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Situational awareness: A vital skill to ensure patient safety

This is article twenty in an RCVS Knowledge series of features on patient safety, clinical human factors, and the principles and associated themes of Quality Improvement (QI).

It had been another busy day in the theatre, and as the last patient was transferred to recovery, the team gathered to debrief. Whilst three of the four surgeries completed had been straightforward and went smoothly, adrenaline still coursed through the veins of the team as they began to reflect on the first patient of the day. Cathy (one of the nurses) led the debrief:

“Summarise the case… Pickle, a 7-year-old Bichon Frise had been admitted to have a mass removed. During the dissection of the mass, the jugular vein was torn, and the patient lost 20% of its circulating blood volume. The tear was repaired quickly, mass removed, and the patient continues to make a good recovery”.

“Things that went well…”, Emma, the surgeon, spoke first, “We reacted quickly to jugular tear and communicated well… Jack, you were amazing… all I can remember is putting my finger in the hole and thinking this is not great! Before I even looked up you were there, scrubbed in next to me with the Statinksy’s… you knew exactly what instrument I needed… fantastic situational awareness, thank you so much!”

Situational awareness

The military first described situational awareness as ‘gaining an awareness of the enemy before the enemy gained a similar awareness’. Within high risk, safety critical industries such as aviation, nuclear power, and healthcare, a loss of situational awareness can result in a serious compromise in safety if it is not recognised and regained quickly. Case examples such as Chernobyl, United Airlines 173,1 and Elaine Bromiley,2 teach us that a loss of situational awareness can result from task fixation. If we are fixated on completing a task, we can develop tunnel vision and are unable to notice the passage of time or what is going on around us, this can result in devastating consequences. For example, in the case of Elaine Bromiley, anaesthetists were so fixated on placing an endotracheal tube that they did not realise that the patient’s oxygen saturation had dropped dangerously low. She was being starved of oxygen, and irreparable brain damage was occurring. They also did not notice that one of the nurses had correctly anticipated that a tracheostomy tube should be placed and seemingly ignored her advising them that the kit was ready to use.

Within the veterinary profession, which is also considered a safety critical industry, 51% of errors are primarily caused by cognitive limitations (Oxtoby, 2015).3 While very little research has been conducted into the behavioural components affecting clinical veterinary practice, it is accepted that good non-technical skills have been found to have a positive effect on performance, reducing the incidence of error, and improving patient outcomes (Flin, O’Connor, and Crighton 2008).4

Situational awareness is a cognitive non-technical skill and can be explained simply as ‘knowing what is going on around you’ (Flin, O’Connor, and Crighton, 2008).

There are three recognised levels of situational awareness, according to Flin, O’Connor, and Crighton, (2008)4 sometimes referred to as ‘what?’, ‘so what?’ and ‘now what?’


Gathering information (through listening, watching and picking up on non-verbal cues).

‘So what?’

Interpreting information.

‘Now what?’     

Anticipating future states.

Situational awareness is the first stage of the decision-making process. It triggers a more focused situational assessment when a significant change is noticed to understand or diagnose a new or altered situation. (Flin, O’Connor and Crighton, 2008).

Situational awareness is, like other non-technical skills, developed through experience, often gained from watching, listening, and learning from others in the role. It is recognised by Flin, O’Connor, and Crighton (2008) that “novices have fewer and less rich mental models” and take longer to interpret information and respond. Novices are known, however, to be better at noticing when something doesn’t seem right, alerting others to concerns and therefore play an important role within any team.

In the scenario above, Jack was an extremely experienced veterinary nurse; he was able to apply his knowledge and experience (which was stored in his memory as mental models) to interpret the situation rapidly, and anticipate the actions and instruments required to enable the surgeon to regain control of the surgery and arrest the haemorrhage as quickly as possible. This process is known as pattern matching and enables experienced members of the team to react extremely quickly. In some cases, this level of competence in situational awareness would result in the ability to pre-empt a likely course of action.

To improve situational awareness, we can:

1. Use an acronym or model such as NUT to familiarise ourselves with the levels of situational awareness and enable us to focus on them.5

  • N- Notice
  • U – Understand
  • T – Think ahead

2. Perform a briefing at the beginning of every day so that a shared mental model can be developed, to identify areas when situational awareness could be lost and agree team strategies for raising concern.

