1. Authors' response

    Dear Editor,

    We thank Dr. McCarthy for his thoughtful insights on the application of situational awareness (SA) in medicine. We agree that physicians begin with a limited amount of SA and often fail to maximize their SA using a team approach. Because of the increasing complexity and acuity of care in the outpatient setting, the risk of outpatient medical errors has increased during the past several years.[1] Thus, the use of SA in outpatient care has become more critical than ever. Although physicians function at times with a high degree of SA, they seldom continue to be "aggressively skeptic" in the environment of outpatient care due to factors such as fragmented communication, as Dr. McCarthy noted. In our article we propose that achieving "team SA" could overcome some of these obstacles. Team SA can act as a safety net for primary care physicians "flying solo" and can be facilitated by a culture change in physician-physician communication.

    We do acknowledge omission of a post-event debriefing in our discussion. Nevertheless, we believe learning resulted from this case to some extent. We discussed the case in detail at a traditional M&M conference and communicated several lessons to the audience. Unfortunately, as many physicians would agree, the quest to make systems improvements and policy changes based on isolated "stories" is not always successful.[2] Unlike aviation, medicine seeks evidence from randomized controlled trials and other evidence-based literature to change health care systems. With decreasing funding opportunities to support research on medical error management, we hope that cases such as ours illustrate the learning opportunities from other high-risk industries.

    Hardeep Singh, MD MPH,
    Laura A. Petersen, MD MPH,
    Eric J. Thomas, MD MPH

    No competing interests


    (1) Phillips RL Jr, Bartholomew LA, Dovey SM, Fryer GE Jr, Miyoshi TJ, Green LA. Learning from malpractice claims about negligent, adverse events in primary care in the United States. Qual Saf Health Care 2004; 13(2):121-126.

    (2) Steiner JF. The Use of Stories in Clinical Research and Health Policy. JAMA 2005; 294(22):2901-2904.

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  2. Situational Awareness in medicine

    Dear Editor,

    As a retired USAF pilot-physician, I commend Singh et al. for their excellent use of aviation Situational Awareness as an analysis tool. I wish only to add a subtle dimension to their illustration of situational awareness: "LSA" - loss of situational awareness – began as a universally recognized NATO acronym. But…one can not lose what one never had. SA in military and air carrier aviation universally begins at a maximum, and may deteriorate backwards from Level 3 of Endsley’s model. Maximal SA at the outset of a mission is achieved by all team members studying all environmental factors that might affect the outcome; mentally rehearsing the mission timeline, actions, and threats; and planning for contingencies during the preflight briefing. The team begins with a high level, mental model of what is to come. Sadly, pre-event reviews are vanishingly rare in medicine, and physicians begin with very limited, or absent SA, as illustrated by the outpatient case in the paper. Further, SA in outpatient medicine, if it exists at all, is compromised by the fragmentation and time displacement of cues and communications. Ironically, is easier to discern SA, good and bad, in the confines of the high risk areas of inpatient care: the OR, Labor and Delivery, and ED. Medical team training courses emphasize the value of briefings in setting the stage for good SA, and train high risk team leaders to conduct them.

    Thus far team training is not widely deployed or accepted. Nor are briefings cited in such patient safety resources as the AHRQ Web M&M.1 Another fundamental, but subtle, difference between aviation and medicine is decision making. The hapless primary care physician was "flying solo" and making independent judgments. Despite the Hollywood images, fighter pilots rarely make solo decisions. Flying in multiples for "mutual support," air combat teams operate with strong, visible, designated leadership, but simultaneously practice collaborative, consensus decision making. Similarly, "cockpit resource management," the progenitor of medical team training, reversed decades of left-seat, hierarchical, autocratic decisions that placed passengers at the same risk level as the described patient in favor of collaborative decision making after inputs by all, even passengers.2 Lastly, the authors omit any discussion of a post-event debriefing of this adverse outcome. Thus, learning was not captured, nor system improvements made. Debriefings – as short as 30s or lasting for hours – are mandatory in aviation and result in real-time, actual, lasting CQI. Early efforts to use traditional M&M conferences offer some promise in debriefings.3 Medicine has much to adopt and adapt from other high risk professions, aviation, nuclear power, and even mining. The authors have advanced that journey significantly.



    2. Foushee HC. Dyads and triads at 25 000 feet: factors affecting group process and aircrew performance. American Psychologist 1984; 39: 885-993.


    No conflicting interests: Government employee only.

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