Safety culture is a great fit for the OR

Imagine a scenario in which someone on the operating room (OR) team is about to make a mistake while performing a surgical procedure, and no one speaks up. This is an undesirable situation that often results from the hierarchical OR structure that has developed over the years. Under those conditions, individuals are unlikely to raise concerns for fear of disturbing or even offending the most senior member of the team. Safety experts in other areas have recognized that hierarchy trumps safety and that improvements of safety require elimination of this intimidating structure, as well as encouragement of all members of the team “to speak up.”

Creating a culture of safety

According to an article by Mark R. Chassin, MD, MPP, MPH, FACP, president and chief executive officer of The Joint Commission, and Jerod M. Loeb, PhD, titled “High-reliability health care: Getting there from here,” one of the methods that health care institutions can use to attain levels of quality and safety similar to other industries that strive to achieve zero harm includes establishing a safety culture.*

The authors write that “a culture of safety that fully supports high reliability has three central attributes: trust, report, and improve.” Furthermore, “maintaining trust also requires the organization to hold employees accountable for adhering to safety protocols and procedures.”

In the article, Dr. Chassin and Dr. Loeb also state that accountability for adhering to safe practices should be instilled in all employees “and is spurred by implementing standards for invoking disciplinary procedures that apply to all staff, regardless of seniority or professional credentials.… Becoming much safer requires caregivers’ willingness and ability to recognize and report close calls and unsafe conditions, combined with an organizational capacity to act effectively on this report to eliminate the risks they embody.”

Flattening the hierarchy and communicating

I believe surgeons should champion these concepts in the OR. From my perspective, two elements are vital to creating a culture of safety. The first is to establish a nonthreatening environment—one that not only invites team members to question the processes being used but also does away with the traditional hierarchy that has been present in the OR for many years.

The most senior surgeon in the OR should create the right environment by elevating everyone and empowering team members to speak up, which is essential to building a team. The best way to achieve this goal is to ensure that everyone feels that the patient’s welfare is the central focus. Applying this technique will allow everyone on the team to focus on desired outcomes, rather than on the hierarchy. Each member of the team should feel that his or her impressions and thoughts count.

When I am working in the OR, I tell my assistants and the scrub nurse that I would like them to follow every step of the operation, and make sure I don’t make any mistakes. Such a statement is usually met with a little smile, as if I did not mean it. But at a time when we use multiple monitors in the OR and everyone can follow the procedure, I want all members of the team to be involved and to feel empowered to challenge me or to ask a question if they see something they do not understand. I tell them the best way to do that is to ask me any time they find me doing something they don’t follow. There are only two reasons for team members to have these questions: either they do not understand, which gives me the opportunity to teach them; or what I am doing is incorrect, in which case they can make me more alert to a potential error.

After eliminating the hierarchy, the other vital element in OR safety is adequate communication. Communication in the OR should be active, constant, focused on what is being done, and always with an emphasis on what is best for the patient—we should never be talking about unrelated matters or allowing our minds to drift. Constant communication about what we are doing keeps us focused and alert.

A culture of safety increases the chance of safely completing an operation. Surgeons should use their influence to create such an environment in their ORs. The right climate will improve the quality of surgical care, enhance the well-being of the members of the surgical team, and result in better outcomes for patients.


The thoughts and opinions expressed in this column are solely those of Dr. Pellegrini and do not necessarily represent the official views of The Joint Commission or the American College of Surgeons.

*Chassin MR, Loeb JM. High-reliability health care: Getting there from here. Milbank Quarterly. 2013;91(33):459-490. Available at: Accessed July 23, 2015.

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