3. If you are concerned that someone has become task fixated and lost situational awareness, use the PACE  or  CUSS mnemonic to help you exercise appropriate assertiveness.

  • Probe – Raise a concern or gain attention using an open question.
  • Alert  - Use person’s name and raise volume to gain their attention, then state your concern.
  • Challenge – Repeat name and concern, challenge actions and suggest solutions.
  • Emergency – Increase urgency and take actions needed to prevent harm.


  • C – I am concerned.
  • U – I am uncomfortable.
  • S – This has become a serious situation.
  • S – This procedure needs to stop.

4. Use the theatre cap challenge 6 to ensure that every member of the team knows each other’s names. This will ensure that if situational awareness is lost, the team can use each other’s names to help get their attention to regain situational awareness. When every team member knows each others first name, there is a better chance of ensuring trust, work engagement, and reducing adverse outcomes.

5. Consider implementing a sterile cockpit rule during critical tasks such as surgery or medication administration to minimise distractions and maintain situational awareness. The sterile cockpit rule was first implemented in aviation in 1981 and prohibits team members from performing non-essential duties or activities, including taxi, take off, landing, and all activities conducted below 10,000 feet. Also known as the 10,000 feet rule, it has since been adopted by human healthcare, for example during medication administration and at critical points during surgical procedures. The team begins by identifying threats to safety at the briefing or huddle and agrees that if anyone in the team calls out “10,000 feet” everyone in the team will go silent - there will not be any interruptions or distractions. This enables the team to maintain focus and situational awareness at critical points.

6. Check-in with the team: situational awareness skills are likely to be impeded for those who are physically or mentally unwell. Therefore, it is important that appropriate steps are in place to support any member of the team suffering from stress, fatigue, or illness before proceeding. A simple and quick tool to help with this could be The Rolling Take 5, produced by Suzette Woodward and adapted for veterinary settings by RCVS Knowledge.

The ability of all members of the team to gain and maintain situational awareness is fundamental for patient safety and can improve efficiency throughout all areas of veterinary practice. When the concept of situational awareness is understood, we can recognise that all members of the practice team routinely practise situational awareness whether booking appropriate consultation appointments, preparing equipment, or arresting haemorrhage in theatre.

Checklist: What can you do next


  1. Syed, M. (2015) Black box thinking: the surprising truth about success. London: John Murray.
  2. Bromiley, M. (2011) Just a routine operation [YouTube] [online] Available from: [Accessed 27 May 2022]
  3. Oxtoby, C. et al. (2015) We need to talk about error: causes and types of error in veterinary practice. Veterinary Record, 177 (17), pp. 438-438.
  4. Flin, R., O’Connor, P. and Crichton, M. (2008) Safety at the sharp end: a guide to non-technical skills. Aldershot: CRC Press.
  5. Threat Management Training (OGHFA BN) [SKYbrary] [online] Available from: [Accessed 27 May 2022]
  6. # TheatreCapChallenge: where’s the evidence? [PatientSafe Network] [online] Available from: [Accessed 27 May 2022]

About the author

Helen Silver-MacMahon MSc (Dist) PSCHF Cert VNECC DipAVN(surg) Cert SAN RVN

Image of Helen Silver-MacMahonHelen is a veterinary nurse and Senior Trainer and Content Development Lead at VetLed. Having worked in general practice, referral hospitals and nursing education over the past 21 years, she has extensive professional experience and understanding from a wide range of settings.

Helen is passionate about developing the veterinary professions understanding of Human Factors as a powerful aid in improving patient safety, enhancing performance and supporting the wellbeing of the veterinary team. She is an RCVS Knowledge Champion for her role in the sustained training and use of a surgical safety checklist within the small animal theatre at the former Animal Health Trust.

In 2021, Helen completed an MSc in Patient Safety and Clinical Human Factors at the University of Edinburgh.

For her dissertation project Helen researched situational awareness in the veterinary operating theatre and has a special interest in non-technical skills. In her role at VetLed she enjoys applying this knowledge to develop and deliver professionally relevant training for all members of the veterinary team.   


May 2022