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decision made. To make a good decision a person needs to assess all aspects of a problem, identify the possible responses to the problem, consider the consequences of each of those responses and then weigh up the advantages and disadvantages in order to draw a conclusion. Having completed this, they then need to communicate their decision to their team.

      Good situation awareness is a basic prerequisite of this process. To achieve this, the decision maker must ensure they have all the key information. In a well‐functioning team everyone is on the alert for ambiguities, biases or conflicting information. Any inconsistent facts should be treated as a potential marker for faulty situation awareness. It is important not to brush them off as unimportant anomalies in the absence of evidence to support such a decision.

      In many clinical situations there can be a significant pressure of time. Where this is not the case then no decision‐making process should be concluded until the team is satisfied they have all the information and have considered all the options. Where time is a pressure, a certain amount of pragmatism must be employed. There is plenty of evidence to confirm that practice and experience can mitigate some of the negative effects of abbreviating a decision‐making process. Those making decisions under such circumstances need to remain aware of the short‐cuts they have taken and be ready to receive feedback from their team, particularly if any member of the team has significant concerns about the proposed course of action.

      Level 3 (Now what? Anticipating the future state)

      Having gathered information using all of our senses (level 1) we then need to interpret the information (level 2) before we plan forward using previous experience, seeking input from the team when required (level 3). Finally, we must decide the plan of action and communicate this to the team.

       Team situation awareness

      The individuals in the team may have a unique awareness of the situation depending on their previous experience, specialty, physical position, etc. The team’s situation awareness will often be greater than that of any one individual. However this can only be exploited if the individual elements are effectively communicated clearly between team members. Effective leaders actively encourage this as it results in a ‘shared mental model’, a feature associated with effective teams.

      The Royal College of Obstetricians and Gynaecologists (RCOG) is integrating human factors within the new UK postgraduate training curriculum and has developed learning resources within the ‘Each Baby Counts’ initiative: https://www.rcog.org.uk/en/guidelines‐research‐services/audit‐quality‐improvement/each‐baby‐counts/implementation/improving‐human‐factors/ (last accessed October 2020).

4.9 Improving team and individual performance

      In addition to effective communication, team working, situation awareness, leadership and followership skills, there are a number of other ways that team and individual performance can be further developed and improved.

      Awareness of situations when errors are more likely

      If we are aware that an error is more likely we can be more proactive in detecting them. Alongside distractions, two common situations that make errors more likely are stress and fatigue. Stress is not only a source of error when we are overworked and overstimulated, but also, at the other end of the spectrum, when we are understimulated we become inattentive.

      The acronym HALT has been used to describe situations when error is more likely:

H	Hungry
A	Angry
L	Late
T	Tired

      Consider how many times in the last week you have been hungry, angry, late or tired and still worked in a setting where errors could have had significant implications. Unfortunately, in many work cultures these emotional and/or physical states are seen as inevitable.

      I’M SAFE has been used as a checklist in the aviation industry, asking whether the individual may be affected by:

I	Illness
M	Medication
S	Stress
A	Alcohol
F	Fatigue
E	Eating

      Ideally, individuals who are potentially compromised need to be supported appropriately, allowed time to recover and the team made aware. How this can be achieved in the middle of a night shift can be problematic.

      Awareness of error traps

      Humans are prone to several ‘cognitive biases’ (examples include normalcy, confirmation, conformity and fixation biases). Normalcy bias is the tendency to underestimate both the seriousness of a situation and the likelihood of a poor outcome – i.e. you rule out the worst‐case scenario.

      Confirmation bias is also common and is the tendency to only pay attention to information that fits in with your own ‘mental model’ of the situation in hand. There is a reluctance to change one’s mind even in the presence of contradictory evidence. When this occurs, people favour information that confirms their preconceptions or hypotheses regardless of whether the information is true. This may be observed within the healthcare setting during the process of a referral or handover. An example of this might be a clinician receiving a phone call requesting them to attend the ward to review an acutely deteriorating postnatal woman. The clinician is advised that the woman has collapsed. On their way to the ward the clinician builds up a series of preconceived expectations around what they will find upon their arrival. They may even formulate a management plan whilst travelling to the scene, based upon their expectations. Once this ‘mindset’ is established it can be difficult to shift. On arrival, the clinician examines the systems affected by the presumed diagnosis. They seek to confirm their expectation of collapse due to PPH by focusing on palpating the uterine fundus at the expense of a thorough systematic assessment. They do not pick up the fact that the woman is having difficulty breathing and their preconceived ideas that this is due to PPH mean that the remainder of the assessment is completed without due attention and more as a rehearsed exercise rather than an open‐minded exploration. In this case the eventual diagnosis was pulmonary embolism which was a very late consideration in the diagnostic pathway.

      Apart from thorough history and clinical assessment, using the expertise within your team by carefully listening to alternative views or challenges can minimise the effects of these cognitive biases.

      Cognitive aids: checklists, guidelines and protocols

      Cognitive aids such as guidelines or checklists are important because the human memory is not infallible. They also confer team understanding through the use of a standardised response. This reduces stress. This is especially true where an uncommon emergency event occurs. The team may be unfamiliar with one another and each member will be trying to remember what to do, what treatments are required and in what order. A good team leader will use the available

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