The quest for safe surgical care: Are we missing the obvious?

Given the increasing case complexity, the introduction of new diagnostic and therapeutic tools for use in the operating room (OR), and collaboration with other interventionists, the need for safe surgical procedures has become even more essential. Safety remains the surgical profession’s highest priority. The performance of safe operations has been associated with following a checklist of items detailed by the World Health Organization (WHO) and endorsed by a number of medical associations.1,2

Although checklists provide a template for safe conduct, they are limited. This column focuses on the coordination of the surgical team and each member’s behavior as necessary foundations for safe operations.

Communication is key

Although all professional teams strive for excellence in patient care, a universal understanding of what constitutes a safe OR environment remains elusive. A recent review of existing literature on information transfer and communication during surgical procedures demonstrated that deficits in information transfer and communication adversely affect patient care.2 Furthermore, the evidence suggests that certain non-technical aspects of performance may affect technical performance.3 Ongoing evidence of the technical or clinical benefits of teamwork training in medicine is weak.2-5 But there is strong evidence supporting the use of checklists to minimize errors.

Despite the use of complex checklists and advanced computer technology in the surgical environment, errors continue to occur, nonetheless. These errors may be due to the lack of a formal definition and identification of each team member’s roles and expectations, which would function as a continuous qualitative team performance assessment. The safety measure for each individual on the team is missing.

Teams are composed of individuals, each with unique visions, hopes, and fears driving his or her behavior. The strength of the team simply reflects the cumulative strength of each individual, and the weakest individual can detrimentally override the collective strength of other members.

Poor communication and mitigated speech—in which team members do not say what they mean when speaking with team members of differing power or position—undermine teamwork in the OR.6-8 Many people who work in the OR suffer from power distance.6 The greater the perceived difference in social status between individuals—the power distance—the more difficult it becomes for an individual of lower “team” status to communicate directly with the superior.

Team members at any level should feel free to speak up to prevent patient harm at any time. Authoritative speech by the superiors not within the context of patient care can inactivate team members and perhaps distract them from the overall conduct of the operation.

Avedis Donabedian, MD, MPH, a U.S. health care quality theorist, emphasized that quality of care encompasses not only technical excellence of care but also the humanity and manner with which it was delivered.9 One can extend this theory to all the individuals on any surgical team. This distinction is now commonplace. Surgeons always have had the best interest of their patient in hand; however, demonstrations of caring and compassion are now viewed as components of quality of care. Maxwell extended these measures further to identify six dimensions of quality: technical excellence, social acceptability, humanity, cost, equity, and relevance to need.10

In our field, we all at some time witness two broad categories of surgeons—those who not only have excellent technical abilities, but also excellent leadership and communications skills, and those with excellent technical skills but less ability to lead and interact with other team members.

Team safety breeds patient safety

Patient safety often is nothing more than a reflection of team safety. No matter how we interact, it cannot be at the expense of our focus on the patient. Teams in which all members are focused on safety will deliver safe care and more often avoid patient harm even under the most difficult circumstances.

What is safety? A comprehensive definition could be the state of being safe—the condition of being protected against physical, social, spiritual, financial, political, emotional, occupational, psychological, or other types of harm. Most research has focused on the physical harm to the patient resulting from surgical error and poor technical performance. Few studies have focused on the role of individual team members.7,11-12 Yet it is individuals—from surgeons to assistants and nurses, as well as those who help in patient transportation—who contribute to the safe surgery and overall care during the patient’s hospital stay. At the same time, the intangible aspects of their environment, such as poor communication, mitigated speech, social interactions, and perceptions may influence these caregivers.

Historically, the attending or consultant surgeon or the senior nurse has been the “go to” person at times when safety is compromised or when team members believe a patient is at risk of injury. Other teams take a collaborative approach, leveling the playing field so that all team members are given equal weight. In other ORs, team members are polarized, with one person having seniority over the other team members.

How teams are structured and work together is often determined by years of institutional history and customs. These teams, with different inter-member behavior, can go on not comprehending the full effect of their working relationships on patient safety.

What is a safe surgical team?

A safe surgical team is one with members who provide sufficient quality of care, reliability, availability, and maintainability to execute a surgical procedure without causing any errors leading to harm to the patient or any other team member. Members from all levels of professions create a safe environment. They also build cognitive systems to competently resolve any conflicts that may arise.

Of course, it is important to realize that safety is relative. While eliminating all risk is unlikely and costly, it is those inter-member interactions that continue to influence the entire team in either a positive or negative manner. An overall team culture may be influenced by respectfully giving and receiving rewards, constructive critique, collaboration, empathy, and continued succession.13-15 A number of organizations and government agencies promulgate safety standards for consumer products, the transportation industry, and so on. However, surgical teams currently lack defined standards of what is a safe team.14 Standards are rarely discussed in surgical, nursing, anesthesia, and technical training, let alone in practice. The mechanism for determining how individuals get recruited or removed from the surgical team, their individual and collective needs, their strengths and weaknesses, is missing. Until we address the basic functional unit of safety—the team members—the same problems and their consequent errors will continue.

Building safe, competent surgical teams

Building a near 100 percent safe team can be achieved through collaboration among physicians, nurses, and administrators, as well as outside consultants. Fostering trust and safety in all interactions is essential, as are transparency and lack of ambiguity in leadership and communication. The constant turnover of nurses, residents, physician assistants, and sometimes surgeons who do not fit in with the institutional culture will never rectify conflicts without igniting negative emotions that hinder safe practice and team success. Turnover has both a direct and indirect effect on patient experience, outcome, and safety. A team that sees a common goal of patient care and smooth conduct of surgical procedures yet is willing to share their fears, hopes, differences, and disagreements among themselves also allows for improvement and innovation. Active listening is necessary to build a safe team that leverages conflict to its advantage. Moreover, such teams can provide a role model for other working environments within the hospital and beyond.

Our responsibility

In the large perspective of patient care, the relationship between safety and quality is nothing more than a continuum. Although many prominent nonsurgeon thinkers have defined quality in many different ways, the most important aspect—patient safety—remains our priority.9-12,16 When trying to make headway with quality and safety, simplifying the underlying problem(s) and background for each team can help. Surgeons are the natural leaders in the OR; yet, in a high-stress working environment, they may feel powerless to change systemic problems and their environment.17 In my experience, introducing safety concepts in the OR is sometimes met with resistance, and even when changes are made, not all team members have been in agreement.

Overall, we should always maintain risk-averse behavior. And while we should be accepting of new technology, protocols, and operative procedures, we must adopt these innovations only when we are certain they will not put the patient or team at risk. It is our responsibility to deliver the best care possible and to find ways to improve quality and quantity of life for our patients.

A high versus low turnover of team members is not without its advantages to both patient and team alike. Truly appreciating this fact can deliver benefits extending to the entire organization and health care system. Understanding that both the surgeon and his or her team have the reciprocal supportive functional ethos during surgical procedures is desirable and much needed. There can be no more important value than being at our best collectively when taking human life into our hands. This value cannot be fulfilled with advanced technology alone, but rather in combination with our behavior. Continuous collective reflection and resolution of team frustrations may lead to safe team growth and development. Investment in the team members is necessary for the optimal delivery of safe surgical care.


  1. Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AH, Dellinger EP, Herbosa T, Joseph S, Kibatala PL, Lapitan MC, Merry AF, Moorthy K, Reznick RK, Taylor B, Gawande AA. Safe Surgery Saves Lives Study Group. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009;360(5):491-499.
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