High-reliability organizations with extremely low error rates do things by the book. Same way, every time: That's their hallmark. There's no coloring outside the lines on aircraft carrier flight decks and at nuclear power plants.

Then there's surgery, where it's strangely acceptable — even encouraged — to do things by the seat of your scrubs. Autograph your work any which way you like. But there is danger in being a maverick.

Take, for example, the time out. When did your last best chance to prevent catastrophic errors become an improvised skit, where the roles and the lines can change on a daily basis?

We've got the online poll results to prove it. When do you take the time out? Well, it varies. Sometimes before the patient is prepped and draped, sometimes after. Who leads the time out? That varies, too. Most times, it's the circulator, but sometimes it's the surgeon.

"Conducting time outs superficially is like playing Russian roulette," says Spence Byrum, a safety and process improvement expert.

How do you mark the surgical site? That's another practice with perhaps too much variability and not enough reliability. According to polls we've conducted, everything from "yes" to the surgeon's initials to an "x" to an arrow to a checkmark are OK.

When we asked who starts pre-op antibiotics in your facility, the poll results were like an uncertain shoulder shrug: anesthesia 59% of the time, pre-op nurse 41% of the time.

Do you have a policy prohibiting cell phones in the OR? Another tossup: 40% do, 42% don't and 18% are thinking about enacting one.

We asked about prewarming patients who are at risk of unplanned hypothermia before induction of anesthesia. You guessed it: Responses were all over the board — always (46%), sometimes (26%), rarely (10%), never (18%).

AORN says that nail polish that is unchipped may be worn by staff in the operating room. Studies have demonstrated that nail polish begins to harbor microorganisms when it is chipped or worn for more than 4 days. Artificial nails (defined as any fingernail enhancement, resin bonding, extension, tip, gel or acrylic treatment) should not be worn in the perioperative environment, says AORN. Studies have shown higher microbial counts under artificial nails than under natural nails before and after hand washing. When we asked if nail polish and gel nail finishes are allowed in your surgical suite, 46% said nail polish is OK, artificial nails are not, 36% said both are forbidden and 14% said either is fine.

Maybe it's asking too much of community-based hospitals and physician-owned surgical centers to be predictable, high-reliability organizations. To practice, as Atul Gawande, MD, puts it, "large-scale, production-line medicine?" But wherever possible, for the sake of the quality and the safety of your care, get your surgeons and staff to agree on precise standards of care and figure out how to standardize it.