Author’s Accepted Manuscript

Creating a Safer Operating Room: Groups, Team

Dynamics and Crew Resource Management
Principles

Derek Wakeman, Max R. Langham

www.elsevier.com/locate/sempedsurg

PII: S1055-8586(18)30008-8
DOI: https://doi.org/10.1053/j.sempedsurg.2018.02.008
Reference: YSPSU50739
To appear in: Seminars in Pediatric Surgery
Cite this article as: Derek Wakeman and Max R. Langham, Creating a Safer
Operating Room: Groups, Team Dynamics and Crew Resource Management
P r i n c i p l e s , Seminars in Pediatric Surgery,
https://doi.org/10.1053/j.sempedsurg.2018.02.008
This is a PDF file of an unedited manuscript that has been accepted for
publication. As a service to our customers we are providing this early version of
the manuscript. The manuscript will undergo copyediting, typesetting, and
review of the resulting galley proof before it is published in its final citable form.
Please note that during the production process errors may be discovered which
could affect the content, and all legal disclaimers that apply to the journal pertain.
 Creating a Safer Operating Room: Groups, Team Dynamics and

Crew Resource Management Principles

Authors: Derek Wakemana,* and Max R Langham Jr.b

a
Department of Surgery, University of Rochester School of Medicine, 601 Elmwood Ave, Box

SURG, Rochester, NY, 14642.

b
Department of General Surgery, University of Tennessee Health Science Center, Memphis, TN.

Abstract

The operating room (OR) is a special place wherein groups of highly skilled individuals

must work in a coordinated and harmonious fashion to deliver optimal patient care. Team

dynamics and human factors principles were initially studied by the aviation industry to better

understand and prevent airline accidents. As a result, crew resource management (CRM) training

was designed for all flight personnel to create a highly reliable industry with a commitment to a

culture of safety. CRM has since been adapted to health care, resulting in care improvement and

harm reduction across a wide variety of medical specialties. When implemented in the OR, CRM

has been shown not only to improve communication and morale for OR staff, but also reduce

morbidity and mortality for patients. As increasing focus is placed on quality, safety, and high-

reliability, surgeons will be expected to participate and lead efforts to facilitate a team approach

in this new era of patient care.

Keywords: Team Dynamics, operating room, crew resource management, TeamSTEPPS,

patient safety

A three-year-old girl presents to the emergency room with hematuria. Overnight, she fills

multiple diapers with bloody urine and ultimately requires blood transfusion for anemia. Cross-

sectional imaging demonstrates a large right-sided kidney tumor consistent with a Wilms tumor

with no evidence of metastases. She is taken to the operating room for a right radical

nephrectomy. Due to the urgent nature of the case, the operation takes place with an

inexperienced nursing team that rarely performs general surgical cases. The case bridges a shift

change for nurses and anesthesiologists. Additional hand-offs for work breaks occur during

specimen removal. Ultimately, the patient makes an uneventful post-operative recovery.

Pathologic examination of the specimens confirms a Wilms tumor with favorable histology that

does not extend beyond the renal capsule. However, no lymph nodes are received. This finding

potentially upstages the patient’s disease from stage 1 to stage 3, which would mandate

escalation of chemotherapy and the addition of abdominal radiation. The surgeon recalls

providing additional tissue to be separately sent as nodes but this is not documented in the

nursing flow sheet or dictated operative report. The general surgery nurses usually help remind

the surgeon to remove lymph nodes during nephrectomy for Wilms tumors. No surgical sign out

or debriefing was performed during the operation.

 What factors contributed to this error?

 How can this be prevented?

Background

Pediatric surgeons have multifaceted responsibilities for patients with problems that

range from common to exceedingly rare. Beyond creating a therapeutic atmosphere for the

patient and family, surgeons are constantly interacting with other healthcare providers, each of

whom has his or her own perspective and background. The complexities of these interactions are

often coupled with critical time constraints of delivering high acuity care. Although every effort

is made to provide responsible, comprehensive, safe, and efficient care to our patients, there are

unlimited opportunities for conflict, misunderstanding, or unintentional failures as in the case

described. Over the past decade, a growing body of evidence has emerged surrounding the

importance of human factors in high-stakes, high acuity settings such as the operating room

(OR).

The perioperative experience brings together multiple people with different backgrounds

toward a common goal – to bring a patient through an operation as effectively, efficiently, and

safely as possible. This requires coordination among providers with different expertise and skill

sets. The pre-operative phase begins with a surgeon recommending a specific operation to the

patient and their family. The risks and benefits of surgical intervention are reviewed, and

informed consent is obtained. Depending on operative and patient factors, careful coordination

between physicians, nurses, and administrative support staff in the surgeon’s, anesthesiologist’s,

and primary care provider’s offices may be required to optimize a patient’s medical

comorbidities before an operation. A successful operative experience requires synchronization

of safe transitions through phases of care from admission, to pre-anesthesia, to the OR, to the

post-anesthesia recovery unit (PACU), to the intensive care unit or floor, and, lastly, to home.
 ORs were created in the 1800’s as advances in anesthesia allowed surgery to be

