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Good Catch in the Operating Room

John Day and John T. Paige, MD | May 1, 2019
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The Case

A 46-year-old woman with extensive history of back pain from lumbar stenosis was scheduled for an elective laminectomy and spinal fusion. The procedure initially started well and the surgeon followed his expected operative plan. About halfway through the procedure, the anesthesiologist noticed that the patient's blood pressure was dropping, and she alerted the surgeon. Since the surgeon did not notice excessive bleeding, he initially continued with the procedure. The anesthesiologist administered a bolus of intravenous fluids, but over the next few minutes the patient's blood pressure continued to drop.

The anesthesiologist was very concerned about the patient and said to the surgeon, "I think we have an unsafe situation. I can't explain her hypotension. Are you sure she isn't bleeding? We should stop the procedure and figure out what's wrong." Although the surgeon was surprised by the anesthesiologist's forcefulness, he recognized her concern, stopped the procedure, and began searching for a source of bleeding. He quickly realized that the blade of the laminectomy tool was damaged and a fragment was missing, raising concern that a blood vessel may have been damaged. A vascular surgeon was urgently consulted. Upon exploration, the team realized that the damaged blade had torn the patient's iliac artery, and she was hemorrhaging into her pelvis. The patient required transfusion of multiple units of blood, and fortunately the injury was repaired before more serious consequences occurred. The patient required care in the intensive care unit postoperatively, but she recovered and was discharged home in good condition several days later.

The Commentary

Commentary by John Day and John T. Paige, MD

In this case, clear communication in the operating room (OR) prevented serious harm. Effective teamwork in high-risk environments such as the OR relies on clear, concise, and comprehensible communication among members of the clinical care team. Its absence can quickly lead to misunderstandings, failed directives, and disruptions in workflow that negatively impact team function and, as a result, patient outcomes.(1-3) A variety of barriers to effective communication exist in an OR, such as hierarchies, distractions, and environmental impediments.(4) Overcoming these barriers can foster frank communication across disciplines, professions, and hierarchies, which prevented a catastrophic outcome in the case example above.

High reliability organizations (HROs) prioritize safety, emphasizing consistent performance with reliable outcomes in unforgiving environments (5) and a high degree of mindfulness and communication throughout the organization.(6-8) Promoting a culture of safety, HROs maintain their vigilance and consistency using two broad types of interventions: systems-based engineering and people-focused approaches.(9,10) Concise, structured communication is essential in this process of identifying, trapping, and mitigating hazards and threats within the practice environment.

Strategies for improving communication often focus on enhancing teamwork and team interaction to ensure safety issues are recognized, announced, and treated by the team in a timely fashion, as occurred in this case. Such strategies, like many others in patient safety, were originally developed outside health care—largely in the commercial aviation industry. They constitute what is known as crew resource management (CRM). Today, variants of the original CRM team training program exist throughout the aviation industry, with many of them containing components germane to health care teams (Table).(11)

The Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) program for health care teams (12) has several effective communication tools to help prevent adverse events, including the CUS Tool and the Two-Challenge Rule. An acronym for key expressions containing code words signaling a potential urgent safety problem, the CUS Tool allows a team member to express concern regarding a perceived situation that might harm a patient. Thus, when a team hears one of its members say "I am Concerned," "I am Uncomfortable," or "This is a Safety issue," it indicates that the member wants to "stop the line" to address a problem. In this case, the anesthesiologist used the expression "I think we have an unsafe situation" as her CUS.

The Two-Challenge Rule is a communication strategy designed to ensure that a concern is properly emphasized. Its framework requires the individual harboring the safety concern to voice it to the appropriate person at least two times. The concern should be stated in an assertive manner, and the team member being challenged must acknowledge it. In this case, the first challenge occurred when the anesthesiologist alerted the surgeon during the initial drop in blood pressure. The second challenge was her use of a CUS word to focus the surgeon on the persistent hypotension of the patient.

Both the CUS Tool and the Two-Challenge Rule are communication tools to empower individual team members to advocate for the patient by escalating their assertiveness. To be effective, an assertive statement must be respectful and supportive of authority, nonthreatening, clear in its concerns and suggestions, and relay critical information. TeamSTEPPS proposes a five-step process for making an assertive statement, which the anesthesiologist did on her second challenge containing the CUS word. First, she opened the discussion with her CUS statement. Second, she stated her concern that she could not determine the cause of the patient's hypotension. Third, she stated what she felt was the perceived problem of unrecognized hemorrhage. Fourth, she offered her solution by suggesting to stop the procedure and figure out the problem. Finally, through her use of the CUS expression and clear articulation of her concerns, she obtained agreement from the surgeon to stop and determine the nature of the problem. If she had failed to get the surgeon to agree to stop, her next option would be to escalate her concerns up the ladder of authority to get the issue addressed.

