Good awareness of what is happening in and around the operative field is a self evident requisite of the operating surgeon yet a multitude of factors may conspire to compromise that vision and perception. Situation awareness,-as defined by Endsley [8], involves collecting the information around you that is needed for the task (noting that at times, some of that desired information may be unavailable), understanding that information and then using it to project forward and deciding on a plan or course of actions. That tripartite, – “what, – so what, – now what” sequence, is fundamentally important to both the tempo of the surgery as well as the choice and course of the procedure; and yet, it is a dynamic subject to various interruptions resulting in potentially adverse decisions or actions. The required information may not be available or indeed it may even be suppressed for fear of provoking an adverse reaction from its recipient (possibly an ill-natured surgeon?) or because of steep hierarchy within the team. Thus it may not be offered or not received (or given in the wrong format, by the “wrong person”,– ? given at the wrong time).

Intense concentration on one element of the operative task may inhibit and compromise recognition of other concurrent finding events actually occurring within the field of vision (see “gorilla in our midst” for a fuller explanation of inattentional blindness and compromise produced by undue fixation on tasks) [9]. When information is given that does not “fit” with the expected pattern,-then a tendency can exist to either subconsciously discard it (exclusion bias) or amend it because it does not suit our primary objectives and mental pattern (confirmation bias); we are prone to such error – particularly if we have multiple tasks needing attention concurrently and there is competition for our finite attention. In the presence of increasing stress levels, our cognitive “space” may thus fail to accommodate fresh or conflicting information and consequently our processing facilities diminish. This coping ability is in part dependent on experience of prior similar circumstances, but is also partially dependent on our personal well-being on that day. Calibration of your own “personal status” can be performed using the “I’m safe” mnemonic used in aviation [10] to run a well-being check on your situation awareness and how it is holding up on the day (Box 7.1).

All these affect various aspects of situation awareness and due note should be taken that these effects may also be shared by other team members. In particular rudeness has a scattered effect and the cognitive ability of those observing as well as those who are the primary recipients of the target of rudeness will result in shrinkage of the cognitive space of those involved. An outburst therefore intended to “improve” the performance of the recipient may have quite a contrary effect [11, 12].

Examples of factors which produce disruption to situation awareness therefore are:-

Examples of how to militate against disruption of that second phase of comprehension include:-

Just as intense concentration on a particular task may reduce overall situation awareness, so may undue familiarity with the task potentially result in a loss of vigilance. The potential risk of automaticity needs constant prompting such that recognition of cues which convert automaticity into mindfulness and increasing awareness of difficulty or hazard requires an attention to avoid inappropriate manoeuvres and is a feature of good surgical performance [13]. Similarly, while a number of surgeons will find background music a positive contribution to the ambience of the operating room, that noise,-along with other uninvited noises (e.g. chatter from other OR personnel including medical students) may impact detrimentally upon our consciousness. Similarly the likes of stress and fatigue will all shrink the cognitive capacity of our minds resulting in compromise of situation awareness. The use of the “sterile cockpit” policy and explaining it to the other OR personnel, is a helpful way of managing distraction [14]. The aviation industry is conscious of the demands made of pilot attention to flight related tasks in the first and last 10,000 feet of takeoff and landing respectively. Only flight-related information is exchanged on the flight deck and between/to air traffic control during these phases of aviation. Choosing those elements of surgical procedure which represent that first or last 10,000 feet, allows you to deploy a sterile cockpit equivalent in your operating room and control the amount of distraction you are subjected to. It also appears to have an beneficial effect in engaging others in the complexity of your task and promoting better teamwork. It is equally important to terminate the particular phase with a note of appreciation for that engagement.

The third part of situational awareness-the now what-or projecting forward is also a phase subject to error and incorrect anticipation. This is a distressing event for the surgeon if it comes about, because it indicates a mistaken intention. Indeed plan continuation error – a feature again taken from aviation [15], where ambiguous or incomplete information arising during the course of the procedure, points to the need for a change in direction. However, with an uncertainty surrounding the final destination or outcome, this often results in the operator being faced with incomplete information, options and uncertainty in authenticity of the new information, and hence adhering to the original course or plan (usually incorrectly).