performed for a wider variety of more complex indications. ORs have evolved in lock step with

the evolution of surgical specialties incorporating advances in technology, equipment, and safety

standards. ORs are usually staffed by skilled groups of healthcare professionals performing

specific tasks. In the United States, a Doctor of Allopathic or Osteopathic Medicine must be

involved, in at least a supervisory manner, for the performance of the procedure and the

provision of anesthesia.1 Nurses may plan, implement and evaluate treatment of the patient2. The

professional requirements and scope of practice for surgical technologists varies considerably

and include creating, maintaining, and monitoring aseptic surgical techniques; anticipating the

instruments and supplies needed for a procedure; and ensuring the efficient conduct of the

procedure is possible. Custodial staff usually maintain a clean, safe environment as required by

the Joint Commission. An efficient supply chain is essential for stocking thousands of

instruments, devices, and medications used during an operation.

Administrative staff responsible for handling the complexity and human resources

aspects of the OR environment are most often recruited from a nursing background, while

scheduling and daily workflow is usually handled by an anesthesiologist. While physicians may

practice at several hospitals or surgical centers, other OR staff are usually full-time at a specific

geographic location. Within a large, multi-specialty OR, groups of healthcare professionals may

be aligned or assigned into various types of working groups depending on the type of procedure

being performed and the specific context within which it is being conducted. Group interactions

are of at least 3 types: Crew, Team, and Flash Mob (Figure 1).
 Hospitals often provide a continuum of patient care that includes peak hours with full OR

staffing and capability to provide emergent services 24-hours a day throughout the year. To

maintain this level of availability, staffing models for anesthesiologists, nurses and other

personnel are generally based on shifts worked for specific durations. Beyond maintaining an

elective practice during normal working hours, most surgeons provide emergency coverage for

their institutions on a rotating basis, and are available for required operative procedures at night,

on weekends, and during holidays. Staff sizes can be quite large resulting in an astronomical

possible combinations of individuals working together on a case (Table 1).

It is out of necessity that crews perform most operations. Historically, the structure of the

OR is hierarchical with the surgeon as the sole leader. While decisions about preparation and

timing of operations are usually shared with an anesthesiologist, once the operation begins, the

surgeon’s role is primary. While other members of the crew may come and go during the

operation, the surgeon is the constant presence and leader. Hierarchy is vital for effective crew

work, but must not be confused with the abusive behaviors often associated with the term. An

important aspect of crews is an acceptance of new crewmembers who have limited experience.

As long as the individual is qualified and competent, his or her presence has little negative

impact on crew function. The level of comfort with inexperienced crewmembers may be highest

with common operations and lowest in tense situations or technically difficult operations.

Though being part of a high functioning surgical team is rewarding, teams are talked

about in surgery more often than they actually exist. The more complex an operation, the more

likely an institution is to create a team. Examples are Cardiac surgical teams, Transplant teams

and special teams such as those created to separate conjoined twins. Within the team setting there

is limited acceptance for team members to rotate in and out during an operation, or to leave
before the operation is completed. While it is normal for the primary surgeon to serve as leader,

teams tend to be less hierarchical, with more comfort and social equality between members. In

turn, teams often have better interpersonal communication. Teams are especially good at learning

highly complex, time sensitive, coordinated procedures. They have real advantages over crews in

the realm of collective learning and rapid process improvement. They are, however, less flexible

from a scheduling standpoint, and are, generally, more expensive.

While not routine for surgical teams, one fundamental of the team dynamic is the

importance of a coach. The coach’s role observing the team’s performance, and adjusting roles

and responsibilities based on these observations is accepted by the team. This allows the coach to

lead individual and group learning. Most often a senior surgeon, who may or may not be doing

most of the technical part of the procedure, assumes this role. Inherent in the position is

responsibility for administrative oversight of the team and accountability for the team’s results.

Flash mobs are assembled rapidly during unexpected events that may include loss of an

airway, cardiopulmonary arrest during an operation, unexpected massive blood loss, or a mass

casualty event. The make-up of flash mobs is highly variable depending on the event. Typically,

mobs devolve into subgroups performing specific tasks. Leadership is often uncertain or shared.

Recruits from outside the OR may be pulled into service such as Emergency Department

personnel or intensive care providers. At the end of the event, the mob disperses quickly, often

without a collective debrief. Record keeping is typically problematic and group learning requires

a forensic reconstruction of the event, often with incomplete information.

 Any successful operation requires all stakeholders working together and communicating.

Much of the current medical literature uses the term “team” broadly and does not differentiate

between crews, teams, and flash mobs. In this review we will focus on teams and crews, with

specific emphasis on human factors principles that underlie most of this work.

