Situation Awareness Errors Research Articles

Situational Awareness in the Context of Clinical Practice

In the context of clinical practice, situational awareness refers to conscious awareness (knowledge), which is a mental model of a given clinical situation in terms of its elements and the significance of their interrelation. Situational awareness (SA) facilitates clinical reasoning, diagnostic accuracy, and appropriate goal-directed performance, and it enables clinicians to immediately adapt treatment strategies in response to changes in clinical situational actualities and to modify the course of goal-directed activities accordingly. It also helps clinicians prepare future operational plans and procedures based on the projection of situational developments. SA, therefore, is an important prerequisite for safe clinical procedures. The purpose of this narrative review is to highlight certain cognitive and external (environmental) situational factors that influence the development of situational awareness. Understanding the dynamic, adaptive, and complex interactions between these factors may assist clinicians and managers of healthcare systems in developing methods aimed at facilitating the acquisition of accurate clinical situational awareness and, in turn, may bring about a reduction in the incidence of SA, diagnostic, and operational errors.

Situation awareness in outage work – A study of events occurring in U.S. nuclear power plants between 2016 and 2020

In this study, we sought to identify if human errors responsible for incidents occurring during scheduled outage periods in nuclear power plants correspond to situation awareness errors in perception, comprehension, or projection. We also sought to identify factors contributing to situation awareness errors at all levels. To do this, we analysed 58 events occurring during planned nuclear power plant outages between 2016 and 2020, as documented in U.S. Licensee Event Reports (LERs). Of the human errors analysed in these events, 14 were classified as situation awareness errors related to perception (Level 1 errors), 30 were classified as situation awareness errors related to comprehension (Level 2 errors), and an additional 14 were classified as situation awareness errors related to projection (Level 3 errors). Furthermore, we found that insufficient procedure use was identified in the LERs as a factor contributing to most errors occurring at Level 1, whereas insufficient procedures was identified to contribute to most errors occurring at Level 2 and 3.

Evacuation action during torrential rain considering situation awareness error using protection motivation theory

The torrential rains in July 2018 caused considerable river overflow, flood damage, and landslides, particularly in western Japan. At that time, 232 fatalities and missing persons were recorded, with most human damage caused by delays in evacuation. These delays occur during most torrential rain events, and can presumably be attributed to a situation awareness error in the disaster response of residents. This study analyzed the evacuation decision-making structure by adding a situation awareness error to the protection motivation theory framework. Accordingly, the evacuation actions of residents during torrential rains in Japan in 2018 were surveyed and analyzed using structural equation modeling and logistic regression. Most respondents chose not to evacuate despite showing a high intention to do so. Such respondents evacuated only in response to a trigger such as a dramatic change in their surrounding environment or the receipt of an evacuation appeal. By considering situation awareness errors in protection motivation theory, this study identified active and passive evacuation decisions to clarify the stage at which evacuation delays occurred. The findings provide guidance on the stage of situation awareness that should be promoted and the specific measures required to achieve efficient evacuation.

Analysis of Evacuation in Heavy Rain Based on Protection Motivation Theory with Situation Awareness Error

Analysis of Evacuation in Heavy Rain Based on Protection Motivation Theory with Situation Awareness Error

Assessing validity evidence for a serious game dedicated to patient clinical deterioration and communication

BackgroundA serious game (SG) is a useful tool for nurse training. The objectives of this study were to assess validity evidence of a new SG designed to improve nurses’ ability to detect patient clinical deterioration.MethodsThe SG (LabForGames Warning) was developed through interaction between clinical and pedagogical experts and one developer. For the game study, consenting nurses were divided into three groups: nursing students (pre-graduate) (group S), recently graduated nurses (graduated < 2 years before the study) (group R) and expert nurses (graduated > 4 years before the study and working in an ICU) (group E). Each volunteer played three cases of the game (haemorrhage, brain trauma and obstructed intestinal tract). The validity evidence was assessed following Messick’s framework: content, response process (questionnaire, observational analysis), internal structure, relations to other variables (by scoring each case and measuring playing time) and consequences (a posteriori analysis).ResultsThe content validity was supported by the game design produced by clinical, pedagogical and interprofessional experts in accordance with the French nurse training curriculum, literature review and pilot testing. Seventy-one nurses participated in the study: S (n = 25), R (n = 25) and E (n = 21). The content validity in all three cases was highly valued by group E. The response process evidence was supported by good security control. There was no significant difference in the three groups’ high rating of the game’s realism, satisfaction and educational value. All participants stated that their knowledge of the different steps of the clinical reasoning process had improved. Regarding the internal structure, the factor analysis showed a common source of variance between the steps of the clinical reasoning process and communication or the situational awareness errors made predominantly by students. No statistical difference was observed between groups regarding scores and playing time. A posteriori analysis of the results of final examinations assessing study-related topics found no significant difference between group S participants and students who did not participate in the study.ConclusionWhile it appears that this SG cannot be used for summative assessment (score validity undemonstrated), it is positively valued as an educational tool.Trial registrationClinicalTrials.gov ID: NCT03092440

