have used unsterilized drill! The primary objective of safely releasing the hematoma would have been achieved. Infections if occurred could have been dealt with later. Information overload can lead to paralysis of mind as seen in this case. A good history taking, revealing his inexperience in handling Hudson's brace, noticing but not reacting abruptly when alarmed, calling for help, simulated drill training on cadavers/models, would have either deferred or minimized the impact of the damage.

Analysis of Situation 2 in the model-In this case, an experienced surgeon landed up with terrible complication, not due to his lack of technical skill or talent, rather, due to a system and methodology flaw. The resident, without being aware of the importance of skin bunching around the pin site, remained blind, leading to level 1 error as explained above. The chief surgeon was also probably distracted by the need to finish the case soon and failed to comprehend the impending problem hence losing level 2 awareness. The anesthetist in addition to being blind to the fact that pins were not put properly was distracted too. Failing to notice early warning signs of a patient being “light” was an act of omission or incorrect judgment or prediction. This is a loss of level 3 SA.

The OR technician, though he was aware of the anomaly, did not pass this information to the surgeon due to a strict hierarchical structure. He was afraid of getting rebuked by a senior surgeon. He had facts, he knew this could be a problem. However, he failed to realize the most likely scenario that could happen, possibly in the worst way. This is error level 3. In addition, he had a choice to disclose or not. He made the wrong choice demonstrating level 4 error which is not knowing which best option to take?

All these were cognitive factors of individuals; however, environmental/methodological factors such as keeping a complex case at the end of an unusually busy day, a mentally distracted surgeon due to overload of cases, and a preoccupied anesthetist, probably also played their role. So as you see, the bad outcome was directly related to situational blindness more so with the team rather than the surgeon alone.

SA incorporates the cognitive approach and the systems approach that gives an excellent opportunity to address surgical errors and improve patient safety. In other words, SA could be lost due to any adverse event that could disturb the equilibrium between the men (patient, surgeon, medical and non-medical staff), the material (OT material-Bipolar, suction, lights, navigation, etc.,) the method. Here method signifies both static and dynamic information subsets shared between the men and material [Figure 2].
Figure 2: Surgeon is the center of information input from the patient, other staff, and the hardware being used. This data can be static (e.g., patient's premorbidity, limitations of equipment, etc.,) or dynamic (blood pressure, communication with the scrub nurse, assistant, etc.,). This can lead to data overload and inattention blindness

Click here to view

As seen in this case, it was a catastrophic failure of the team and it shows the importance of “Being aware” by not a single person but ALL concerned individuals in a complex dynamic environment such as neurosurgical operation theater.

 » “methods to Improve Situational Awareness” Top

Taking examples from the Aviation sector, it is possible that this soft skill can be taught and trained just as pure technical skill. Even in medicine, it has been shown in fields such as emergency medicine,[4] anesthesiology,[5] intensive care units[6] that proper addressal to SA and its utilization indeed raise the safety standards. Taking inspiration from this there are few ways SA can be improved.

  1. Impart SA training to ALL – Surgery is a complex teamwork and hence it is vital that each member in OR is aware at all levels what role to play in routine, crisis, and never been there situation. Everybody should know what to do in both routine and crisis events. Surgical crisis code and drills are the way to move forward in this regard. Proposed is an algorithmic loop that can utilized during an occurrence of any adverse event during surgery which would help declutter the information and reveal a broader picture so that the appropriate action can be taken in a short time to negate complications. To reemphasize, preparation starts preoperatively. This loop is like a checklist that should run through the mind, before, during, and after any surgical procedure and occurrence of adverse surgical events [Figure 3]
  2. Simulation-based training – Simulation based training can be provided to the residents to hone their surgical skills before even trying on patients. Even accomplished surgeons can use this technology. It raises SA by replicating real-time scenarios and possibly worst-case scenarios, to predict the disaster preparedness[7]
  3. Significant distraction can occur due to vast array of alarms, and data sets-Simulation training should include how to avoid distractions such as alarms, comments, telephonic conversations, repeated door opening, and closing in the operation theatre
  4. Teamwork and communication – Measures should be taken to build team spirit, where every individual develops a sense of belonging and he/she subconsciously becomes part of the process. Things such as time in/time out, universal surgical safety checklists, confidence-building measures, and mock drills can be useful
  5. Creating a strong hierarchical structure creates barriers to effective communication within a team as witnessed in our clinical scenario. Instead of a blame game, any wrong doing should be dealt in a humane fact-finding method instead of witch-hunting
  6. In addition to mortality and morbidity meetings, there should be a critical analysis of so-called near-miss events as well. Near miss events are those, in which adverse events did occur however they were managed and a worse outcome averted without resulting in morbidity or mortality
  7. It should be emphasized, particularly to junior colleagues, to remain calm in a crisis and to “Call out” and not “Shout out or pass out.” Calling for help from another colleague can be of immense value
  8. Knowledge update – It is just impossible for a single surgeon to experience all adverse events in his lifetime. Thus to enhance this awareness, sharing experience on national and international platforms, local body meetings, journals, relevant social media handles, can improve one's awareness and raise patient safety standards to which we are all committed to.
Figure 3: Proposed surgical safety loop that should run through a Surgeon's mind before and during operation. This would help in maintaining situational awareness, declutter sensory overload

Click here to view

 » Conclusion Top

In addition to pure surgical skill, SA is an extremely important behavioral, non-technical, “soft skill” that must be learned, acquired, trained, and shared to minimize surgical errors and crisis mitigation. A structured teaching framework directed to improve SA is the need of the hour. Awareness of Safety loop that's proposed, in addition to the universal surgical checklist will further help surgeons to counter adverse events during surgical procedures and raise standards for patient safety.


The author sincerely acknowledges Dr (Prof) Keki Turel, Senior Neurosurgeon, Bombay Hospital, Mumbai, India for his valuable insight, encouragement and contribution to this article, especially, during the creation of “Surgical Safety Loop”.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

 » References Top

Endsley MR. Toward a theory of situation awareness in dynamic systems. Human Factors 1995b; 37:32-64.  Back to cited text no. 1
Endsley MR. Measurement of situation awareness in dynamic systems. Human Factors 1995a; 37:65-84.  Back to cited text no. 2
Biferno MA. Flight Crew Computer Interaction. Long Beach, CA: Douglas Aircraft Company, Internal Research and Development; 1985.  Back to cited text no. 3
Briggs A, Raja AS, Joyce MF, Yule SJ, Jiang W, Lipsitz SR, et al. The role of nontechnical skills in simulated trauma resuscitation. J Surg Educ 2015;72:732-9.  Back to cited text no. 4
Haber JA, Ellaway RH, Chun R, Lockyer JM. Exploring anesthesiologists' understanding of situational awareness: A qualitative study. Can J Anaesth 2017;64:810-9.  Back to cited text no. 5
Engelman D, Higgins TL, Talati R, Grimsman J. Maintaining situational awareness in a cardiac intensive care unit. J Thorac Cardiovasc Surg 2014;147:1105-6.  Back to cited text no. 6
Monod C, Buechel J, Gisin S, Abo El Ela A, Vogt DR, Hoesli I. Simulation of an impacted fetal head extraction during cesarean section: Description of the creation and evaluation of a new training program. J Perinat Med 2019;47:857-66.  Back to cited text no. 7


  [Figure 1], [Figure 2], [Figure 3]


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