Introduction to Team Dynamics

Team dynamics describe how unconscious, psychological forces affect the behavior and

impact performance of groups of people working together. The landmark Institute of Medicine

report To Err is Human declared the need to “promote effective team functioning” as one of five

values for creating safe hospitals.3 In the OR, teamwork is fundamental to patient safety and a

culture of open communication.4

Beyond patient safety concerns, team dynamics have a significant impact on job

satisfaction. Perioperative safety briefings intended to improve communication and team-work

among OR staff have been found to enhance employee job satisfaction and reduce OR nursing

staff turnover.5 Moreover, high-quality teamwork has been correlated with reduced sick leave

taken by health professionals.6 It has been suggested that low perceptions of teamwork by nurses

leads to job dissatisfaction and contributes to nursing shortages.4 For these reasons, Makary’s

team at Johns’ Hopkins Medical Center developed a tool to measure teamwork in the OR. In

validating their Safety Attitudes Questionnaire, they found discrepant perceptions of teamwork

in the OR. While surgeons and anesthesiologists perceived good teamwork among OR staff,

nurses rated teamwork as mediocre.4 In fact, surgeons had the most egregious misperceptions

rating their collaboration with nurses as good 88% of the time, while nurses rated it as high-

quality only 48% of the time.

Roles in the OR

Understanding roles in the OR is a key first step to understanding team dynamics. At the

University of Southern California, OR personnel were queried about which behaviors they

thought most affected the performance of an operation.7 Surgeons most frequently cited their

own management of the team and case, while others (anesthesiologists, technicians, and nurses)

believed the surgeon’s preparation was most important. All parties agreed that the

anesthesiologist’s technical competence is the most important factor for providing quality

anesthesia care. From the nursing perspective, circulating nurses noted technical competence and

preparation most often. Interestingly, non-nurses believed the circulator’s management of the

case was their most important role.7 Surgical technicians cited their own preparation as most

important while other OR staff thought the technician’s technical competence was most

important. Overall, preparation and technical competence were found to account for two-thirds

of the role behaviors affecting performance.7 Team factors were reported to account for

approximately 20% of role behaviors influencing surgical performance. Of these, communication

(30%), teamwork (26%), and interpersonal relations (19%) were cited as being most influential.7

A group in Auckland, New Zealand recently developed a computer based model to assess

perceptions of role responsibilities among OR teams (surgery, anesthesia, and nursing). They

found differences in individual mental models regarding accountability for tasks during

simulated emergency laparotomies.8 The operation was divided into 20 tasks; the groups lacked

agreement for who was responsible for half of the tasks.8 Without a shared mental model

teamwork is jeopardized. Creating a shared mental model of OR tasks within crews or teams that

may rarely work together is even more challenging. A model of leadership, situation awareness,
communication, and a joint commitment to patient safety are vital for clearly establishing roles

and making the “crew” into a high functioning “team.”

Leadership in the OR

The surgeon most often assumes the role of leader as the team member with continuity

throughout the perioperative period and the person ultimately responsible for the patient’s well-

being. It is critical not to confuse leadership with absolute authority or dictatorial style. An

effective leader sets the team at ease, encourages communication, and allows team members the

freedom to think critically and function effectively in their role. Effective leaders also must

designate authority promptly in situations that preclude them from maintaining perspective, and

leading the crew. Crewmembers should be empowered to ask for help or designate leadership

authority if the surgeon is so occupied with a particular task that he or she cannot survey the

entire room and manage it appropriately. In these crucial times, another surgeon, an

anesthesiologist, or another key team member must lead the group. Having the crew or team

devolve into a flash mob is a failure of leadership.

The circulating nurse also has a vital leadership role. Anesthesiologists and surgeons

frequently cite the circulating nurse as “being in charge of the OR”.7 Surgeons should respect

and encourage the leadership role for nursing staff in the OR.

While the OR has a hierarchical structure with the surgeon traditionally at the top of the

team dynamic, too often surgeons have not understood the proper conduct of teams and have

displayed abusive or destructive behavior. An autocracy, with surgeons “pulling rank” over

anesthesiologists and physicians “outranking” nursing staff is not appropriate and leads to

increased errors.9 In these settings, effective communication is stifled, and staff are afraid to

speak up. Effective communication and collaboration in the OR require elimination of autocracy
and support of all staff contributing to the procedure. This flattening of the hierarchy can be

thought of as a more democratic environment. Developing a culture of respect and mutual

support between crewmembers allows all members to enjoy the experience as they contribute to

an increasingly safe patient experience. Significant education and culture change will be required

to achieve this vision in the OR.

Instances may arise when a leader’s authority must be set aside against his or her will.

Substance abuse issues, mental illness (often depression), physical illness, exhaustion, and other

issues may render a surgeon unfit to provide safe care. This is best handled by the surgeon

recognizing the problem and voluntarily removing him or herself from direct patient care.

Similar issues affect pilots. The Federal Aviation Administration (FAA) has added training on

self-awareness. IMSAFE – Illness, Medication, Stress, Alcohol, Fatigue, Emotion – is a useful

mnemonic that is easily modified to fit surgeons and members of the surgical team (Table 2).10

Cognitive factors involving IMSAFE elements have been correlated with medical malpractice

cases.11

Physician fatigue is particularly relevant for surgeons. Providing continuous emergency

coverage often causes surgeons to have interrupted sleep cycles and some level of fatigue.

