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Teamwork in the OR

In the relentless pursuit to advance the practice of good medicine, teamwork has come to the forefront as the most effective way of catching individual errors before they occur and of mitigating system failures. An important part of teamwork is the ability to communicate.

One study found that critical information is often transferred in a reactive, ad hoc manner and that communicative tension is frequent.¹ In 2003, Atul Gawande, MD, MPH, et al., determined that failures in communication were implicated in 43 percent of surgeon-described adverse events. Additionally, failures in vigilance played a role in more than half of the incidents.² Health care and patient safety leaders alike say that a substantial reduction of health care errors will not occur until we pay more attention to human solutions, such as improving teamwork and communications.

Building the OR Team

The team approach in the OR is not a new concept. For years, we have defined the grouping of people together in one OR suite as the “OR team.” It is much easier to use the term “team” than it is to grasp the true meaning of the word. The true meaning of the team approach implies that each member is able to:

• anticipate the needs of others;
• adjust to each other’s actions and to the changing environment; and
• have a shared understanding of how a procedure should happen in order to identify when errors occur and how to correct for these errors.³

Developing the team mentality isn’t easy—especially when taking into consideration the different personalities, skills, agendas, styles, and objectives that team members bring to the table. A harmonious and unified team can be difficult to build, but it is certainly not impossible.

The first step in developing a cohesive team is to recognize that teams are better equipped to handle challenges within a department and that decisions made through teamwork are significantly better than the decisions of an individual. Individuals who have been responsible for handling problems and making decisions in the past will most likely have the hardest time embracing this concept. But the truth is that when something adverse occurs in the OR, it is usually not a small or isolated problem; it is a problem that has a significant impact on everyone in the room. Since any single negative event can potentially affect all members of the OR team adversely, it seems reasonable that the entire team should actively participate in problem resolution.

Characteristics of an Effective Team

Improvement of patient safety through emphasis on the team approach requires an understanding of the factors that make a team successful.

An effective team:

• Recognizes that each team member brings his or her own individual talent, skill, and experience to the table and acknowledges individual team member contributions.
• Recognizes that when issues are complex, there is often more than one right way to solve a problem.
• Accepts that its combined decision is greater than the needs of its individual members.
• Recognizes that any team decision must be just and ethical.
• Recognizes that once problem solving is complete and a decision has been reached, the decision must then be implemented and monitored for effectiveness. The team must be ready and open to changing its action if the resolution proves ineffective.
• Is ready to accept accountability and ownership of the team’s decisions, even if it was not his or her first or individual recommendation.
• Knows that open communication is necessary to promote empowerment in getting the job done and accepting team decisions.

Effective Team Communication

When was the last time you heard something like this in the operating room:

“I haven’t worked with this piece of equipment in a long time.”
“Last time this machine wasn’t working correctly.”
“I’m worried about the blood loss.”
“This is an older patient; make sure the room is warm.”
“Keep the heart rate lower; this patient has a previous MI.”

Effective team communication requires the exchange of concise and relevant information between team members. Effective communication demands good listening skills, where participants join in the conversation only after they have a thorough understanding of the issues.

Standardizing communication practices within the OR facilitates stronger team communication. Standardized communication tools, such as a preoperative team communication checklist, can be implemented to promote information exchange and team cohesion. By briefing team members before starting a procedure, each member knows his or her exact role and common goals. This briefing should cover the status and stability of the patient, clearly delineate team members’ roles, and discuss the team’s immediate plans, as well as potential pitfalls to those plans.⁴

By promoting situational monitoring among team members, vigilance can be maintained. When team members actively scan and assess what’s going on, they gain information on the situation and can pick up on deviations. Conveying this information to other team members can prevent small errors from becoming big errors. Part of this includes a statement by the surgeon encouraging communication, such as, “If you see, suspect, or feel that something is not right, please speak up.”

Communicating in a closed-loop fashion is a technique that ensures the entire team is aware of what is going on and helps in retaining the shared mental model. Acknowledging comments or questions ensures that each communication has been heard and understood. Repeating back essential information allows the sender to know that the message has been heard.

Results

The Joint Commission, supported by more than 40 health care organizations nationwide that have endorsed the Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery,⁵ is convinced that active involvement and effective communication among all members of the surgical/procedure team must occur in order to reduce errors and protect patients.

Communication and group dynamics have been, and will continue to be, the subjects of intense research and study. The team approach in a health care setting is not new, but its value and definition are changing. One thing we know for certain today is that good communication, along with a focused team approach in dealing with problems, can make a positive difference in any outcome.

When the team approach is used to resolve OR problems and concerns, it fosters a better understanding of the problem and results in a more unified, informed approach to problem resolution. The end result: a safer and improved environment for all surgical patients and OR personnel.

J4258 12/07

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