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Home / The Bulletin of the Royal College of Surgeons of England / Vol. 105, No. 3

 OPEN ACCESS Discussion  Published Online 30 April 2023    

Human factors in surgery: optimal surgical team proficiency and

decision making
Authors: T Arulampalam and P Barach AUTHORS INFO & AFFILIATIONS

Publication: The Bulletin of the Royal College of Surgeons of England Volume 105, Number 3 https://doi.org/10.1308/rcsbull.2023.45

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Abstract
Why considering human factors is equally important in the progress and development of surgical care teams. 
Abstract

THE ELEPHANT IN THE
ROOM

WHAT ARE HUMAN Healthcare technology has advanced at an exponential rate during the last 30 years but there are still high levels of
FACTORS? 
preventable harm in medical care, leading some to characterise the profession’s approach to care as “primitive,
COMMUNICATION
fragmented, and cavalier”.1 This balance has been changing over the last decade with more transparent reporting 
LEADERSHIP
of adverse events and increasing patient demand for actionable outcomes data after well reported cases in the 
PSYCHOLOGICAL SAFETY
media as well as a change in the mindset of regulators and political commissioners of services.2
CIVILITY 
DISCUSSION Healthcare is finally being looked at as a system that needs all the moving parts to work in harmony. Our patients
CONCLUSIONS are more frail, older, have increased and multiple comorbidities, and may be overweight while the surgery that we
REFERENCES
propose is more radical and physiologically aggressive (albeit performed with minimally invasive techniques).3 The

role of human factors (HF) in healthcare tends to be overlooked compared with specific skills or knowledge

training.

Surgery shares many properties with high technology systems in which performance and outcomes depend on

complex individual, technical and organisational factors and their interactions.4 It relies on a sophisticated

structure where coordinated efforts of multiple individuals working as a team, and high levels of cognitive and

technical performance are necessary.5 This article seeks to define what HF are, and looks at the specific positive

role these factors may play in enhancing patient safety, outcomes and physician wellbeing.

THE ELEPHANT IN THE ROOM

Over the past 20 years, what we know is that 1 in 10 patients are harmed in hospital from poor quality care, leading

to between 5.7 and 8.4 million deaths.2 Fourteen out of every hundred patients are affected by healthcare

associated infections.6 For the estimated 234 million operations carried out each year globally,6 the rate of

complications is 2–3% and 20–40% of healthcare spending is wasted owing to poor quality care.7 At a hospital level,

15% of hospital costs are due to patient harm caused by adverse events.7

The Joint Commission found that the top three root causes of patient harm adverse events are HF, leadership and

communication failings.8 Surgical errors have been identified as wrong-sided or wrong site surgical error in renal,

orthopaedic and thoracic cases.9 Malpositioning of surgical instruments during laparoscopic cholecystectomy is

known to lead to major vascular injury and misdiagnosis of unexpected complications. Errors made by operating

theatre scrub nurses include handing the wrong instruments to surgeons and poor sterilisation of surgical

equipment.10

WHAT ARE HUMAN FACTORS?

HF approaches apply knowledge about human behaviour, motives, abilities, limitations and other characteristics to

gain a complete understanding of improved performance of the team (Figure 1).3 The operating theatre is an

advanced technical ecosystem in which highly trained subspecialists must interact regularly with each other using

sophisticated equipment to best care for patients who may be frail, comorbid or overweight. It has been shown

that surgeons and anaesthetists work under varying and escalating HF constraints11 in complex, technology

infused, rapidly changing, time constrained and stressful work environments, where effective and safe

performance demands expert knowledge, appropriate problem solving strategies, effective communication and

fine motor skills.12

 OPEN IN VIEWER

Figure 1 Human factors considerations (https://research-collective.com/important-human-factors-in-healthcare)

Similar to the surgical field, accidents in the aviation and rail industries are often attributed to human error.13 While

a particular human action or omission may be the immediate cause of an incident, closer analysis usually reveals a

series of events and departures from safe practice, potentially influenced by the working environment and the

wider organisational context. Understanding the characteristics of a safe and highly performing system therefore

requires research on a number of interrelated topics. These include the specific context, the acquisition and

maintenance of individual skills, the role of technology and the impact of working conditions on team

performance. Safety in these organisations is ultimately understood as a characteristic of the system much beyond

the core competences of individual team members – the sum of all its parts and their interactions.14

The HF strategies most likely to be effective are those that “design out” the chance of an error or adverse event

occurring (Figure 2). HF research on team decision making in complex task environments is of extreme relevance

to improving surgical team performance. The operating theatre environment greatly affects and shapes surgical

outcomes. Factors that influence the team’s effectiveness include the performance of individual team members,

the equipment used, established care processes and procedures, the mental models of team members, and any

underlying organisational and cultural factors.15 Action science and ethnography methods have been applied in

surgical care settings to assess the impact of HF on patient and staff outcomes.16 Addressing these complex issues

requires an understanding of key domains of HF science. We will touch on each of these below and summarise a

roadmap for implementing change, which will in itself be challenging.

