Dr. Pronovost ([email protected]) is senior vice president for patient safety and quality at Johns Hopkins Medicine in Baltimore, Md. He authored the book Safe Patients, Smart Hospitals: How One Doctor's Checklist Can Help Us Change Health Care from the Inside Out.

What's the top safety challenge surgical facilities must address?
It's still teamwork and communication. The OR is a fast-paced, high turnover environment with hazards all around. Being mindful of those risks and having effective teamwork in place to mitigate them are critical.

How can surgical professionals work better as a team?
They need to treat patients emphatically and they need to treat their colleagues respectfully. If they don't work in a culture of respect, staff members might see risk, but they won't speak up about it. OR teams have to get to know caregivers in pre-op and PACU. They often have a myopic view of teamwork, which they think involves only the people who work in the OR. In reality, they're working in a team of teams.

What is a "culture of safety"
and what does it mean in the OR?
It means the organization and all the people in it prioritize patient safety. They're constantly looking for things that could go wrong. There's an infrastructure that lets clinicians do their jobs. That sounds simple, but many ORs don't have the equipment or staff training needed to protect patients. Facilities with strong safety cultures have those things in place.

"Never events" continue to happen. Why?
Sadly, though we try, it's hard to get to zero bad events. That doesn't mean we can't do better. Too often the lessons we've borrowed from safe industries have been superficial and siloed. Surgery borrowed teamwork training from aviation, but unlike pilots, who have to pass a competency in teamwork to fly, surgeons and nurses can work in the OR with no such training. We took the concept, but didn't follow through on the execution.

Can improvement to surgical technology also improve patient safety?
It should. But safety is largely based on the heroism of clinicians rather than the design of safe systems. Vendors often develop technology with very little clinical input and tell doctors and nurses to use it. Other industries do a better job of co-developing technologies with users, so the tools serve their needs.

What can OR teams learn from near-misses and adverse events?
Clinical teams are great at recovering from mistakes, but poor at learning from them. They don't have the time or ability to pause and reflect on what drove the error and design systems that prevent it from happening again. Production pressure prevents that from happening. Blame and fear certainly do, too. We can't work in a culture that doesn't allow mistakes to be openly discussed and addressed.