The hallmark of surgical attitudes and behaviours is the willingness to make and follow through on decisions, sometimes taken as a matter of urgency, with incomplete information and yet a full awareness of the associated level of procedural risk. While the risk usually relates to patient well-being, professional and reputational risks are also new concepts emerging from the recent surgical literature which bear an impact on the choice of decisions made [16]. That “strong but wrong” profile of surgical decision-making of the past, is now less attractive than previously perceived and carries with it numerous consequences. Decision-making is contingent upon accurate situation awareness and frequently acts as a sequitur to that third – “now what” – phase. The course of action to be employed can use one or more of four common methods [17]. These are

RPD is used by the expert as opposed to the novice. It is entirely dependent on “having been there before” and being able to match the actions used successfully in the past to the current task or problem. By its nature, it has a high accuracy and success rate and is often used in time-limited, higher risk circumstances; it is known as “fast and frugal” by virtue of the low requirements for cognitive effort [18]. That ability to match actions to circumstances, is dependent on a “store” or “library” of past experience but also creates a cognitive capacity that is liberated by use of this type of decision-making, – allowing mental capacity for other purposes and hence its value is in those urgent, high-risk circumstances when stress has the effect of potentially reducing the available cognitive space but where rapidity of action is also essential.

By contradistinction, the analytical decision-making mode requires time, more cognitive effort, and is an obligate process for those with no access to pattern matching by virtue of lack of previous experience. For the inexperienced/novice surgeon, this level of decision-making requires more effort, leaves less available resource for other tasks, and has a greater stress affect with the potential for overload and freezing. It is in such circumstances, therefore, that slowing down and using time to equilibrate and spread the demands of the situation by producing an intraoperative pause, allows a review of the situation and an opportunity to spread the load and create time in order to allow consideration of options. The elements in the NOTSS taxonomy on decision-making encourage disclosure and sharing of the options to ensure optimal selection and that again creates time to good effect.

Rule-based decision-making is knowledge – dependent and is algorithmic in its nature. It is therefore accessible to all with the appropriate information base. It is less time-dependent than the analytical decision-making method and should require little discriminating thinking in its implementation other than recognition of the circumstances being appropriate for application of that rule or guideline/protocol.

Finally, and used only very occasionally, is the method of creative decision-making, which requires luxuriant amounts of time to originate solutions which are not stored in either memory or knowledge banks. Nonetheless, this will require a pragmatic solution to often a unique problem and needs both time and attention.

In practice these methods are not mutually exclusive but maybe blended to cope with the challenges of the operative task.

There is a strange irony in the fact that when surgical errors occur, as in the case of a Never Event, that the surgeon is commonly working as part of a team and not in isolation. In effect, other team members observe the operating surgeon perpetrate a significant error, but without effective intervention from themselves. These team members are frequently highly experienced. Why that permissive relationship goes unchecked is unclear. A number of potential reasons may exist

In relation to a lack of confidence to intervene, the “Power Distance Index” expanded by Gladwell in his book “Outliers”, may originate in cultural values which confuse the ability to challenge with some code of good manners, courtesy and politeness. That deference to status may be created for the surgeon rather than by the surgeon and may mistakenly denote a form of respect [19]. This needs active management. A “speak up” or graded assertiveness policy should be in place for all to use rather than “hoping and hinting” that an incipient error will be diverted. One mnemonic which has found favour is the “CUSS” tool featuring keywords indicative of escalating levels of concern (Box 7.2) [20].

Communication within high-performing teams is an expansive topic with a rich literature on the effect on outcomes following surgery [21]. There are also lessons to be learned from adverse events in other high-risk domains as a consequence of communication failure. In particular the factors that contribute to fratricide- mortality as a consequence of friendly fire in battle situations (see Chap. 24), – points to the fact that low volumes of communication may not themselves result in poor team performance, but, excessive communication, – particularly if indiscriminate and poorly directed, may be ineffective or possibly even hazardous (e.g. distracting for the team, – so-called “communication masking”). Indeed simulation studies of British Army tank commanders found that high levels of communication, if associated with a high proportion of negative commands, produced a higher fratricide rate (so-called “blue on blue” incidents) than the more discriminating and positively communicating commander who did not share the high fratricide rate-perhaps a finding of implication for surgical trainers [22].

Various tools have been developed to promote effective communication. SBAR is one such model that ensures effective transmission of critical information in a time efficient and succinct manner [23]. Again it has its origins in military protocol (nuclear submarines) and is of particular value in urgent or unanticipated communications (e.g. the need to request assistance in the OR), – providing both context and signalling the nature of the problem in hand (Box 7.3).