항해사의 상황인식이 국내 연안의 선박 충돌사고에 미치는 영향

Objective: The purpose of this study was to investigate the effect of situational awareness on ship collision accidents in Korea coast.BRBRBackground: The lack of situational awareness of maritime officers is reported to be a major cause of marine accidents. Research on situational awareness in Korea was not active. Especially, situation awareness research through analysis of accident data is very rare.BRBRMethod: Using archival data on ship collision accidents that happened in the costal sea of Korea from 2017 to 2019, it was analyzed what types of situation awareness errors were related to ships

An Optimal Control Approach to Identify the Worst-Case Cascading Failures in Power Systems

Cascading failures in power systems normally occur as a result of initial disturbances or faults on electrical elements, closely followed by situational awareness errors of human operators. It remains a great challenge to systematically trace the source of cascading failures in power systems. In this paper, we develop a mathematical model to describe the cascading outages of transmission lines in power networks. In particular, the direct current power-flow equation is employed to calculate the power flow on the branches. By regarding the disturbances on branches as the control inputs, the problem of identifying the initial disruptive disturbances is formulated with optimal control theory, which provides a systematic approach to explore the most disruptive disturbances that give rise to changes of branch admittance in addition to direct branch outages. Moreover, an iterative search algorithm is proposed to look for the optimal solution leading to the worst-case cascading failures. Theoretical analysis guarantees the asymptotic convergence of the iterative search algorithm. Finally, numerical simulations are carried out on the IEEE test systems to validate the proposed approach.

Thinking Ahead of the Tractor: Driver Safety and Situation Awareness

ABSTRACTObjective: Situation awareness has been identified as a key skill in maintaining safety in high-risk, dynamic industries. However, there is a lack of research evaluating situation awareness requirements and error types in agricultural operators. The aim of this study was to explore situation awareness among farmers in the United Kingdom (UK) when operating heavy agricultural machinery.Method: The study used an online qualitative survey to collect data in three main areas: situation awareness requirements, factors impacting situation awareness, and the safety context for UK farmers. A total of 57 farmers completed the survey, responding to seven open-ended questions. Data were analyzed using directed content analysis.Results: The results indicate the importance of situation awareness for safe and efficient work practice in farming. Situation awareness requirements span the machinery system, including awareness of internal cab systems and the status of implements attached to the external machine. Farmers needed to map and monitor the surrounding conditions in addition to considering personal requirements. Data also indicated the impact of a range of factors, including system-based elements such as blind spots, individual factors such as level of fatigue, and issues related to a lack of knowledge and failure to think ahead on the maintenance of situation awareness.Conclusion: This research highlights the situation awareness requirements for operating agricultural machinery in complex and dynamic environments. By taking a human factors approach, utilizing design and practical interventions, it may be possible to both support and enhance farmer situation awareness and, therefore, reduce errors and adverse incidents.

Proceed with caution: using verbal protocol analysis to measure situation awareness

Verbal protocol analysis (VPA) is often used to elicit information about the cognitive processes of operators as it provides rich data and can be used in naturalistic settings. Recently VPA has been used to investigate the acquisition and maintenance of situation awareness (SA), and to make comparisons between groups despite a lack of research regarding the efficacy of using VPA for this purpose. This train simulator experiment investigated whether VPA can effectively measure SA. Novice and expert participants were recorded on an audio device while talking aloud throughout the trials and their verbalisations were transcribed verbatim. A coding scheme developed from the transcripts was used to code the verbalisations. Results did not support the use of VPA as a measure of SA but did show that VPA detected differences in SA errors. Potential reasons for the conflicting findings between this experiment and those conducted by other researchers are discussed.Practitioner summary: This paper examined the validity of verbal protocol analysis (VPA) as a situation awareness (SA) measure. A repeated measures experiment was conducted using a train simulator. Normal VPA did not detect changes in SA but a measure of errors did. Caution should be used when using VPA to measure SA.Abbreviations: LETSSA: low-event task subjective situation awareness technique; SA: situation awareness; SAGAT: situation awareness global assessment technique; TPD: train performance display; VPA: verbal protocol analysis

A validation research on fuzzy logic-AHP-based assessment method of operator’s situation awareness reliability

Situation awareness (SA) reliability of operators is an important component of human reliability analysis (HRA) in digital nuclear power plants (NPPs). Therefore, how to identify effectively and reliably the risk of SA errors is of great significance for SA error prevention and risk reduction. SA reliability assessment model or method based on fuzzy logic and analytic hierarchy process (AHP) is forwarded in the first paper. In order to prove its effectiveness and reliability, sensitivity analysis and simulator experiments are applied to testify our model in this paper. The results show that the proposed assessment model of SA reliability has a certain degree of sensitivity as well as an accuracy of prediction, and there are a strong correlation and consistency between the predicted value from fuzzy inference system and the real value (or observed value) from simulator experiments. Although there are some differences between the predicted value and the real value based on the perspective of HRA, the model can be used to predict SA error probability or SA reliability within the range of 10 error factors as well as provide data and theoretical support for SA reliability assessment.

