The importance of teamwork in the operating rooms

Patient safety has become an essential component in quality healthcare. The complexity of surgical interventions demands increasing technical skills. The human being may err and scientific training is not enough to ensure the desired outcomes; hence, there is a need to develop non-technical skills such as teamwork capabilities. In a recent editorial in this same journal, emphasis was placed on the importance of simulation as part of the anesthetist training for developing experience and proper attitudes to solve problems during a crisis, for developing leadership abilities and above all, to be a team player.¹

Approximately 50% of hospital errors occur in the OR or in the Resuscitation suites.² Most of them are due to poor communication.³ In order to improve teamwork, simulation, standardization of information, specific training and adequate role definition are required. Airline accidents evidencing human error are also associated with poor communications. This is why the obligatory Crew Resource Management program was developed in the United States since 1995. This program is based on the fact that in addition to technical training, good coordination is required to prevent human errors.⁴ Crew briefings prior to takeoff favor communications. The best example of using “briefings” in the OR is the surgical checklist. The first two phases, “sign-in” and “time-out” must be completed before the surgical procedure begins.⁵ The WHO surgical checklist has proven to reduce perioperative morbidity and mortality, with particular impact on laterality errors, wrongful identification, antibiotic prophylaxis, preoperative evaluation check, and the need for blood by-products. Promoting teamwork in the operating theater has been associated with lower mortality according to other publications.⁶

Working as a team requires sharing common goals and specific roles for each team member. The OR environment is a good example. However, training in this area has not been traditionally encouraged. A positive attitude towards other team members, sound communications, leadership, understanding and learning about the different roles, ability to assist, feedback to learn, and finally coordination, are all needed. Many actions are undertaken in the OR without express orders given; however, in the light of complications, being more explicit is best when dealing with unusual circumstances.

An interesting paper is published in this issue, entitled “Effectiveness of a program for improving teamwork in the Operating Room”.⁷ This study is a valuable tool to train the OR staff in non-technical skills and to assess the impact of such training.

To train the staff, a program including the following items is used: 4 h training workshops, five on-line modules uploaded to a Moodle^® platform and timeout training; initial informative meetings or Briefings and Debriefings. Furthermore, some meetings were held aimed at getting the commitment of the institution with the change process and with strategies for maintaining the improvement processes in the long term.

The topics discussed during the training workshops included: systems model for patient safety, teamwork, non-technical skills (communication, cooperation, coordination, leadership and situational awareness), timeout and effective WHO checklist utilization. The on-line information covers the same topics.

With regards to teamwork evaluation, the OTAS-S tool was used before and after the intervention, in its validated Spanish version “Observational teamwork assessment for surgery”.⁸ The OTAS-S measures five dimensions of teamwork: communication, coordination, cooperation/support, leadership and supervision/situational awareness.

What's interesting about this trial is first how the training is accomplished, and second the wise selection of the evaluation tool, specifically designed to assess teamwork in the operating room and validated in its Spanish translation. The Spanish manual of this tool is available at the “Imperial College London” Webpage.⁹ The study has a few limitations – as the authors themselves acknowledge – such as: a quasi-experimental method, one single center, non-controlled, in addition to the fact that it is a short-term trial. However, it paves the way with regards to team training and evaluation.

The medical practice is changing; technical skills must go hand in hand with proper teamwork. Hospitals will be evaluated not just in terms of production, but also in terms of quality and outcomes. This means that other aspects or indicators begin to be surveyed such as unexpected complications, infection rates or failure to use checklists.

Finally, the patient must be at the core of our activities and patient safety has to be our number one concern. Because of the anesthesiologist's technical training and his/her non-technical skills, including the development of leadership and communication abilities with the OR staff, the anesthesiologist plays a key role in achieving the desired outcomes.

Funding

None.

Conflicts of interest

The author has no conflicts of interest to declare.