Fatigue leads to diminished ability to deal with frustration, impaired judgement, and suboptimal

decision-making. If working in crews, other health professionals may not know the surgeon well

or be able to judge his or her actions in a manner informed by personal knowledge of the

surgeon’s strengths and weaknesses. In contrast, close team members are often the first to

recognize when surgeons need assistance and should be empowered to raise concerns to OR

leadership. Hospitals are grappling with how to handle situations when surgeons do not fulfill
their professional responsibilities. The American College of Surgeons12 and the Joint

Commission13 have released statements on recognizing and managing fatigue.

Situation awareness and shared mental models

Situation awareness involves appreciating the conditions that affect one's work such as

environment, time, and place. Having awareness requires constant monitoring of an ever-

changing situation. Ideally, all crew or team members would have a similar level of situation

awareness, or share a mental model of the task at hand. The concept of situation awareness was

developed from investigations of airline accidents. Most airline crashes were found to be

preventable and due to inappropriate responses to changing situations exacerbated by poor

communication between crew members. Human factors, or what many might call “human error,”

is responsible for most plane crashes instead of instrument or mechanical failures.14 These errors

can be broken down into decisional, procedural or operational, and perceptual/motor or

technical. Over half of accidents in civilian, military, and private aviation are decisional and

most of these are due to loss of situation awareness.15

Research into human factors developed the principle of a shared mental model. In

aviation, the pilot and co-pilot gain a shared understanding of a fluid scenario that is

communicated to the cabin and ground crew. These principles provide the framework for Crew

Resource Management (CRM) which is taught ubiquitously to improve flight crew effectiveness,

efficiency, and aviation safety.

Central to creating a shared mental model is effective communication. Crew members are

empowered to speak up and share ideas. The saying “If you see something, say something” has

roots in principles of CRM. While airplane design has certainly improved with time, many
attribute the phenomenal safety record of the American airline industry, which has not had a

single fatality on a commercial airline since 200916, to the adoption of CRM.

Patient Safety and Communication

Preventable medical errors have long been recognized as a cause of morbidity and

mortality.17 Medical errors are now estimated to be the third leading cause of death in the United

States.18 Further reports expose that communication failure accounts for 70% of sentinel events

reported to the Joint Commission from 2004-201119 and about 75% of approximately 7000 root

cause analysis reports from Veterans Affairs hospitals20.

The OR is not immune to communication failures. While advances in technology,

surgical techniques, and anesthesia have been made, patients continue to suffer preventable harm

ascribed to imperfect team dynamics (or non-technical skills) rather than technical failures.21, 22

Lack of teamwork and information sharing in the perioperative setting has been correlated with

an increased risk of postoperative complications and death.23 Addressing communication failures

in the OR requires human factors education and training.

Crew Resource Management (CRM)

Given its exemplary safety record, the American aviation industry serves as an example

from which the health care industry can learn. In the 1970’s and 80’s CRM principles were

developed by the National Aeronautics and Space Administration and airline industry experts

after scrutinizing the role of human error on plane crashes.24 Human errors, communication

failures, leadership problems, and cockpit decision making were found to be major contributors

to errors in aviation. In many instances, other personnel in the aircraft knew a mistake was being
made and did not speak up to an established captain. CRM values input for all available

information sources including equipment and personnel to ensure efficient and safe flights. The

goal is not to eliminate the hierarchy but to improve performance by increasing the support for

and importance of all crew and to affirm everyone’s responsibility and right to be assertive and

speak up if anyone perceives a problem. Demonstrated characteristics of good communication

and feedback to the leader are that it be timely, specific, and constructive.15 It is important that

the captain or leader specifically acknowledge and respond to all issues that are raised.

Simulation, crewmember debriefings, and crew performance measurement are used to improve

team dynamics, reduce errors, and create a culture of safety.

CRM has been applied in medicine and surgery to promote teamwork and patient safety.

Aviation-style CRM team training focusing on teamwork and communication was studied in

maxillofacial, vascular, and neuro-surgical OR teams in the United Kingdom.25 After training,

OR teams performed significantly more briefings, time outs, and debriefings after surgical

procedures. Another group at the Baylor College of Medicine found that CRM-based training

improved communication between anesthesiologists and surgeons, performance of preoperative

briefings, and administration of antibiotics and sequential compression devices.26

The Veterans Administration (VA) National Center for Patient Safety built a Medical

Team Training Program based on CRM. The program, using team training and surgical

checklists to drive preoperative briefings and postoperative debriefings, was implemented at 43

VA medical centers between 2003 and 2006.20 Based on favorable data from this pilot study, the