An assessment method of operator’s situation awareness reliability based on fuzzy logic-AHP

In digital control rooms, situation awareness (SA) reliability has become an important element affecting operator's reliability. In order to establish a more reasonable assessment method of SA reliability under the condition of very lack of data, based on the established influential factor model of SA reliability considering the causality relationship of performance shaping factors (PSFs) in this paper, a fuzzy logic and analytic hierarchy process (AHP)-based method is established to more objectively assess SA reliability. The weight of PSFs is identified using AHP, and a fuzzy logic method is used to simulate the fuzzy assessment and reasoning process of operator's SA reliability, and a standardized method is built to determine the fuzzy rule base of fuzzy reasoning system for SA reliability assessment for reducing the subjectivity and uncertainty of expert judgment. Finally, an example is provided to illustrate the specific application of the proposed method. The results show that the established method takes account of the weight of PSFs and their causal influencing relationship, and the fuzzy logic method used to assess SA reliability can overcome the subjectivity and uncertainty of expert judgment, which makes the assessment results more objective and realistic. Furthermore, the method can be used to get more SA error data and have a wide range of application value.

Bayesian network for the prediction of situation awareness errors

A new method is proposed to predict situation awareness errors in training simulations. It is based on Endsley's model and the eight 'situation awareness demons' that she described. The predictions are determined thanks to a Bayesian network and noisy-or nodes. A maturity model is introduced to come up with the initialisation problem. The NASA behavioural competency model is also used to take individual differences into account.

Bayesian network for the prediction of situation awareness errors

Bayesian network for the prediction of situation awareness errors

Frequency and Type of Situational Awareness Errors Contributing to Death and Brain Damage

Situational awareness errors may play an important role in the genesis of patient harm. The authors examined closed anesthesia malpractice claims for death or brain damage to determine the frequency and type of situational awareness errors. Surgical and procedural anesthesia death and brain damage claims in the Anesthesia Closed Claims Project database were analyzed. Situational awareness error was defined as failure to perceive relevant clinical information, failure to comprehend the meaning of available information, or failure to project, anticipate, or plan. Patient and case characteristics, primary damaging events, and anesthesia payments in claims with situational awareness errors were compared to other death and brain damage claims from 2002 to 2013. Anesthesiologist situational awareness errors contributed to death or brain damage in 198 of 266 claims (74%). Respiratory system damaging events were more common in claims with situational awareness errors (56%) than other claims (21%, P < 0.001). The most common specific respiratory events in error claims were inadequate oxygenation or ventilation (24%), difficult intubation (11%), and aspiration (10%). Payments were made in 85% of situational awareness error claims compared to 46% in other claims (P = 0.001), with no significant difference in payment size. Among 198 claims with anesthesia situational awareness error, perception errors were most common (42%), whereas comprehension errors (29%) and projection errors (29%) were relatively less common. Situational awareness error definitions were operationalized for reliable application to real-world anesthesia cases. Situational awareness errors may have contributed to catastrophic outcomes in three quarters of recent anesthesia malpractice claims.Situational awareness errors resulting in death or brain damage remain prevalent causes of malpractice claims in the 21st century.

Study on operator's SA reliability in digital NPPs. Part 2: Data-driven causality model of SA

This paper tries to overcome shortcomings of the traditional assessment method of situation awareness (SA) reliability and build more robust causality model of SA. Firstly, the organization-oriented analysis framework or method of SA error was used to analyze human factor events in nuclear power plants (NPPs) and the data of 132 samples were obtained. Then, the correlation analysis method is used to identify the correlation relationships between factors influencing SA and next factor analysis method is used to identify the scenes triggering SA error. It includes: operator’s mental level, operator's work attitude, stress level and system situation display level. Finally, based on the study of the results highlighted above, a data-driven SA causality model is established. These results shows that, the data-based SA causality model can identify the scenes triggering SA error, and it is very useful to improve the accuracy of quantitative assessment of SA reliability because of considering the causality relationships of performance shaping factors (PSFs).

