Situational Awareness, Patient Safety, and Systems Architecture
A recent post entitled “Innovative technologies can markedly enhance safety,” by Stephen Schimpff, MD, prompts the writing of this post. The famous book “To Err Is Human” that many (most?) are aware of, published back in the late ’90s by the Institute of Medicine identified or estimated that upwards of 98,000 individuals died each year due to preventable medical errors, and that the bulk of these errors were estimated to be due to medication or surgically-related causes. Technologies have evolved as well as procedures since that time. The Electronic Medical Record (EMR) has evolved since then as well as specific functions in clinical decision support, including electronic medication administration checking (sometimes referred to as eMAC or eMAR) and computerized practitioner order entry (CPOE) among others. Several elements of situational awareness in these functions including affording the practitioner of patient-specific information (vitals, demographics, laboratory information, etc.) that might inform the practitioner of certain facts to assist in better decision making, as well as verifying that a specific patient is indeed the recipient of a specific drug at a specific dose and at a specific time.
“Situational awareness,” as defined in an NIH Medical Surge Capacity Workshop, “is a term that simply means understanding the current situation. It is the ability to look at a huge variety of data, determine what is relevant, synthesize the data, and act on it.”
Many years ago, in a previous life of mine (I think it is in excess of 20 years now) I had cause to apply this concept in another field–aerospace. I link the concept described above with another extra-medical term: that of multi-source data fusion (I used this term a few times at a recent medical device alarm summit, which I chronicled in a past post). The terms are not unrelated and apply to the larger picture of making sure all information surrounding a decision that can be had is provided for the decision maker’s purposes, as well as the nature of the surrounding environment.
Situational awareness, multi-source data fusion, interoperability are all terms that I have used and “interacted” with in past lives stretching back more than 20 years now in “that other field” of mine before I entered into healthcare and healthcare information technology. The essence of systems engineering is taking multiple sources of information or multiple systems (or a combination of the two) and developing an understanding of how they operate and interoperate to solve a larger problem involving the fusion and/or coupling of them. Examples abound around us.
One example known by most of us that combines the concepts of situational awareness and systems engineering is the automobile. The automobile combines many systems: engine, brakes, passenger compartment, electrical, … These are separate systems with interfaces among one another to support their integrated whole in the entity of what we call the “car” or “truck.” The separate systems on their own contain elements that are completely independent of one another; do not even depend on one another for their localized functions. Yet, to accomplish the end-user’s purpose of “driving down the road” and supporting a variety of use cases for the end-user (e.g.: driving to the grocery store; driving to work; driving to grandma’; pulling a boat, etc., etc., etc.), all must operate in conjunction with one another through defined interfaces that pass prescribed information.
The situational awareness of the end-user (i.e., the driver) is essential to safe and effective operation of this integrated systems architecture. The scenario of “turning left” involves the integration of the systems described in the paragraph above. However, “turning left” into traffic could be a fatal operation. Situational awareness dictates when it is safe, appropriate, legal to “turn left.”
Returning to the world of medicine, the end-user in this instance (say, the physician) is presented with a system of systems (some integrated, some not), possibly presented in the form of vital signs, laboratory information, orders, etc.. The physician can order a specific drug, but the situational awareness of that physician will define whether at the current moment it is safe and effective to do so based upon the patient’s condition, past history, etc.
As information continues to become a key enabler and facilitator for medicine, it is important to understand that it is not simply that data are provided, but that the integration of the whole of the information available along with past history and knowledge within the “wet wear” of the physician dictate (and constrain) what must be done at a given moment. Providing the tools leading to that knowledge vital to decision making is where healthcare information technology’s true value may lie–just as providing rear-view mirrors on a car are key to the situational awareness of the driver.