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Patient Safety Scenario #17: A Tale of Two Departments
Captain Rick Saber at the controls.

This essay is the 17th installment of the monthly Patient Safety essays, produced by the Patient Safety Subcommittee of the Ethics and Professionalism Committee. The essays are written in the spirit of the aviation industry’s “Black Box Thinking”: in order to inform and improve our medical safety record, we need to analyze our errors. To read earlier essays and learn how to contribute, please click here.

Data analysis of aviation accidents and near misses has demonstrated that no matter how qualified or experienced the pilot, mistakes can still happen. In fact, the worst aviation accident in history was caused by the most qualified pilot in the airline, Captain Jacob Veldhuyzen van Zanten. He was not only the chief safety officer, he was also the chief flight instructor, the pilot who gave all the other pilots their annual check rides. He may have been the most qualified person in the cockpit, but he made a mistake the team did not catch. The plane crashed and burned, and 583 people died, because of a failure of teamwork in the cockpit. This essay is about improving teamwork in your OR.

David Nelson, MD Chair, Patient Safety Subcommittee
Scott Lifchez, MD Co-Chair, Ethics and Professionalism Committee
Julie Adams, MD Co-Chair, Ethics and Professionalism Committee

The Operating Room

The lead hand surgery nurse was getting a room ready for a wrist arthroscopy. She noted that the suction apparatus was not in the position the surgeon normally used, so she checked the preference card. The preference card agreed with the position, but she still felt this was not the position that the doctor usually used for this kind of case, and was fairly sure that the preference card was wrong. When the hand surgeon came in the room, she checked with him about the position of the suction apparatus, and asked if it was in the right position.

The surgeon, without replying, grabbed her hand and dragged her into the adjoining operating room where another hand surgeon was beginning a case. The staff in that room stopped and turned to learn what the disturbance was. They froze, knowing that there was going to be a scene, because this kind of thing had happened before. The hand surgeon humiliated her in front of the entire staff: “Do you guys ever even read the preference card? Why do you even bother to have them? Stop asking me stupid questions! That is what the preference cards are for!” The staff was dumbfounded and stood around in silence. The surgeon then stomped out of the room, feeling highly satisfied with himself. He taught that nurse a lesson! In the future she would read the preference card. The fact that she was trying to correct the error on the preference card in order to help him with this case in future cases never occurred to him. The humiliated nurse sadly left the room, and did not bother to bring this event to the attention of the administration. This had been going on for a long time and no one ever did anything about it. All the staff were afraid to go into that surgeon’s room, because they were always intimidated and denigrated. Nobody had a good day in that room and the staff turnover was high.

The Emergency Department

It was a typical busy night in the emergency room. Each room was full and all the staff were feeling a bit overextended. There was a rule-out MI in Room 1, an MVA in Room 2, an ankle fracture in Room 3, and an asthmatic in Room 4 who was rather short of breath. There were 3 nurses on duty and 2 doctors, one of whom was tied up in Room 1 with the MI. Everyone was scurrying around, with the usual amount of chaos that everyone has learned to cope with. The doctor who was managing the patients in Rooms 2, 3, and 4 gave an order to the nurse to increase the oxygen from 4 L to 6 L on the patient in Room 3. Suspecting an error, she clarified the order by saying, “Dr, I think you meant to increase the oxygen for the asthmatic, the patient in Room 4. The patient Room 3 is the ankle fracture, and they are doing fine.” The doctor did not feel the least bit threatened, thanked her for correcting him, and said, “You are correct, I meant to increase the oxygen for the asthmatic, and if they are in Room 4, you are correct that the order should be to increase the oxygen for the patient Room 4, from 4 L to 6 L.” The doctor felt comfortable knowing the right thing would be done, and the nurse felt valued as a contributing member of the team.


The analysis of these two situations is so obvious that nothing more needs to be said. We just need to be aware of our own actions and examine our own behavior, and to look at how it is perceived by the staff. A question each of us should ask about our own behavior: Is it getting us where we want to go?

In this particular hospital, the teamwork in the ED is excellent, but it was not always that way. A new head of the ED had been hired a few years back, to overhaul a rather dysfunctional department. I interviewed him for this article, since I had been so impressed with the teamwork in the ED when I had gone there to see a patient. In addition, one of the ED nurses was my patient and had told me how everyone in the ED could challenge an order, and be respected for it. I decided to investigate, since this spirit was so different from what I experienced in the OR.