 OPEN IN VIEWER
Least
effective

a t i on
c
Edu ing
t ra in
and

t i ons
i t i ga
M

i er s
ar r
B

Design
Most
effective

Figure 2 Human factors hierarchy of control and effectiveness levels (From: https://associationofanaesthetists-

publications.onlinelibrary.wiley.com/doi/10.1111/anae.15941)

COMMUNICATION
Effective communication is an essential tenet of good HF practice. Human communication is complex and subtle

with nuances based on culture and background as well as tone of voice, as seen in effective patient handoffs.17 The

environment, context and physical attributes such as hearing contribute to what is heard (and then also what is

understood) by an individual and a group. The rate of major complications after surgery may be anywhere

between 3% and 16% in industrialised countries,6 with communications and teamwork contributing to around 43%

of all surgical failures.18,19

Research has shown that errors in the operating theatre occur within and between teams.20 Errors often result

from a breakdown in coordination and communication between the theatre sub-teams.21 For example, the scrub

nurse and surgeon may fail to synchronise their actions so that blood is not sucked away from the surgical field

quickly enough, obscuring a damaged blood vessel, or the anaesthetist may act unilaterally because they have lost

pace with the progress of the surgical team.9 Unclear and vague instructions from the attending surgeon and

anaesthetist to their assistants (or vice versa) can frequently result in errors (eg failure to administer heparin before

connecting the patient to the cardiopulmonary bypass machine).22 In addition, less than honest and timely

communication between the surgeon and anaesthetist has been found to occur on a regular basis.23

Preoperative planning failures may also have a negative effect on performance in the operating theatre; examples

include poor quality or unavailable test results or patient notes, cross-matching errors in the blood bank and failure

to record known drug allergies or other key patient details.24 Another major source of surgical errors and harm

starts with variable and unreliable hand-off of information and responsibility for a patient from one health

professional to another.25,26 Similarly, faulty communication and lack of follow-through in the intensive care unit

have been identified as critical in the lack of error prevention and mitigation.27

The hierarchy of communications from social language to professional language and then to the brief, focused

language used in a crisis needs understanding and practice by surgical teams. This involves how best to facilitate

knowledge sharing, developing a deeper understanding of the backgrounds (both cultural and professional) of the

team members, and ensuring that requests or commands are delivered in a professional, civil and meaningful

manner. Checking for understanding feels awkward and is unusual in operating theatres throughout the world.

Training in professional communication with the use of structured language such as the SBAR (situation,

background, assessment, recommendation) model allows consistent and methodical communication during high

pressure situations.

It is important to understand that human listening is poor. We all listen in segments so that we receive smaller

packets of information to process. Much can be lost unless there is a focus on the delivery of information. The

information must be prioritised and précised (word count reduced) with an active challenge to the listener to

confirm that they have heard and to indicate what the response is. Healthcare has much to learn from the military

in this regard, which was used to develop the award-winning TeamSTEPPS®, a structured, competence-based

approach towards improved team effectiveness and outcomes.28 Teams using this type of training were able to see

an 18% reduction in mortality in 182,000 patients across 74 facilities.29

LEADERSHIP
Leadership in the surgical care team sets the tone for the entire team, governing behaviour and (ultimately) the

culture, which has been found to be associated with surgical outcomes.30 Research by the University of Texas and

NASA has shown that of all the domains of leadership, the management of interpersonal relationships was the

most important gatekeeper of all the other very important factors such as followership, workload and distractions,

prioritisation, preparation, team self-feedback, briefing, communication and advocacy.31 The skills are human skills:

those of understanding, making difficult decisions and communicating clearly.

Effective leaders are often humble, have respect for the team and facilitate civility within the group.32 The trust that

develops is hard to quantify but is the unseen bond in the team, and is frequently the crux around which deep

team engagement, loyalty and support come through.33 When assessing the performance of a military team and

asking individuals what makes them ready to enter life threatening situations, the answer is respect, civility,

humility and (most of all) trust. This is the glue that bonds the team together in times of crisis.