VA Medical Team Training Program was implemented nationwide starting in 2006.27 Medical

centers that completed the CRM training program (74 facilities) had an 18% reduction in annual

procedural mortality compared to the 7% decrease seen in 34 centers that had not completed the
program.27 Importantly, a dose-response relationship was found in that every quarter of a year of

team training was associated with 0.5 fewer deaths per 1000 procedures.27 This program was also

associated with reductions in venous thromboembolism, surgical site infections, all infections,

and all-cause morbidity over the same period.28

More recently CRM-based training was found to improve staff perceptions of the safety

climate at a VA hospital in Shreveport, LA.29 They adopted a clinical team training curriculum

from the VA National Center for Patient Safety.30 The program was administered through

didactic learning sessions coupled with group discussion and simulation training to reinforce

content. They measured their institutional safety climate with a 27 point questionnaire. After 6

months, improvements were noted for all 27 elements. After one year, 23 of 27 points

maintained enhancement. The greatest improvements were found in performance of briefings,

cooperation between doctors and nurses, valuing contributions from nursing staff, patient safety

knowledge, and institutional promotion of culture of safety.29

The World Health Organization (WHO) incorporated a CRM-style briefing and

debriefing with a surgical pause (time out) when developing their surgical safety checklist (SSC).

Implementation of the WHO SSC has been shown to significantly reduce surgical morbidity and

mortality across disparate hospitals globally31 and in emergency situations32. As a result of this

seminal work, many hospitals have added a SSC to the workflow in their OR’s. SSC’s are

adaptable and may work best when customized to local patterns of care (Table 3). While the

utility of the surgical pause or time out is nearly universally accepted, performance of the brief

and debrief have lagged33 (authors’ observations). Hopefully, in time, adoption of briefing and

debriefing will be as engrained in OR culture as completion of the time out before skin incision.
TeamSTEPPS®

The Agency for Health Care Research and Quality (AHRQ) adapted CRM training and

created a team training curriculum for medical practitioners called TeamSTEPPS® (Strategies

and Tools to Enhance Performance and Patient Safety).34 The principles were borrowed from a

curriculum that focuses on teaching communication and leadership qualities shown to reduce

errors. In 2006 the AHRQ released the TeamSTEPPS® course free of charge under public

domain. The course focuses on teaching strategies for improving leadership, communication,

situation monitoring, and mutual support (Figure 2).35 The curriculum, course materials, and a

list of articles demonstrating TeamSTEPPS® efficacy can be found on AHRQ’s website

(http://www.ahrq.gov/teamstepps/index.html).

The TeamSTEPPS® curriculum is malleable and can be taught as basic principles to

providers across medical disciplines; the course material can also be customized for specialty

specific instruction36, 37 including simulation training38. Indeed, TeamSTEPPS® has been

adapted to the OR environment. Urology OR teams at the San Antonio Military Medical Center

focused on a “Brief” at the beginning of the day and a “Debriefing” at the end of each

operation.36 After implementing TeamSTEPPS® mean OR case durations were shorter and first-

start on-time rates increased. Further, patient safety concerns discussed during the debriefing

declined from 16% at study inception to 6% one year later.36

In 2011 a group at Creighton University published their experience with team training in

the perioperative setting.37 They taught TeamSTEPPS® to all OR staff including surgeons,

anesthesiologists, nurse anesthetists, residents, nurses, and technicians in early 2007. They

reported significant improvements in teamwork and communication measures in the OR. Metrics

of OR efficiency, percentage of first-case on-time starts, and room turnover time improved from
2006 to 2010. Compliance with several perioperative quality improvement measures rose

dramatically in association with training OR staff for teamwork: pre-operative antibiotic

administration (78% to 97%), venous thromboembolism prophylaxis (74% to 91%), and beta-

blocker administration (20% to 100%).37 Morbidity (20% to 11%) and mortality (2.7% to 1%) as

measured by the American College of Surgeons National Surgical Quality Improvement

Program (NSQIP) also declined after TeamSTEPPS® training. Importantly, many of the

favorable outcomes were not enduring. Outpatient surgical patient satisfaction scores peaked

after TeamSTEPPS® training and declined to prior baseline levels in subsequent years when no

team training was offered.37 The authors note that administrative support for team training ceased

after its initial roll out due to financial cutbacks. Nearly all measures returned to the prior

baseline one or two years after training, underscoring the need for continued commitment to

training.

A group at The Mount Sinai Hospital recently reported their experience after

implementing TeamSTEPPS® in the OR merged with a SSC.39 They focused on employing

three specific TeamSTEPPS® skills: call-out (when a provider announces important

information), check-back (when a provider repeats something to ensure it was heard correctly),

and 2- challenge rule (when a provider repeats information if initially dismissed). Compliance

with measures of communication (time out, check-backs), situation monitoring, and mutual

support increased dramatically over the study period during the time out (58% to 92%) and

debrief (58% to 95%). Perhaps more strikingly, the number of wrong patient/wrong site surgeries

and unintentionally retained foreign bodies decreased by 67% after TeamSTEPPS® training.39
 This evidence demonstrates the efficacy of crew resource management and team training

for surgical teams. The aviation industry requires ongoing, repetitive training in CRM

environments. The FAA requires operational ‘line checks’ every 24 months for captains of

aircraft. Rigorous continued practice and training in CRM has not been adopted by most

hospitals or surgical groups. Given the dose-response benefit to the amount of CRM offered to

the VA OR staff,27 and the finding that benefits of TeamSTEPPS® degrade over time with

eventual return to the pre-training baseline if instruction is not continued,37 it is clear that a “one

and done” approach to team training will likely not have lasting results. Optimal training content

and schedules remain to be defined.