The ED Director related how job satisfaction among the staff had been low, turnover had been high and cost the hospital a lot of money. But what really got the administration’s attention was when the low patient satisfaction scores hit the local paper. The administration threatened to revoke the ED contract with the group. The new ED director had been hired with the explicit charge to fix the ED. He felt that mutual respect and teamwork were the keys to job satisfaction, patient safety, and avoiding burnout. He had made it a point to lead by example when he arrived, treating the staff with respect. Once when he was rather stressed, attending a critical patient for whom he did not quite know the best next step, a nurse had asked him a question about an unrelated relatively trivial matter, and he was rather terse in his reply. Later, realizing that his manner was a bit gruff (has this not happened to all of us?),  and did not promote the team spirit that he wanted he quietly sought out the nurse and explained how he was feeling, both then (afraid) and now (a bit guilty), and apologized. The nurse, feeling understood, said that she appreciated the situation and had let it slide. She had missed reading the fact that he was fully mentally engaged with a very sick patient, and she admitted that she should have sensed that, and waited to ask her question. Later, this interaction was discussed among the staff. The new Director could not only talk the talk, he could walk the walk. With time, the rest of the staff saw and felt the mutual respect from the new Director, and began reflecting it in their own work. Discussion sessions were held on the topics of burnout, job satisfaction, and interpersonal interactions in the department. The ED physicians, all part of the same group, could see the value of teamwork with their partners, and how it extended to teamwork with the rest of the staff. The change was slow, but it happened, because the entire staff, the physicians as well as the nurses, could see the advantages. Job satisfaction surveys showed increased scores and turnover decreased, and the budget for recruiting and training showed it. The patient satisfaction scores naturally showed an uptrend. It was clear to everyone that this was a win-win situation.

The operating room is a rather different environment from the emergency department. The surgeons are not all partners in the same group, and by nature surgeons tend to be more independent, and arguably more arrogant. The administration addresses the situation and gives feedback to the surgeons, but as a matter of fact, little changes. To a certain amount, the administration tolerates rude and bullying behavior, especially from surgeons who bring in a lot of business.

But the operating room is not all that different from the emergency department or any other work environment. Teamwork promotes pride, job satisfaction, lower turnover, and a desire to try harder for the sake of the patients (customers, passengers, etc.). The business community (Sisk 2018), industrial safety specialists, the aviation industry (Lauber, 1979), the military, and professional sports organizations have all found that teamwork pays dividends in many ways. “Talent wins games, but teamwork and intelligence win championships.” – Michael Jordan. Do you think any basketball team would ever be successful half the team was denigrating the other half the team? It is the same in the operating room: denigrating the staff, belittling nurses, and feeling righteous about abusive behavior is a guaranteed way to lose a championship. The great Babe Ruth said it this way: “The way a team plays as a whole determines its success. You may have the greatest bunch of individual stars in the world, but if they don’t play together, the club won’t be worth a dime.”

Most professional athletes, even those at the top of their field, are continually analyzing their technique in an attempt to improve. If a professional athlete can do it, why not you the surgeon (Gawande, 2017)? A bit of introspection can reveal some new insights into your own manner in the operating room and how well you manage teamwork. At first it may seem strange. This happened in the aviation industry, when research revealed that crews often knew the captain was making a mistake, but were afraid to speak up (Lauber, 1979). Captains were instructed to listen to their teams.  Initially, captains felt that their authority was being challenged and that they were being demoted, relegated to second-class status. Over time, their assessment has changed. They are still the captain of the ship, and still have the final authority. However, teamwork has made their job safer and more enjoyable.  A senior captain, when starting a flight with a more junior first officer (the title of “copilot” has been dropped), will make it a point to encourage the more junior officer to be an active part of the team, and tell them to be sure to speak up if they have any concern, and the two of them will discuss it. We have a lot to learn from the aviation industry. Have you ever made it a point to encourage the staff in your OR to speak up if they feel that an error is being made? Have you ever had a private conversation with a lower ranking staff member who you may have spoken to harshly? Have you ever written a staff member up for a compliment, rather than only write up complaints? Have you ever considered what it is like to be the RN in your room?

In the Tale of Two Departments, which one are you in?

1) Lauber, John: 1979. Resource management on the flight deck. Proceedings of a NASA/industry workshop. Https://

2) Gawande, Atul:  2017.

3) Sisk, Annie:  2018.

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