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  Why does one team encounter a challenging situation in the operating room and cause harm to a patient, while another team facing the same situation is able to find a different path and safely care for the patient?

  
  
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  We spend most of our time in medical training and practice working on what to do, when to do it, and consider the HOW to only be a matter of technical proficiency.

  
  
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  Safety is an emergent phenomenon occurring within a system at the interface between the provider and the patient, and includes the knowledge, judgment, technical and nontechnical skills of the provider, and the resources available within a situation.

The first checklist designed for aviation was created in 1937 for what became the B-17, after a test pilot’s memory lapse contributed to crash, loss of the aircraft, and his own death. The checklist solved one of the pivotal problems recognized by people working in fields of increasing complexity: humans have limited memory, attention span, and ability to carry out multiple tasks simultaneously. At that time a simple tool such as a checklist had high impact with respect to safety because checklists helped the crews prevent the most common mode of failure: mechanical breakdown of the aircraft. The benefit of checklists was immediately apparent, and checklists became standard operating procedure on commercial aircraft from the 1940s onward. Following the invention of the jet engine, however, mechanical failure became extremely rare, and aviation became so predictably safe that a new type of human error became the dominant mode of failure: humans working—or more precisely—not working together. Checklists fail in health care, just as they fail in aviation, when the team assumes safety because of the mere presence of the checklist, as if the checklist were some sort of talisman conferring its benefits on the team and warding off evil. While an appropriately designed checklist will support the creation of such a high-functioning team, it remains the end user who determines the effectiveness of even the best checklist.

What is the Team’s Function?

We know the better team is more likely to win the game, and the better team gets out of the dangerous surgical case without harm to the patient more often as well. But what is the work such teams actually do? Task completion for any team, irrespective of the specific endeavor, is dependent upon adequate management of two components: complexity outside the control of the team and mishaps generated by the team. The team’s work toward task completion therefore has been conceptualized as threat and error management (TEM).

The basic premise of TEM is that no goal-directed activity goes off without a hitch. No matter what you are trying to accomplish, you (or the team) must deal with events beyond your control. Therefore, the ability to manage threats adequately is essential to maintaining adequate safety margins. Consider a drive home on a winter night after an ice storm. If you happened to know the weather report predicted an ice storm, your awareness of the potential danger might cause you to take any number of protective actions—from not driving with the radio on (closer attention to the road), not using your cruise control (more dangerous on slick roads), driving with both hands on the wheel (better tactile feedback regarding vehicle-road interface), braking earlier and taking corners more slowly, or choosing a route without a steep hill leading to an intersection. These are tactics employed to manage the threat. Ultimately, it is the management of the threat that is most important, because, of course, you cannot control the weather, or where the county highway department decides to plow or salt the roads.

The slightly more difficult part of TEM to accept is the fact that errors or mishaps by members of a team are occurring all the time. (For the past 20 years, aviation has become increasingly adept at TEM, because the industry understands errors will always occur. Consider that in recent studies by the United States commercial airline industry through line observation safety audits, the rate of pilot and air traffic control error is roughly 2 to 3 per hour.) Like it or not, WE CANNOT REFRAIN FROM MAKING SOME ERRORS. This is a fact that medicine, and especially surgery, has resisted for far too long. Managing errors appropriately consists of two elements: detection and mitigation. One of the simplest benefits of a checklist is the detection of error (“oops… forgot to do that…) immediately prompting mitigation (… so I will do it now.”). Just like threats, errors must be managed appropriately given the current situation facing the team.

The final element of the TEM model is the undesired state (US), defined as a situation arising as the result of team error that has known increased potential for a negative outcome (in this case, most likely harm). Similar to threats and errors, undesired states must be identified (the most likely pathway to harm is not being aware you have skated onto thin ice), and mitigated through team action.

