Operating Room Scene

Patient Safety Scenario: Leadership Prevails Within the OR

This essay was originally published by the American Society for Surgery of the Hand (ASSH) in the January 2019 issue of ASSH Perspectives newsletter, this article was authored by David Nelson, MD, as chair of the Patient Safety Subcommittee, a subcommittee of the ASSH Ethics and Professionalism Committee.


A patient was involved in a motor vehicle accident at night and sustained a grade II open radius/ulna fracture and in addition complained of numbness in the median nerve distribution. Due to the nature of the open fracture and the degree of numbness, the decision was made to proceed that night with surgical intervention, to consist of ORIF of the radius and the ulna, as well as decompression of the median nerve at the wrist.

The patient was brought to the OR and underwent anesthesia. The time-out was performed in the normal manner by the circulator with the team participating. Because of the issues associated with the patient’s injuries and the surgical timing, there was a lot of activity and the typical “chaos” associated with an open fracture and a surgical case done urgently in “the middle of the night.”

The surgeon started the case, and only after making incision and preparing for fixation, discovered that the wrong instrument set had been brought in the room. Subsequently, the proper set was brought to the OR and opened, only for the team to then discover that the desired plate was missing from the set. Another set was procured and opened.

The fractures were properly fixed. However, there was more than the expected amount of soft tissue swelling, which created problems closing the wounds. Nevertheless, with care and persistence, the skin was finally closed. The final check films showed a great reduction of both the radius and the ulna fracture, and the surgeon was glad the case was finally and successfully completed, despite the challenges associated with the “off hours” urgent case, a different OR team than his usual team, the delays, the soft-tissue swelling, and the equipment problems.

A dressing and splint were applied, the patient’s anesthesia reversed, and he was brought to the recovery room.

It was not until the patient was in the recovery room that the surgeon realized that he had forgotten to decompress the median nerve.


It is quite likely that all of us have experienced the equivalent of the previously described made-up scenario, although hopefully not all in the same case. While it is normal to blame the OR staff for the problems encountered, it is more helpful if the surgeon asks themselves, “What leadership role do I play in this situation and what can I do differently in such scenarios to prevent some of these issues in the future?”

The term crew resource management (CRM) traces its beginning to a 1979 NASA workshop titled “Resource Management on the Flight Deck.” It was based on NASA research into the causes of accidents in aviation. They identified human error, not mechanical error, as the primary factor in many accidents. The aviation industry was quick to adopt the concepts advocated at this workshop, with United Airlines initiating a comprehensive CRM program for all pilots two years later, in 1981. Most airlines developed their own CRM training programs over the next few years. The Federal Aviation Administration made it optional in 1990, and it became the global standard within the decade. CRM is now in its fifth generation of development and is considered a mainstay of all high-reliability organizations.

CRM has been seen as widely applicable to the medical environment, but we have been very slow to adopt it.

All humans make errors. Any system that involves humans and expects that no human will make an error is doomed from the beginning to fail. Systems with humans need to be designed to account for human error, indeed, to expect human error, and to prevent the error from affecting the mission, or in terms of the OR, to prevent the error from affecting the patient. One common example of a system that is designed to account for failure is a fuse: Most circuits are designed with a fuse, which breaks the circuit when overloaded, preventing the entire circuit from being destroyed. The OR environment is subject to the same dictum that humans make errors and needs to have systems that catch human error. CRM is one modality that has been employed to help limit human error from causing aviation accidents and OR disasters.

The primary goal of CRM is enhanced situational awareness, self-awareness, leadership, assertiveness, decision making, flexibility, adaptability, event and mission analysis, and communication. This article examines CRM in the OR—in particular, the role of leadership in the OR. A future article will examine the role of communication.

Leadership in the OR

Surgeons have been taught that their job is to do the surgery, and everyone else’s job is to support the surgeon. While this may seem reasonable, in the light of CRM and other experience in teamwork such as leading military missions, it might be better to view the surgeon’s job as to perform the surgery while leading the team, and everyone else’s job is to support the goal of the team, which is the successful surgery. That is, they support the mission of the team, not the surgeon. This focuses the surgery on the patient, not on the surgeon. The reductio ad absurdum case makes the point: If the surgeon should die mid-case, should the team stop working, or should they continue the mission by searching for a substitute surgeon? If the team focuses on the surgery, they are more likely to assume more responsibility for their portion of the procedure. In this light, the surgeon’s job is then seen as the team leader. This makes leadership skills important. Let’s look at a few aspects of surgery and see why leadership is important.

Many ORs have nurses running the time-outs, but in light of CRM, the surgeon is probably a better person to lead the time-out. Only the surgeon really knows the surgery that has been scheduled and should therefore be the person leading the time-out. For instance, few OR team personnel know the difference between, say, a surgery on the carpal tunnel or the cubital tunnel or the radial tunnel. The surgeon, therefore, should assume the role of leader of the team and lead the time-out. As team leader, the surgeon should brief the team on the nature of the surgery, especially if it is other than a routine surgery that the team does regularly or if there is anything special about this particular surgery. The surgeon leading the time-out also shows that he or she values the time-out and ensures that the entire team takes it seriously. If the surgeon does not take the time-out seriously, no one else will either.

The surgeon, as the team leader, needs to verify that the team is ready to start the surgery. This means verifying and marking the side and site before the patient enters the OR, checking that the equipment needed is available in the room, and ensuring that the team members know what is likely to be required of them during the case (e.g., an extra change of gown and gloves after initial debridement in a contaminated case). This will save the team from unnecessary Brownian motion during the case, so that they are available in the room for the surgery. As the team leader, the surgeon should also lead the debriefing: The surgeon needs to analyze the performance of the team and offer suggestions. Although it may seem radical, in keeping with the team spirit, the surgeon should also solicit and listen to any suggestions that the team makes during the debriefing, including how the surgeon could improve in communicating to the team what to expect. In the U.S. Air Force, the leader of a squadron of jet fighters is expected to solicit and openly listen to the suggestions of his or her squadron during their mission debriefing; we can do no less in the OR. In this scenario, a proper debriefing would have prevented the error.

In the scenario previously described, the surgeon did not forget to release the median nerve; rather, the team forgot. It was a team error, not an individual error. The team’s goal is supporting the surgery, not the surgeon. It is a team error because each team member in the OR has a responsibility to ensure a successful surgery, which includes an active participation in the time-out and the debriefing.

The surgeon, as the leader of the team, should, during the time-out, mention all three procedures (ORIF of radius fracture, ORIF of ulna fracture, decompression of median nerve). It would be wise for the surgeon to recognize in advance that in cases with multiple procedures, it is easy to overlook one of the procedures. A strong team leader should mention during the time-out anything that they think might be a challenge to the successful completion of the surgery. In this case, omitting the third procedure (nerve decompression) was a risk, and the surgeon should encourage the team to be vigilant that all three were performed. A debriefing, prior to breaking scrub, would catch the omitted procedure. As a team leader, the surgeon should also encourage all team members to be active, not passive, participants in the surgery and to speak up if they feel uncomfortable about any aspect of the surgery.

The principles of aviation CRM state that a senior captain who is working with a junior first officer for the first time should directly request the junior officer to speak up if they have any feeling that a safety issue is occurring. You should ask yourself, does my OR team feel empowered to speak up? A strong leader in the OR will encourage the team members to speak up; if you have never openly told this to your team, you should the next time you are in the OR.