OPEN COMMUNICATION A big key in a culture of safety is the time out. But, it's only effective when performed in the right environment.

Before a recent lung biopsy at a Minnesota hospital, everything seemed to be going smoothly. The surgeon initialed the site, the patient gave consent and the physician's notes said a biopsy was to be done on the right lung. But there was a problem. The notes were wrong. In fact, the biopsy was to be done on the left lung.

"The patient mentioned offhand that she thought it was supposed to be the left side, not the right," says Tania Daniels, PT, MBA, vice president of patient safety at the Minnesota Hospital Association. "The surgical nurse heard this and circled back to the original notes from the clinic. She found that the notes from the hospital provider listed the wrong side."

The surgical nurse spoke up and told the physician immediately after discovering the error, ensuring he performed the procedure correctly. The physician was grateful for the nurse's input and thanked her after she spoke up, says Ms. Daniels. He reinforced the hospital's culture of safety, which prevented the wrong-site surgery from occurring.

Easier said than done
Never events, despite their name, still happen. Why? Most patient safety experts agree that the largest single contributing factor in these catastrophes is that the OR lacks a culture of safety in which all staff members feel comfortable and have the knowledge to speak up if something is wrong, says Spence Byrum, CEO and co-founder of HRS Consulting. "You need an environment where the surgical team is on the same page," he says. "They're communicating in an open environment, and when there's something wrong, any member can speak up."

It seems like a simple idea, but it can be tough to implement in practice, the experts say. While this culture is often deeply rooted in high-risk jobs — most notably the airline industry — ingraining these values in the medical community has been more of a struggle. That's particularly true in fast-paced, high-stressed operating rooms, says Mr. Byrum.

CULTURE CHANGE Having surgeons lead the time out — while encouraging staff to speak up during the case — can increase OR safety.

"There are so many complicated factors that keep healthcare workers from doing what other high-risk industries do to promote safety," he says. "I hear it all the time, 'We have so many responsibilities. We just don't have time to build a culture of safety.'

"But you don't have time not to do it," adds Mr. Byrum. "This is a matter of doing what is best for the patient."

The key to any culture of safety is communication. That means that in your facility, no one — from the surgeon to the scheduler — is afraid to speak up if they think something is wrong, says Ms. Daniels. She notes that this simple idea can be incredibly effective in enhancing a facility's overall safety.

Developing this strong safety culture, though, is tough, says Mr. Byrum. While the airline industry standardizes nearly every aspect of its work to enhance overall safety, the healthcare community is a different beast.

"The big problem is the variability associated with each patient," explains Mr. Byrum. "Individual practitioners have different standards and different ways of doing things. They perform time outs differently or use various implants. The same also goes for each individual facility."

This variability can lead to mistakes, especially when you couple it with everyday stresses of the OR such as late start times, fatigue, distractions and quick turnovers.

"Each factor isn't catastrophic in and of itself," says Mr. Byrum. "But when 1 or 2 or 3 are strung together, it becomes a predictor of an adverse event. If everyone is in heads-down mode, they can't look up and see that these things are starting to stack up."

Clear communication
Mr. Byrum says effective communication between your staff members and surgeons is vital to prevent a cascade of errors. That is often difficult, however, thanks to the OR's strict pecking order.

"Surgery has always been hierarchal," says Mr. Byrum. "There's no question about who's in charge and who's executing orders. It's good to have a chain of command, but not if that precludes communication."

To enhance team communication in your OR, proper training is necessary. Just ask Scott Hulbert, MD, senior medical director of surgery at the University of Colorado Health's Memorial Hospital. In 2009, the hospital received a grant that allowed it to provide human factors training — a science that looks at the relationships between human beings as well as the systems they interact with — to surgeons and staff. Training in human factors enhances a team's overall communication skills, increasing efficiency and productivity while minimizing errors, says Dr. Hulbert. That training, he says, went a long way toward developing the hospital's culture of safety.

Finding this type of training isn't hard — there are several organizations that offer specialized courses in human factors for healthcare providers. However, Dr. Hulbert notes that the most difficult part is getting staff and surgeons on board with the changes the training suggests, such as adopting safety checklists.

To make the training more appealing, Memorial Hospital made it voluntary and combined both surgeons and staff into a single group, which Dr. Hulbert says fostered a team approach. "Our philosophy was to get the people who were interested in it and have them start the culture change," he says. "That worked better than mandating it."

Mr. Byrum notes that communication in the OR must mean more than just a passing comment from a circulator, or an observation muttered under a surgical tech's breath. Instead, it requires a specific skill set and communication format that must be honed and practiced.

There are 4 steps to effective communication, explains Mr. Byrum. First, you must get the person's attention and ensure they are listening. Next, you must state the issue or problem clearly and concisely, and after that, offer a solution. Finally, you need to ensure that a decision is reached among the team and that it is implemented.

Those 4 steps sound obvious, he says, but if you miss one step in the process there's a chance the communication won't be effective. For example, if a nurse states she thinks a sponge is at risk of being left in the patient, but doesn't ensure that she got the surgeon's attention and the team doesn't check to guarantee it's been taken out, the speaking up didn't work.

Hold regular drills where staff can practice using the 4 steps to communicate with surgeons and fellow team members, says Mr. Byrum. The more staff follow this communication format, the more comfortable and natural it will be when a real situation arises. "It's one thing to speak up," says Mr. Byrum. "It's another to speak up with comments that are clear and concise and resolve the situation."

Getting surgeons onboard
For a culture of safety to work you also need an OR environment that celebrates and encourages everyone — regardless of position — to share ideas. That's where you must work with your surgeons directly.

Physicians are notoriously resistant to change, says Dr. Hulbert, especially when that change sounds like just another mandate to add to their ever-increasing list of responsibilities. Instead, start your culture change by finding surgeon and anesthesia champions who can serve as peer teachers.

"As you can imagine, physicians — especially these days — are bombarded by stuff being done to them," says Dr. Hulbert. "Adding one more thing they have to do causes resistance, and makes it harder to get the idea implemented. Instead, the champions can show them that the requests are for patient safety."

Also consider giving physician champions specific actions that enhance the overall safety atmosphere in the OR. Ask surgeons to lead the time out, during which they should remind staff that they want them to speak up during the case if they see a problem, suggests Ms. Daniels.

Even small gestures can inspire change. Ms. Daniels says that starting each case with introductions of all the team members — especially important in larger facilities — can reinforce the culture of safety. "It will make staff more comfortable to speak up, since they know who they're working with," she says.

Even if you have physician champions, you're still likely to encounter those unwilling to get on board with the changes. For the docs who scoff at the idea, Mr. Byrum recommends an honest, but tough, talk.

The best way to start this conversation with your logic-driven surgeons is to focus on evidence that shows adopting a culture of safety improves case outcomes, says Mr. Byrum. He notes that research clearly shows that if a team is working well together and feels comfortable speaking up, the risk of adverse events is diminished.

"It's fair for the administrator to help the surgeons understand their role in the process," he says. "They're the ones setting the tone in the OR. The administrator should tell the surgeon, 'Look if you're open and tell staff to speak up during the case, they will. If you don't, or you're adversarial, they will not speak up, or if they do, it will be too late.'"

And while you surely value your physicians' time and effort — and appreciate their role as breadwinners — you can't back down in your quest for a culture of safety, says Mr. Byrum.

"It almost needs to be a condition of employment," he says. "You may be a tremendous surgeon, but if you can't work with your team, eventually a mistake will be made."