TEM revolutionized teamwork training and thinking within the aviation industry for two important reasons. First, it was intuitively understood by the pilots as a clear description of the work they felt they were doing on a regular basis. This allowed them to embrace it so thoroughly that it has become standard training at the beginning of flight training, and is now also taught to air traffic controllers. Second, it allowed for a systematic way to explain and analyze what teams were doing, creating an undeniable link between behavior and risk. One of the more difficult aspects of maintaining safety is our inherent emotional tendency to outcome bias (ie, our interpretation of behavior is dramatically altered based on the outcome of the situation). The harsh reality is much of the behavior that creates risk in the hospital is permitted because the risk is elevated only to a minimal to moderate degree. This provides us with constant feedback that our risky actions are not causing harm, allowing us to falsely conclude they are safe. When something catastrophic happens, leadership and regulatory agencies jump up and down, frequently trying to hang the solo practitioner or the system for an egregious act (often depending on their own personal beliefs), when in fact the practitioner and system were simply performing in their usual manner. This affords practitioners not involved in the event significant psychological distance from the problem, allowing them to paradoxically see their own work as terminally different from the instances where something went wrong.

Partially because of this systemic inertia, we have set the bar far too low for ourselves with respect to safety. Indeed, if you ask most operating room personnel why we use a surgical safety checklist, the overwhelming answer will have something to do with “so we do the correct surgery on the correct patient.” This is a true but woefully inadequate idea. We use the surgical safety checklist because we need to be better prepared to manage the threats that we will encounter, the errors we will make, and the risk we will create. Managing risk in health care begins with good threat and error management executed by a high-functioning team.

Knowing what the team must do, we now turn to how the team members accomplish it. Teamwork—whether we call it crew resource management (the aviation name), TeamSTEPPS (the AHRQ name for the healthcare version of the same behaviors), or “nontechnical skills”—is nothing more than a toolbox we thoughtfully draw from to best manage threats, errors, and undesired states. TEM is therefore WHAT we do and TeamSTEPPS is HOW we do it. Teamwork skills can be thought of as analogous to the trays delivered to us from central sterile supply department for a case; they are not all necessary in every case, but instead give us what we are most likely to require in a given situation. Carrying that analogy further, during a case, what we may need to do is protect a structure near the area where we are working, and how we do that is to place a retractor and have an assistant gently move the tissue out of the field. Specific tools are therefore useful for specific actions. In that context, what are the specific teamwork behaviors most suited to effective management of threats, errors, and undesired states? These skills can be loosely conceptualized as relevant to one of four domains: team climate, planning, execution, and review/modify. See Figure 4.1.

The high-functioning team requires two things at all times: open lines of communication and an accurate shared mental model of the current state of affairs. Let’s now consider team climate, planning, and execution in terms of how they relate to those needs.

Establishment of the team and the climate within which the team operates is crucial for maximal team function. Human factors psychologists can predict with 95% certainty which teams will fail at simulator exercises within the first 3 minutes of work simply by analyzing the teams’ interactions. Whether we appreciate it or not, the surgeon establishes the communication environment in the room—for better or worse—within seconds of entering the room. Using an appropriately designed checklist can facilitate effective communication at the start of a case. Much of it, however, is basic human decency such as:

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  Learning team members’ names and using them often

  
  
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  Asking a personal question (eg, How was your weekend? How has your family been?)

  
  
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  Making eye contact when speaking with team members

Captain Chesley Sullenberger (made famous for piloting the US Airways “Miracle on the Hudson” landing in 2009) understood this well, as he describes in his book:

Threat management begins with planning. Because the ideal team is maintaining a shared mental model (considered team situational awareness), planning is best done as a team in a briefing prior to start. This is the time when checklists are probably the most useful because they free us from the need to remember what to review in a given situation. Effective use of a team briefing, regardless of whether or not a checklist is used, always includes the following:

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  Introduction of all team members

  
  
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  Clear statement of goals

  
  
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  Review of critical steps/progress measures, and assignment of roles and responsibilities

  
  
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  Statement of possible complications and review of contingency plans

  
  
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  Time for the team to ask clarifying questions