Training OR teams in elements of effective communication and coordination requires the presence of an OR team and time to train. Training could constitute a team simply going through "what if" scenarios between cases. Additionally, it could involve an OR team engaging in high-fidelity simulation-based training. For this case, the OR team discussing what would need to be done in the case of a massive loss of blood would allow a mental rehearsal to prepare them for the situation described.

Finally, a systems-based approach to prevent the adverse event in this case would focus on the technology used in addition to the team performance. This solution would involve designing the laminectomy tool to stop working or to alarm if the blade fractured. In such a situation, the entire team would know that something had happened to the blade, allowing them to realize it might be responsible for the hypotensive event occurring shortly after it breaking. This change in the saw design would have a broader reach, since it would serve as a safety intervention wherever the saw is utilized.

Training OR teams in CRM techniques and communication strategies in both classroom- and simulation-based sessions has been demonstrated to be effective.(13,14) At the Veterans Health Administration, the widespread implementation of a medical team training program has resulted in several improvements: (i) a decrease in surgical morbidity and annual mortality; (ii) a reduction in hospital-acquired conditions; (iii) a decrease in OR delays; and (iv) an improvement on safety climate.(15,16) Work in Sweden has demonstrated that a comprehensive CRM training program targeting a large pediatric surgical service had a positive effect on safety climate, technical and nontechnical skills, and surgical outcomes over several years.(17) Teaching CRM using point-of-care simulation-based training also increased perceived safety, teamwork, and the overall safety climate.(18) Using checklists in the perioperative setting has also been demonstrated to enhance communication and teamwork and improve surgical outcomes by decreasing complications and mortality.(19,20)


Health care systems should strive to promote a culture consistent with a high reliability organization. Individuals can help by learning and using effective communication strategies such as the CUS Tool and the Two-Challenge Rule. In addition, they can participate in team training exercises to hone their own teamwork skills. Finally, they can adopt effective practices such as using preoperative checklists to help identify potential problems before a case in order to develop effective contingency plans. In summary, frank, effective communication among members of an OR team does not develop on its own. Instead, it must be fostered through team training; adopting structured, standardized communication strategies; and promoting a culture of mindfulness and safety in the organization.

Take-Home Points

  • The CUS Tool can help alert other team members to a safety problem and should prompt the stoppage of all other activity to focus on it.
  • The Two-Challenge Rule can empower team members to advocate on behalf of the patient by giving them a structured format for asserting themselves.
  • High reliability organizations promote mindfulness throughout their structures to help identify, trap, and mitigate potential problems.

John Day
Medical Student
LSU Health New Orleans School of Medicine
New Orleans, LA

John T. Paige, MD
Professor of Clinical Surgery
Director of Wound Care
LSU Health New Orleans Health Sciences Center
School of Medicine
Department of Surgery
New Orleans, LA


1. Gillespie BM, Harbeck E, Kang E, Steel C, Fairweather N, Chaboyer W. Correlates of non-technical skills in surgery: a prospective study. BMJ Open. 2017;7:e014480. [go to PubMed]

2. Wheelock A, Suliman A, Wharton R, et al. The impact of operating room distractions on stress, workload, and teamwork. Ann Surg. 2015;261:1079-1084. [go to PubMed]

3. Villafranca A, Hamlin C, Enns S, Jacobsohn E. Disruptive behaviour in the perioperative setting: a contemporary review. Can J Anaesth. 2017;64:128-140. [go to PubMed]

4. Guttman OT, Lazzara EH, Keebler JR, Webster KL, Gisick LM, Baker AL. Dissecting communication barriers in healthcare: a path to enhancing communication resiliency, reliability, and patient safety. J Patient Saf. 2018 Nov 9; [Epub ahead of print]. [go to PubMed]

5. Sanchez JA, Barach PR. High reliability organizations and surgical microsystems: re-engineering surgical care. Surg Clin N Am. 2012;92:1-14. [go to PubMed]

6. Weick KE, Sutcliffe KM. Managing the Unexpected: Assuring High Performance in an Age of Complexity. San Francisco, CA: Jossey-Bass; 2001. IBSN: 9780787956271.

