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Communication and culture: opportunities for safer surgery
  1. Jennifer P Stevens1,
  2. Selwyn O Rogers2
  1. 1
    Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
  2. 2
    Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts, USA
  1. Dr Selwyn O Rogers, Surgical Critical Care, Department of Surgery, 75 Francis Street, Brigham and Women’s Hospital, Boston, MA 02115, USA; srogers{at}

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The Institute of Medicine’s report in 1999 To Err is Human estimated that 44 000 to 98 000 deaths occur due to preventable medical errors every year in the USA. These startling numbers thrust patient safety and medical error into the spotlight of public discourse and professional debate.1 The field of surgery has responded by positioning to lead process and outcomes improvement in the operating theatre and critical care settings. In the US, the adoption of the National Surgery Quality Improvement Project from the Veterans Administration by the American College of Surgeons (ACS) has led to a reduction in 30-day mortality by nearly one-third and 30-day morbidity by nearly two-fifths in the initial cohort of participating hospitals.2 The Surgical Care Improvement Project, a collaboration between the US Centers for Medicare and Medicaid Services, the ACS, the American Hospital Association and others, has set its goal to reduce surgical complications by one-quarter by the year 2010.3

In spite of these initiatives, there remains a gap in safe and effective communication in the operating room and in the surgical intensive care unit. Communication failures frequently are engendered by status asymmetry and high-tension situations.45 In the face of communication failure, many staff members turn to process work-arounds, which may solve the immediate problem but fail to improve the system.6 Quick fixes should no longer be acceptable to staff confronting safety and quality failures within their own hospital microsystems, such as operating theatres or surgical intensive care units (SICU). This calls for higher-order problem solving to eliminate the system failure entirely.6 Moreover, while significant improvement gains may be made with process design, communication improvement for patient safety requires a culture redesign. This is a paradigm shift away from the personalities and politics of small insular systems to a highly reliable, nimble and safe setting that a SICU or operating theatre should be.


Poor communication has profound implications for patient safety and mortality. One discussion of malpractice claims noted that nearly three-quarters of the claims involved at least one communication failure with several factors promoting these communication breakdowns. The majority of these communication failures involved “status asymmetry,” according to the authors, or a breakdown that was between two individuals with unequal power.5 In the current issue,7 McCulloch et al note the entrenched asymmetry in the operating room (see page 109). Lingard and colleagues found that events designated as “high tension” apparently caused surgical trainees to either withdraw from communication entirely or mimic the senior surgeon.8 In another observational study, Lingard found miscommunication up to one-third of the time in the OR with a third of these miscommunications leading to problems such as delay, work around, increased tension, resource waste or patient inconvenience.4

Despite the frequent observation of status asymmetry and limited communication, many actors misperceive their ability to communicate in an operating room or intensive care unit setting. Makary and colleagues noted that while 85% of surgeons ranked the communication skills of their surgical colleagues in the operating room as high, nurses ranked surgeons high only 48% of the time.9 Thomas et al found similar results when they surveyed ICU nurses and physicians. While nearly three-quarters of physicians thought physician-to-nurse communication was good, only a third of nurses believed communication with physicians was effective.10

McCulloch and colleagues note a similar challenge to improving communication among surgical colleagues.7 Turning to the high-performance field of airline safety, they instituted a Crew Resource Management programme among surgical staff to promote safety and communication with dramatic improvement in technical performance. Nevertheless, despite a formal change strategy that explicitly permitted safety-related challenging of dangerous behaviour in the operating theatre, professional staff found the culture shift difficult.

Rigorous studies around communication interventions and improvement in outcomes such as that of McCulloch and associates are uncommon. Wheelan et al noted that ICUs with staff who perceived their teams as functioning effectively and in a more advanced stage of group development had lower rates of patient mortality.11 Baggs et al noted that nurses’ perception of good communication among team members correlated with positive patient outcomes in the ICU across three ICUs in New York State.12 Haynes and colleagues reported the use of a surgical checklist demonstrating that formalising basic communication strategies are associated with a reduction in mortality and inpatient complications.13


Tucker and Edmondson describe first- and second-order problem solving and hospital staff’s reliance on the former.6 First-order problem solving involves solving the problem as it presents itself, traditionally with heavy emphasis on work-arounds. An example of this might be a nurse who finds the surgical intensive care unit low on gauze simply leaving the floor to get some from another unit, thereby solving her immediate challenge but failing to truly solve the problem. There are no long-term solutions here; only the risk of future burnout by staff. Second-order problem solving leads to system change and eliminating the need for work-arounds in the first place. Moving to second-order problem-solving requires, for example, improved communication among team members, a safe environment in which to discuss errors and problems, and a reliable, predictable way for the unit or operating room to function as a team. Further, it requires the elimination of first-order solutions as acceptable to the community and the elimination of local politics and traditions.

Our hospital instituted a strategy employed by air transport to improve communication within our surgical ICUs to make first-order problem solving around safety issues unacceptable. It explicitly designates language to be used by any member of the care team to non-judgementally identify risky behaviour. At United Airlines, the system is called the CUS system and the designated words are first “I’m Concerned,” then if there is no response, “I’m Uncomfortable this is Unsafe,” and finally “I’m Scared.”14 We use similar words to designate an action or intention that any member of the care team feels is dangerous. The intent of the programme, still under evaluation, is to change the culture of the SICUs to mandate individual responsibility for safety and quality, and to eliminate problematic communication across different levels of resident trainees, nurses and senior surgeons.

The critical care unit and operating room must continue to learn from other high-stakes professions to adapt to the professional and patient demands for constant improvement. In this regard, we advocate the following central aims to enhance patient safety in critical care and surgical settings. First, redefine local culture to make challenges to errors acceptable. Properly implemented, this does not result in degradation of the appropriate responsibility and authority. Instead, we recommend, as McCullouch’s report demonstrates, modification of culture so that challenging authority for purposes of safety is acceptable. Second, foster intolerance of both work-arounds and first-order problem solving. This requires in particular that surgical leadership expects that second-order problem solving becomes the norm.


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  • Competing interests: None.

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