PSYCHOLOGICAL SAFETY
Effective leadership in high reliability organisations relies on being able to speak up and be heard.34 The concept is

very much in existence in the corporate world, based on the work of Professor Amy Edmondson, an organisational

behavioural scientist who popularised the term “team psychological safety”, and the concept of a shared belief

held by team members that the team is safe for interpersonal risk taking and speaking up.35 The five steps to

fostering psychological safety are establishing open and respectful communication, being transparent in order to

build trust, setting clear expectations, reframing failure and mistakes as opportunities to grow and learn, and

finally, taking a supporting and consultative approach to leadership. Much of this domain requires excellent

leadership and communication but it takes time, training and deliberate practice.36

CIVILITY
Civility, or treating people with politeness and respect, is one of the most important aspects of exceptionally

performing teams. This mindset and attitude has been promoted by many authors, none as effective as Dr Chris

Turner, who has championed the concept that civility saves lives.37 Turner states that if everyone did as they are

mandated, then we should not have any error or harm. In 2015, Riskin et al demonstrated in two matched teams

undergoing healthcare simulation that those subjected to mild rudeness showed a 60% reduction in

performance.38 These processes can be recorded on paper. However, the practice of medicine happens between

individuals and in environments. The latter is often not recorded and consequently, it cannot be easily identified as

contributing to harm when carrying out a root cause analysis.

Porath has written extensively on incivility, showing that we are subjected to more incivility in the workplace.39

Chris Turner suggests that this results in a 61% reduction in individual “bandwidth” (or the ability to function at

personal best) and the effect on those who witness incivility is significant.40 There is a 20% reduction in

performance in those who witness this behaviour and of these people, 50% are less likely to help others. Patients of

nurses who feel respected and supported by physicians and management are frequently more satisfied with their

work, and have better patient outcomes.41 It is therefore apparent that civility in a team is what makes the team

members function at their best and fulfil their potential. This is the invisible component of what we like to call

teamwork.

DISCUSSION
Safety remains a problem with far too many adverse surgical outcomes. Fortunately, we now know from

sociotechnical theory that surgery has at its core the idea that the design and performance of surgical outcomes

can only be understood and improved if both “social” and “technical” aspects are brought together, and treated as

interdependent parts of a complex learning system. We have learnt deep lessons from complex, high risk systems

such as in aviation, nuclear power, chemical processing and space travel, where it is highly undesirable and

prohibitively expensive to wait for a serious accident to occur before analysing a system’s safety attributes.42

The operating theatre is considered a clinical “microsystem” – a small, well defined frontline unit providing care for

a specific patient population with clear, defined boundaries of the clinical microsystem.43 There has been a

resurgence of interest in the science of learning health systems, safety management systems science, near miss

analysis44 and the importance of learning from rare events.45 Successful examples of these lessons include smarter

alarm management,46 unobtrusive assessment of team and organisation states for performance assessment and

optimisation,47 fatigue and distraction management strategies, system-based performance measurement for

improved efficiency and proficiency, threat and error management, and crew resource and team training

management focused on non-technical skills and total team performance assessment.28

CONCLUSIONS
Despite great advantages in technology and technical training, the surgical community needs to embrace HF and

study this in order to plan workforce training and resource allocation. HF is an important concept that must be

championed if we are to travel from competence to mastery and from unsafe to reliable healthcare systems. The

domains of communication, leadership, psychological safety and civility are not individual threads but factors that

are deeply entwined to result in a highly functioning group whose performance is much more than the sum of its

parts.

The interdisciplinary nature of work in the perioperative environment and the necessity of entrusting cooperation

among the team members play an important role in enabling patient safety and avoiding errors.47 Training team

leaders and surgical teams in this manner will lead to better satisfaction, joy at work,48 reduced burnout of surgical

team members and higher overall financial gains.49 We propose that HF approaches are employed to engage

clinicians, engineers and data scientists in designing new medical device technologies, and to address how best to

improve perioperative flow,50 data transparency, organisational safety, authentic teamwork, and the implications of

overwhelming data overload (such as alarm fatigue) for planning the optimal physical and organisational

environment.51 This work is ongoing and essential.

The sweet spot in this endeavour is to embrace the learnings from other high risk industries. It has been shown

how important effective integration of technology, better self and patient monitoring, smarter automation and

better team communication are in building a reliable culture of safety, and in sustaining surgical team resilience to

provide patient-centred, safe and reliable care.

We have been talking about patient safety and HF for over 30 years with the evidence clearly reflected back at us.

We cannot wait another five or ten years for the perfect solutions. We must address these HF challenges right now.

The question is whether the surgical community is ready to accept HF training as an essential and mandatory part

of the curriculum, and if so, how we should effectively assess our surgeons. The time for action is here; our patients

expect nothing less.

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