- Preventable harm still occurs in operating theatres often due to systems failures related to non-technical errors, distractions, interruptions, and lack of checklists, guidelines, and teamwork training. - Identifying sources of error through systematic observation and implementing initiatives like checklists, guidelines for distractions, and training in non-technical skills and teamwork can help reduce risks. - Regular team meetings and use of behavioral marker systems to provide feedback can help build mutual understanding, trust, and effective communication among operating theatre team members.

1. The importance of non-technical skills and risk reduction
in the operating theatre
K Suzanne Jackson MD MClinEd MRCOG*
Consultant Obstetrician, Department of Obstetrics, Royal Victoria Infirmary, Newcastle upon Tyne NE1 4LP, UK
*Correspondence: Suzanne Jackson. Email: Kathryn.jackson8@nuth.nhs.uk
Accepted on 15 April 2016
Key content
Preventable harm still occurs at unacceptable levels in the
operating theatre and this is often due to systems failure.
Systems failures are often the result of non-technical errors.
Identifying and capturing errors in the system is important for
improving patient safety.
Initiatives such as checklists should be supported.
Distractions and interruptions in the operating theatre should
be limited.
Non-technical skills and teamwork training are important in
this area.
Behavioural marker systems may be useful in evaluating non–
technical skills.
Learning objectives
To identify risk areas in the operating theatre environment.
To describe ways to identify and capture error.
To describe the role of training and teamwork in reducing risk.
Ethical issues
How do we identify risks and raise concerns?
Keywords: non-technical skills / risk / surgery
Please cite this paper as: Jackson KS. The importance of non-technical skills and risk reduction in the operating theatre. The Obstetrician Gynaecologist
2016;18:309–14. DOI: 10.1111/tog.12307
Introduction
Achievement of goals and patient safety are the main
objectives of teamwork in the operating theatre; however,
there is evidence that preventable adverse events continue to
happen at unacceptably high rates in this area.1
Traditionally,
surgical performance and outcomes have been seen as a
function of a patient’s risk factors and the technical skill of
the surgeon. However, it is now accepted that non-technical
skill is of equal importance. Henriksen et al.1
termed the
operating theatre environment as a ‘microsystem’ within the
larger system of the hospital. Within the microsystem, a
number of smaller interacting systems function within a
variable environment. Surgery cannot be a solitary activity,
and patient safety and good practice also depend on effective
team functioning. This approach has been termed the
‘systems approach’, with individual team behaviour
providing information on the internal effectiveness,
structure and process of the team.1
The non-technical skills of situation awareness, decision-
making, teamwork, communication, leadership and trust
have been previously described.2
This article describes the
importance and interplay of non-technical skills, specifically
in the operating theatre, and the ways in which an awareness
of these cognitive and social functions could help reduce the
risks involved in clinical practice.
What makes a good team?
Multiple factors play a role in the success of the operating
theatre team, including resource availability, team effort,
leadership, communication and the complexity of the task.
One of the major challenges faced in the operating theatre is
the unpredictable nature of surgery, the need for the
surgeon to make risky and irreversible decisions, and the
ability of the whole team to shift rapidly from a routine to
an emergency state.3
This requires fast and effective task
coordination in order to achieve a specified and shared goal.
A ‘good’ team will coordinate the timely and correct
execution of tasks through collaborative information
sampling to build a shared mental model of the situation,
conduct collaborative decision making, and prioritise and
delegate tasks.4
In observational studies, such effective
teamwork has been shown to be associated with fewer
minor problems per operation, higher intraoperative
performance and shorter operating times.3
Further analysis
of individual teamwork behaviour can provide information
on whether or not a subteam (individual or individuals) has
a favourable impact.
In order to collaborate, team members must adjust their
behaviour to that of the other members. Specifically, leading
and following are significant collaborative adjustment
behaviours for solving social coordination problems.3
ª 2016 Royal College of Obstetricians and Gynaecologists 309
DOI: 10.1111/tog.12307
The Obstetrician Gynaecologist
http://onlinetog.org
2016;18:309–14
Review

