We thank Dr McCarthy for his thoughtful insights on the application of situational awareness in medicine. We agree that doctors begin with a limited amount of situational awareness and often fail to maximise their situational awareness using a team approach. Owing to 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 situational awareness in outpatient care has become more critical than ever. Although doctors function at times with a high degree of situational awareness, they seldom continue to be “aggressively sceptic” in the environment of outpatient care, owing to factors such as fragmented communication, as Dr McCarthy noted. In our article, we propose that achieving “team situational awareness” could overcome some of these obstacles. Team situational awareness can act as a safety net for primary care doctors “flying solo” and can be facilitated by a culture change in communication among doctors.

We do acknowledge the omission of a post-event debriefing in our discussion. Nevertheless, we believe that learning resulted from this case to some extent. We discussed the case in detail at a traditional conference on morbidity and mortality and communicated several lessons to the audience. Unfortunately, as many doctors 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 randomised controlled trials and other evidence-based literature to change healthcare 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.