A granular computing framework for approximate reasoning in situation awareness

We present our results on the adoption of a set-theoretic framework for granular computing to situation awareness. The proposed framework guarantees a high degree of flexibility in the process of creation of granules and granular structures allowing to satisfy the wide variety of requirements for perception and comprehension of situations where some elements must be perceived per similarity, others per spatial proximity, some must be fused to improve their comprehension, and so on. A second value is the support for approximate reasoning in situation awareness. A granular structure in particular represents a snapshot of a situation, and is a building block for the development of tools and techniques to reason on situation in order to reduce situation awareness errors and accelerate the process of decision-making. To this purpose, we show a technique to support operators in the analysis of conformity between a recognized situation and an expected one. A third value is the fact that we can support operators in having rapid and indicative measures of how two situations, e.g. a recognized and a projected, may differ. A preliminary evaluation instantiating our approach with self-organizing maps is reported and discussed. The results are encouraging with respect to the capability of improving perception and comprehension of a situation, reducing comprehension errors and supporting projection of situations.

COGNITIVE ASPECTS OF COLLABORATION IN 3D VIRTUAL ENVIRONMENTS

Human-computer interaction has entered the 3D era. The most important models representing spatial information — maps — are transferred into 3D versions regarding the specific content to be displayed. Virtual worlds (VW) become promising area of interest because of possibility to dynamically modify content and multi-user cooperation when solving tasks regardless to physical presence. They can be used for sharing and elaborating information via virtual images or avatars. Attractiveness of VWs is emphasized also by possibility to measure operators’ actions and complex strategies. Collaboration in 3D environments is the crucial issue in many areas where the visualizations are important for the group cooperation. Within the specific 3D user interface the operators' ability to manipulate the displayed content is explored regarding such phenomena as situation awareness, cognitive workload and human error. For such purpose, the VWs offer a great number of tools for measuring the operators’ responses as recording virtual movement or spots of interest in the visual field. Study focuses on the methodological issues of measuring the usability of 3D VWs and comparing them with the existing principles of 2D maps. We explore operators’ strategies to reach and interpret information regarding the specific type of visualization and different level of immersion.

Situation awareness errors in anesthesia and critical care in 200 cases of a critical incident reporting system.

BackgroundA loss of adequate Situation Awareness (SA) may play a major role in the genesis of critical incidents in anesthesia and critical care. This observational study aimed to determine the frequency of SA errors in cases of a critical incident reporting system (CIRS).MethodsTwo experts independently reviewed 200 cases from the German Anesthesia CIRS. For inclusion, reports had to be related to anesthesia or critical care for an individual patient and take place in an in-hospital setting. Based on the SA framework, the frequency of SA errors was determined. Representative cases were analyzed qualitatively to illustrate the role of SA for decision-making.ResultsSA errors were identified in 81.5 %. Predominantly, errors occurred on the levels of perception (38.0 %) and comprehension (31.5 %). Errors on the level of projection played a minor role (12.0 %). The qualitative analysis of selected cases illustrates the crucial role of SA for decision-making and performance.ConclusionsSA errors are very frequent in critical incidents reported in a CIRS. The SA taxonomy was suitable to provide mechanistic insights into the central role of SA for decision-making and thus, patient safety.

Combined use of Cognitive Task Analysis and Observational Research Data to Identify Deficiencies of Support for Situation Awareness

Designers require insight into deficiencies of current support for situation awareness (SA) to be able to improve operators’ SA through better system design. The current methods proposed in literature to gain insight into sources of SA errors are not suitable to identify deficiencies in the field of nautical operational network management. This paper proposes a structured approach for syntactic and semantic processing of cognitive task analysis (CTA) data and observational research data to identify deficiencies. The results show that analysis of CTA data and observational research data complement each other and are best used in parallel.

Situation awareness in bridge operations – A study of collisions between attendant vessels and offshore facilities in the North Sea

This study examined accident reports (n=23) for collisions between attendant vessels and offshore facilities on the Norwegian continental shelf during the period of 2001–2011. An initial analysis indicated that the concept of situation awareness (SA) might be useful for providing a more detailed understanding of the processes that lead to collisions. SA is defined as ‘being aware of what is happening around you and understanding what that information means to you now and in the future’ (Endsley, 2012, p. 13). The first part of the study contains an analysis of accident reports that reveals that the collisions with offshore facilities were preceded by loss of SA on the bridge in 18 of the 23 instances. Three types of SA errors were identified: failure to perceive the situation correctly (Level 1 SA; n=13), failure to comprehend the situation (Level 2 SA; n=4), and failure to project the situation into the future (Level 3 SA; n=1). In the second part of the study, the human, technological and organisational factors described in the accident reports are analysed to evaluate how the factors may have affected the duty officers‘ awareness of the situation. The results indicate that inadequate operation planning, inadequate bridge design, insufficient training, communication failures and distracting elements were the underlying factors that significantly contributed to the collisions.