Teamwork in the OR
In the relentless pursuit to advance the practice of good medicine, teamwork—part of a safety culture—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 in the OR is the ability to communicate.
Critical information is often transferred in a reactive, ad hoc manner that frequently creates communicative tension:
- 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.1
- 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 team approach implies that each member is able to:
- anticipate the needs of others;
- adjust to other team members’ 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 them.2
Developing the team mentality is not easy. It becomes even more challenging when factoring in the different personalities, skills, agendas, styles, and objectives that team members contribute.
The first step in developing a cohesive team is to recognize that teams are better equipped to handle challenges within a department. Decisions made through teamwork are significantly better than the decisions of a single person. Individuals who have been responsible for handling problems and making decisions in the past will usually have the most difficult time embracing this concept. 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 resolving the problem.
Characteristics of an Effective Team
Improving patient safety through emphasis on the team approach requires an understanding of the factors that make a team successful. An effective team recognizes and accepts the following principles:
- Each team member contributes his or her individual talent, skill, and experience and acknowledges other team member contributions.
- When issues are complex, there is often more than one right way to solve a problem.
- The team’s combined decision is greater than the needs of its individual members.
- Any team decision must be just and ethical.
- Once problem solving is complete and a decision has been reached, the decision must be implemented and then monitored for effectiveness.
- The team must be ready and open to changing its action if the resolution proves ineffective.
- Each team member is accountable for the team’s decisions, even if it was not his or her first (or individual) recommendation.
- 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 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. The 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.3
Vigilance can be maintained by promoting situational monitoring among team members. When team members actively scan and assess what’s going on, they gain information about the situation and can identify 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 and questions ensures that each communication has been heard and understood. Repeating back essential information allows the sender to know that the message has been received.
Communication and teamwork within a safety culture remains a foundation in the prevention of harm. Organizations must address risk perception, leadership involvement, assertive staff communications, consistent process implementation, teamwork, and human factors. Teamwork and communication among the team have been recognized as two of the most important facets of patient safety. Organizations that adopt a safety culture are better able 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. 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 can foster a better understanding of the problem and ensure a more unified, informed approach to problem resolution. The end result is a safer and improved environment for all surgical patients and OR personnel.
1. Gawande AA, Zinner MJ, Studdert DM, Brennan, TA. Analysis of errors reported by surgeons at three teaching hospitals. Surgery. 2003;133:614-21.
2. TeamSTEPPs, Instructor Guide. Module 1:1-2.
3. Creating expert teams. Joint Commission Perspectives on Patient Safety. July 2007;7:1-4.
By Susan Shepard, MSN, RN, Director, Patient Safety Education.
The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each health care provider in light of all circumstances prevailing in the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.