Simulation Training

Simulation is deeply entrenched in the aviation industry, and has been adopted in

teaching surgical skills such as minimally invasive techniques. Airline pilots do not fly a

commercial plane until certified in a flight simulator. Further, pilots and crew simulate handling

emergencies during required semi-annual certifications. The medical literature is replete with

evidence of the value of simulation. However, most of the research has been on technical skills,

such as intubating and placing central lines.40 Training non-technical skills such as

communication and team work in the OR during simulation has been less well-studied, and very

few studies include all three major disciplines involved during an operation (surgery, anesthesia,

and nursing). A recent review identified only 10 studies that trained entire OR teams in non-

technical skills.40 Certainly, these training efforts require considerable time and resources to

implement and their value is not yet known. However, initial testing of a crisis management

simulation for entire OR teams at the University of Rochester has already caught a potentially

missed specimen during the surgical sign out/debriefing (author’s observations).

Team Dynamics in Children’s Surgery and Future Directions

Training for teamwork is working its way into children’s surgery. Most hospitals are

focusing on events that were historically cared for by “flash mobs.” Team-based simulation

education has been found to prevent errors and improve injury-specific management during

pediatric trauma.41 The timeliness and efficiency of task completion during resuscitations was

recently shown to be improved by closed loop communication within pediatric trauma teams.42

CRM training has been shown to enhance nontechnical skills for pediatric trauma crews43 and

increase confidence in pediatric critical care units during crisis scenarios44. The use of simulation

to improve collective learning and performance during these uncommon events is exciting and

encouraging.

To the authors’ knowledge, there have been no studies to date investigating the results of

team dynamics and training for team work in the OR in children’s hospitals. A recent survey of

children’s surgeons and anesthesiologists in the American Academy of Pediatrics found that only

about a third of children’s hospitals/institutions offered team training.45 The programs were

reported to be beneficial by pediatric surgeons and anesthesiologists who have completed them.

Further expansion of team-training programs may be valuable to improving a culture of safety in

children’s hospitals. Future research into how often team training should occur, development of

standardized curricula, and creation of tools to accurately measure team work and the efficacy of

team training will be necessary to guide future progress in this area.

Conclusions

Surgeons and hospitals are beginning to invest in the improved understanding of group

dynamics, human factors, and adoption of CRM principles. Preliminary data suggest that training

results in reduced medical errors, improved OR efficiency, and better morale among surgeons

and hospital staff. We anticipate that initial and recurrent training in human factors will become a

part of surgical residency training and maintenance of certification for surgeons. By embracing

the principles of CRM surgeons can foster a team approach to deliver optimal and safer care to

our children.

Table and Figure Legends

Figure 1. Defining types of group interactions in operating rooms

Figure 2 TeamSTEPPS® logo depicting the program’s emphasis on improving leadership,

communication, situation monitoring, and mutual support amongst health care team members.

Reproduced from the Agency for Healthcare Research (AHRQ) with permission.35

Table 1. Staffing at a hypothetical Children’s Hospital demonstrating the possible number of

staff combinations assuming one individual from each group.

Table 2. The mnemonic IMSAFE was created by the Federal Aviation Administration to assess

a pilot’s fitness to operate aircraft.10 It has been adapted here for surgeons.

Table 3. A sample surgical Brief and Sign Out/Debrief implementing CRM principles modified

from a surgical checklist used at the University of Rochester. The surgical Time Out has been

