The Doctor’s Advocate | Third Quarter 2015
An Ounce of Prevention

Teamwork in the OR

Susan Shepard, MSN, RN, Director, Patient Safety Education, The Doctors Company

Teamwork—an essential 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. Studies have shown that implementing team training in the OR is associated with a significant decrease in surgical mortality. 1,2

Building the OR Team

The team approach in the OR is not new. For years, any group working together in the OR suite has been described as an “OR team.” It is not, however, easy to develop a high-functioning team with a culture of teamwork and communication. It becomes even more challenging when factoring in each team member’s different personality, skills, agenda, style, and objective.

The team approach depends on each member’s ability to:

  • Anticipate needs of others.
  • Adjust to each other’s actions and the changing environment.
  • 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

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 difficulty in embracing this concept. When something adverse occurs in the OR, it is not usually a small or isolated problem; it is a problem that has a significant effect on everyone in the room. Since any single negative event can potentially affect all members of the OR team adversely, the entire team should 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 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

An important part of teamwork in the OR is the ability to communicate. 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 had a previous MI.”

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

Standardizing communication practices facilitates stronger team communication. Tools, such as a preoperative team communication checklist, can be implemented to promote information exchange and team cohesion. Before starting a procedure, brief the team so each member knows the common goals and his or her exact role. 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

Maintain vigilance 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 fellow team members can prevent small errors from becoming big errors. Part of this approach 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 ensures the entire team is aware of what is occurring, and helps in retaining the shared mental model. Acknowledging comments and questions ensures that communications have been heard and understood. Repeating back essential information confirms that the sender’s message has been received.


Communication and teamwork within a safety culture remain the foundation for preventing harm and are two of the most important facets of patient safety. Organizations must address risk perception, leadership involvement, assertive staff communications, consistent process implementation, teamwork, and human factors. Adopting a safety culture make them better able to reduce errors and protect patients.

Communication and group dynamics continue to be the subjects of intense research and study. The team approach 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

Using teamwork to resolve OR problems and concerns can foster a better understanding of the problem and ensure a more unified, informed approach to problem resolution. The result is a safer and improved environment for all surgical patients and OR staff.


  1. Neily J, Mills PD, Young-Xu Y, Carney BT, West P, Berger DH, Mazzia LM, Paull DE, Bagian JP. Association between implementation of a medical team training program and surgical mortality. JAMA. 2010;304(15):1693-1700.
  2. Young-Xu Y, Neily J, Mills PD, Carney BT, West P, Berger DH, Mazzia LM, Paull DE, Bagian JP. Association between implementation of a medical team training program and surgical morbidity. Arch Surg. 2011;146(12):1368-1373.
  3. Agency for Healthcare Research and Quality, TeamSTEPPs Fundamentals Course, Module 1.
  4. Walker A, Reshamwalla S, Wilson IH. Surgical safety checklists: do they improve outcomes? Br J Anaesthesia. 2012;109(1):47-54.

The Doctor’s Advocate is published by The Doctors Company to advise and inform its members about loss prevention and insurance issues.

The guidelines suggested in this newsletter are not rules, do not constitute legal advice, and do not ensure a successful outcome. They attempt to define principles of practice for providing appropriate care. The principles are not inclusive of all proper methods of care nor exclusive of other methods reasonably directed at obtaining the same results.

The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.

The Doctor’s Advocate is published quarterly by Corporate Communications, The Doctors Company. Letters and articles, to be edited and published at the editor’s discretion, are welcome. The views expressed are those of the letter writer and do not necessarily reflect the opinion or official policy of The Doctors Company. Please sign your letters, and address them to the editor.

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