7. Bleakley A. You are who I say you are: the rhetorical construction of identity in the operating theatre. J Workplace Learn. 2006;18:414-425. [Available at]

8. Cooper JB. Critical role of the surgeon–anesthesiologist relationship for patient safety. J Am Coll Surg. 2018;227:382-386. [go to PubMed]

9. Tsao K, Browne M. Culture of safety: a foundation for patient care. Semin Pediatr Surg. 2015;24:283-287. [go to PubMed]

10. Cafazzo JA, St-Cyr O. From discovery to design: the evolution of human factors in healthcare. Healthc Q. 2012;15:24-29. [Available at]

11. Commander's Aviation Training and Standardization Program. August 2016. TC 3-04.11

12. TeamSTEPPS: Strategies and Tools to Enhance Performance and Patient Safety. Washington, DC: Department of Defense. Rockville, MD: Agency for Healthcare Research and Quality; 2016. [Available at]

13. Chan CKW, So HK, Ng WY, et al. Does classroom-based crew resource management training have an effect on attitudes between doctors and nurses? Int J Med Educ. 2016;7:109-114. [go to PubMed]

14. Robertson JM, Dias RD, Yule S, Smink DS. Operating room team training with simulation: a systematic review. J Laparoendosc Adv Surg Tech A. 2017;27:475-480. [go to PubMed]

15. Carpenter JE, Bagian JP, Snider RG, Jeray KJ. Medical team training improves team performance: AOA critical issues. J Bone Joint Surg Am. 2017;99:1604-1610. [go to PubMed]

16. Schwartz ME, Welsh DE, Paull DE, et al. The effects of crew resource management on teamwork and safety climate at Veterans Health Administration facilities. J Healthc Risk Manag. 2018;38:17-37. [go to PubMed]

17. Savage C, Gaffney FA, Hussain-Alkhateeb L, et al. Safer paediatric surgical teams: a 5-year evaluation of crew resource management implementation and outcomes. Int J Qual Health Care. 2017;29:853-860. [go to PubMed]

18. Hinde T, Gale T, Anderson I, Roberts M, Sice P. A study to assess the influence of interprofessional point of care simulation training on safety culture in the operating theatre environment of a university teaching hospital. J Interprof Care. 2016;30:251-253. [go to PubMed]

19. Pugel AE, Simianu VV, Flum DR, Patchen Dellinger E. Use of the surgical safety checklist to improve communication and reduce complications. J Infect Public Health. 2015;8:219-225. [go to PubMed]

20. Haynes AB, Edmondson L, Lipsitz SR, et al. Mortality trends after a voluntary checklist-based surgical safety collaborative. Ann Surg. 2017;266:923-929. [go to PubMed]


Table. Crew Coordination Elements Pertinent to Health Care.(11)
Communicate positively Sender directs, requests, announces, or offers. Receiver acknowledges, and sender confirms or corrects the action. Communication should be quick and clear, using specific, explicit vocabulary to maximize efficiency.
Direct assistance During times of task saturation or overly intense periods of concentration, the team members will direct assistance to prevent errors and cross load work.
Announce actions For well-coordinated actions, all members must be aware of expected movements and unexpected individual actions. Each member will announce any action that affects other team members.
Offer assistance Any member should offer assistance in the instance that another team member deviates from normal or expected actions, if information or action is requested, or upon recognizing anything that poses a hazard to the operation.
Acknowledge actions Team members should include supportive feedback to ensure correct understanding. Such understanding is conveyed by repeating critical parts of the message.
Be explicit Team members should use clear terms and phrases that cannot be misconstrued. They should avoid terms that have multiple meanings or indefinite modifiers.
Provide obstacle advisories Although the leader of the team directs actions, it is the responsibility of all team members to identify and help avoid hazards. A team member should never assume that other members have noticed the same thing.
Coordinate action sequence and timing Each team member should ensure that his/her actions mesh with the actions of the other members to successfully execute a task or mission.
This project was funded under contract number 75Q80119C00004 from the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services. The authors are solely responsible for this report’s contents, findings, and conclusions, which do not necessarily represent the views of AHRQ. Readers should not interpret any statement in this report as an official position of AHRQ or of the U.S. Department of Health and Human Services. None of the authors has any affiliation or financial involvement that conflicts with the material presented in this report. View AHRQ Disclaimers
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