omitted.
References
1. American College of Surgeons. Surgical Patient Education Program. Found at
https://www.facs.org/education/patient-education/patient-resources. Accessed January
13, 2018.
2. Nurses for a Healthier Tomorrow. Perioperative (O.R.) Nurse. Found at
https://www.nursesource.org/perioperative.html. Accessed January 12, 2018.
3. Kohn L, Corrigan, JM, Donaldson, MS. To Err is Human: Building a Safer Health
System. Washington (DC): Institute of Medicine Committee on Quality of Health Care in,
America; 2000.
4. Makary MA, Sexton JB, Freischlag JA, et al. Operating room teamwork among
physicians and nurses: teamwork in the eye of the beholder. Journal of the American
College of Surgeons. 2006;202:746-752.
5. DeFontes J, Surbida S. Preoperative safety briefing project. The Permanente Journal.
2004;8:21.
6. Kivimäki M, Sutinen R, Elovainio M, et al. Sickness absence in hospital physicians: 2
year follow up study on determinants. Occupational and Environmental Medicine.
2001;58:361-366.
7. Leach LS, Myrtle RC, Weaver FA. Surgical teams: role perspectives and role dynamics
in the operating room. Health services management research. 2011;24:81-90.
8. Nakarada-Kordic I, Weller JM, Webster CS, et al. Assessing the similarity of mental
models of operating room team members and implications for patient safety: a
prospective, replicated study. BMC medical education. 2016;16:229.
9. Bleakley A, Allard J, Hobbs A. ‘Achieving ensemble’: communication in orthopaedic
surgical teams and the development of situation awareness—an observational study using
live videotaped examples. Advances in Health Sciences Education. 2013;18:33-56.
10. Topic GAJSCSE. Single-Pilot Crew Resource Management. In: Administration FA, ed.
11. Stripe SC, Best LG, Cole-Harding S, et al. Aviation model cognitive risk factors applied
to medical malpractice cases. Journal of the American Board of Family Medicine :
JABFM. 2006;19:627-632.
12. Surgeons ACo. Statement on peak performance and management of fatigue. Bulletin of
the American College of Surgeons. 2014;99(8):53-54. Found at
bulletin.facs.org/2014/08/statement-on-peak-performance-and-management-of-fatigue.
Accessed on January 14, 2018.
13. Commission J. Sentinel Event Alert Issue 48: Health care worker fatigue and patient
safety. Oakbrook Terrace, IL: The Joint Commission. 2011.
14. Smith HR. A simulator study of the interaction of pilot workload with errors, vigilance,
and decisions. 1979.
15. Kern T. Controlling pilot error: Culture, environment, and crm (crew resource
management): McGraw Hill Professional; 2012.
16. Reyes-Velarde A. Nobody died in a U.S. commercial jet crash last year — a trend that
predates Trump: Los Angeles Times.
17. Leape LL, Brennan TA, Laird N, et al. The nature of adverse events in hospitalized
patients: results of the Harvard Medical Practice Study II. New England journal of
medicine. 1991;324:377-384.
18. Makary MA, Daniel M. Medical error-the third leading cause of death in the US. BMJ:
British Medical Journal (Online). 2016;353.
19. Joint Commission. Improving patient and worker safety: opportunities for synergy,
collaboration and innovation. Oakbrook Terrace, IL: The Joint Commission. 2012;171.
20. Dunn EJ, Mills PD, Neily J, et al. Medical team training: applying crew resource
management in the Veterans Health Administration. The Joint Commission Journal on
Quality and Patient Safety. 2007;33:317-325.
21. Gawande AA, Zinner MJ, Studdert DM, Brennan TA. Analysis of errors reported by
surgeons at three teaching hospitals. Surgery. 2003;133:614-621.
22. Lingard L, Espin S, Whyte S, et al. Communication failures in the operating room: an
observational classification of recurrent types and effects. Quality and Safety in Health
Care. 2004;13:330-334.
23. Mazzocco K, Petitti DB, Fong KT, et al. Surgical team behaviors and patient outcomes.
The American Journal of Surgery. 2009;197:678-685.
24. Cooper G, White M, Lauber J. Resource management on the flightdeck: proceedings of a
NASA/industry workshop. Moffett Field, CA: NASA-Ames Research Center; 1980.
NASA Conference Publication No. CP-2l20.
25. Catchpole KR, Dale TJ, Hirst DG, et al. A multicenter trial of aviation-style training for
surgical teams. Journal of patient safety. 2010;6:180-186.
26. Awad SS, Fagan SP, Bellows C, et al. Bridging the communication gap in the operating
room with medical team training. The American Journal of Surgery. 2005;190:770-774.
27. Neily J, Mills PD, Young-Xu Y, et al. Association between implementation of a medical
team training program and surgical mortality. Jama. 2010;304:1693-1700.
28. Young-Xu Y, Neily J, Mills PD, et al. Association between implementation of a medical
team training program and surgical morbidity. Archives of surgery. 2011;146:1368-1373.
29. Kuy S, Romero RA. Improving staff perception of a safety climate with crew resource
management training. Journal of Surgical Research. 2017;213:177-183.
30. VA National Center for Patient Safety. Clinical Team Training. Vol 2017.
31. Haynes AB, Weiser TG, Berry WR, et al. A surgical safety checklist to reduce morbidity
and mortality in a global population. The New England journal of medicine.
2009;360:491-499.
32. Weiser TG, Haynes AB, Dziekan G, et al. Effect of a 19-item surgical safety checklist
during urgent operations in a global patient population. Annals of surgery. 2010;251:976-
980.
33. Bartz-Kurycki MA, Anderson KT, Abraham JE, et al. Debriefing: the forgotten phase of
the surgical safety checklist. The Journal of surgical research. 2017;213:222-227.
34. Agency for Healthcare Research and Quality; United States Office of the Assistant
Secretary of Defense (Health Affairs); TRICARE Management Activity. TeamSTEPPS:
Team Strategies & Tools to Enhance Performance & Patient Safety—Instructor Guide
Rockville, MD: Agency for Healthcare Research and Quality; 2006.
35. Agency for Healthcare Research and Quality. TeamSTEPPS® 2.0. Vol 2017.
36. Weld LR, Stringer MT, Ebertowski JS, et al. TeamSTEPPS Improves Operating Room
Efficiency and Patient Safety. American journal of medical quality : the official journal
of the American College of Medical Quality. 2016;31:408-414.
37. Forse RA, Bramble J, McQuillan R. Team training can improve operating room
performance. Surgery. 2011;150:771-778.
38. Meier AH, Boehler ML, McDowell CM, et al. A surgical simulation curriculum for
senior medical students based on TeamSTEPPS. Archives of surgery. 2012;147:761-766.
39. Rhee AJ, Valentin-Salgado Y, Eshak D, et al. Team training in the perioperative arena: a
methodology for implementation and auditing behavior. American Journal of Medical
Quality. 2016:1062860616662703.
40. Robertson JM, Dias RD, Yule S, Smink DS. Operating Room Team Training with
Simulation: A Systematic Review. Journal of Laparoendoscopic & Advanced Surgical
Techniques. 2017;27:475-480.
41. Falcone RA, Daugherty M, Schweer L, et al. Multidisciplinary pediatric trauma team
training using high-fidelity trauma simulation. Journal of pediatric surgery.
2008;43:1065-1071.
42. El-Shafy IA, Delgado J, Akerman M, et al. Closed-loop communication improves task
completion in pediatric trauma resuscitation. Journal of surgical education. 2017.
43. Lehner M, Heimberg E, Hoffmann F, et al. Evaluation of a Pilot Project to Introduce
Simulation-Based Team Training to Pediatric Surgery Trauma Room Care. International
journal of pediatrics. 2017;2017.
44. Figueroa MI, Sepanski R, Goldberg SP, Shah S. Improving teamwork, confidence, and
collaboration among members of a pediatric cardiovascular intensive care unit
multidisciplinary team using simulation-based team training. Pediatric cardiology.
2013;34:612-619.
45. Esce A RD, Browne M, Rothstein DH, Wakeman D. Prevalence and Perceptions of Team
Training Programs for Pediatric Surgeons and Anesthesiologists. Academic Surgical
Congress. Jacksonville, FL. 2018.
Table 1. Staffing at a hypothetical Children’s Hospital demonstrating the possible number of

staff combinations assuming one individual from each group. (CRNA = Certified Register Nurse

Anesthetist. OR = operating room.)

Surgeons Anesthesiologists CRNAs OR Nurses Scrub Potential

Technicians Combinations

8 16 20 50 45 5,760,000

Table 2. The mnemonic IMSAFE was created by the Federal Aviation Administration to assess

a pilot’s fitness to operate aircraft.10 It has been adapted here for surgeons.

Illness Is the surgeon suffering any acute or chronic illness that distracts him or her

from the operation?

Medication Is the surgeon taking any medications that could affect performance or

judgment?

Stress Is the surgeon under significant stress from events in his or her professional or

personal life?

Alcohol Is the surgeon under the influence of alcohol? (Pilots are required by work

rules to consume NO alcohol within 8 hours of a duty period)

Fatigue Has the surgeon had adequate rest and nutrition? This issue may most often

negatively impact surgical performance.

Emotion Is the surgeon emotionally competent to operate? Unusual emotional events

may distract and degrade performance.

Table 3. A sample surgical Brief and Sign Out/Debrief implementing CRM principles modified

from a surgical checklist used at the University of Rochester. The surgical Time Out has been

omitted. (OR = operating room, VTE = Venous Thromboembolism, PACU = post anesthesia

care unit, ICU = intensive care unit)

BRIEF SIGN OUT / DEBRIEF

Completed in OR, ideally before induction of
anesthesia. A Member from Surgery,
Anesthesia, and Nursing must be present.
Team introductions (names/roles): written down
and visible to all
Special instruments/supplies/implants
Confirm patient identity (2 identifiers)
Allergies
Antibiotics (when appropriate)
VTE prophylaxis/Beta-Blocker (if appropriate)
Temperature management plan
Review Specialty Specific concerns
Planned procedure
Site and side
Estimated duration
Positioning
Estimated blood loss/Blood availability
Critical steps/potential pitfalls
Special requests (x ray, product representative)
Concerns
Completed after completion of the first
count and before the patient leaves the
room, ideally with attending surgeon
present
Confirm procedure name
Verify specimen(s)
Wound classification
Confirm estimated blood loss
Counts correct or is an x ray required
Photos/videos been printed/archived
Plan for catheter/packing/drains including
removal
Verify implants used
Discuss equipment issues
Patient destination (PACU, ICU, etc)
Monitors/special bed needed for transfer
Special needs for destination
Remaining specialty specific concerns
What went right
What went wrong
Concerns
Figure 1. Defining types of group interactions in operating rooms

Crew: A crew refers to a group of people who work together in shared activity toward a
common goal, often in a structured or hierarchical organization.

Team: A team is a group of people linked in a common purpose. Human teams are especially
appropriate for conducting tasks that are high in complexity and have many interdependent
subtasks.

Flash Mob: A flash mob refers to an assembly of individuals who gather quickly in public to
carry out a brief, unusual act, and then quickly disband.

Figure 2 TeamSTEPPS® logo depicting the program’s emphasis on improving leadership,

communication, situation monitoring, and mutual support amongst health care team members.

Reproduced from the Agency for Healthcare Research (AHRQ) with permission.35