2. Current leadership theory largely focuses on the leader–
follower dynamic. There cannot be a leader without
followers, and both leaders and followers need to support
the team structure. No single individual will always be the
leader; it is more likely that he or she will sometimes work
in situations where someone else takes that position. A
situation may also demand a change in roles between a leader
and a follower, and team members should be able to swap
roles without self-esteem issues and with minimal reference
to power or status. A leader is recognised by behaviours such
as taking the initiative to prompt discussions and seek
feedback, make decisions and verbalise plans. Application of
leadership behaviours by several members of a team could
lead to a potential risk of confusion and conflict within the
team. The surgeon should be aware of the impact of his/her
own behaviour on the other people in the operating theatre,
particularly trainees, and should set an example by behaving
professionally and respectfully towards all team members
and patients.5
Surgical decision making
Surgical decisions carry high stakes and can be associated
with complications and their consequences. These decisions
are also potentially irreversible, for example, removing a
uterus. Decision making is a cognitive skill involving a
number of interrelated steps and is becoming increasingly
prominent in the literature, which suggests that good decision
making in high-stakes environments involves at least five
steps: preparedness; analysis of the situation; planning of
action; execution of action; and review of effects.6,7
In surgery, it is recognised that this cognitive process can
take the form of a number of different modes: the implicit/
cognitively untaxing or recognition primed (i.e. just knowing
what to do) and the explicit/cognitively taxing or analytical
decision making (i.e. weighing up the options carefully after
gathering the necessary information). Typically, a surgeon
applies different strategies depending on the time resources,
the potential consequences and his/her level of expertise. For
example, at the preoperative stage, deciding whether or not
to operate can be a balance of risks and benefits, made
without significant time constraints and in consultation with
the patient. This process is shown in Figure 1. However, in
an emergency situation, the same decision is made under
time pressure, which can be challenging. A well-prepared but
junior team member in this situation may adopt ‘rule-based’
decision making, whereas more experienced team members
will consider this, but are likely to take a ‘recognition-
primed approach’.
Communication
Communication is frequently cited as a contributory factor in
the analyses of adverse events,8,9
and it is a dominant focus in
the study of operating room performance. It follows that
increasing clinical complexity requires a reciprocal increase in
communication skills across the disciplines present in the
operating theatre. Several studies have reported the effects of
interruptions and tensions on effective team functioning, and
ethnographic work has shown that the tensions often revolve
around issues of time, safety and sterility.8
Lingard et al.8
went on to develop a checklist of the types of communication
failure and their outcomes during surgical procedures, noting
the incidence of a failed communication to be approximately
1 in 3 (30%) utterances. A third of these cases had observable
consequences such as delay, procedural error and tension.
The communication failures were grouped into four main
areas: occasion, content, purpose and audience. ‘Occasion’
refers to communication being too late to be effective, for
example, asking for equipment at the moment of need, rather
than before the procedure starts. ‘Content’ failures consist of
exchanges of incomplete or inaccurate information, such as
not clarifying whether or not a high-dependency bed has
been booked before starting the operation. The ‘Purpose’
category involves questions whose purpose is not achieved,
i.e. they are not answered, leading to increasingly urgent
requests. The ‘Audience’ category refers to a failure to
communicate with all the relevant individuals on the team
e.g. the surgeon is not told that the equipment in the
operating theatre has been changed. The checklist also
captures the consequences of communication failure that
are immediately visible to the observer, including delay,
Situation assessment
Time/risk pressures
Decision-making strategy
Creative
Analysis of novel events
Analytical
Comparison of different options
Rule-based
Procedures or rules
Recognition-primed
Stored patterns of pre-programmed responses
Low High
Figure 1. The cognitive process.15
Strategies depend on the time resources, potential consequences and the level of expertise of the surgeon
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Improving patient safety in the operating room

3. tension, inefficiency and resource wastage. These records may
then be used to build a communication ‘profile’ over time.
Reducing risks
Removing threats from the system
An understanding of the potential source of error in the
system (‘Safety 1’) is key to reducing risks. Until the past
decade, few studies have described the specific practices or
attitudes that compromise safety, the methods that might
change these patterns, or the ways to reliably measure the
outcomes of such changes. The most frequent failures may
not present the greatest threat to the operative success or
system function, but they can give rise to conditions in
which major failures and adverse events are more likely.
Catchpole et al.10
developed the failure source model in
paediatric surgery as a method of diagnosing the likely
source of threats and errors in the operating theatre
(Figure 2). By observing knee surgeries, the researchers
noted that organisational and cultural threats were the most
commonly encountered, particularly in higher-risk
operations. Task and equipment threats occurred at
similar rates regardless of the risk, and patient threats
were the least common, although the results of patients in
obstetrics and gynaecology may be more variable.
Catchpole et al.10
noted that observing small recurrent
problems in the operating theatre makes it possible to
identify prospective latent failures (threats) that are regularly
mitigated, but occasionally cause harm. Examination of the
properties of the system that are displayed by these minor
failure types allows the identification of a small number of
error reduction strategies that address the problem at
source.10
This identification of weak points in the system is
more advantageous than providing defences to a large
number of unique deficiencies for three main reasons: it is
resistant to hindsight bias, it helps build defences when
adverse events occur and it may improve the efficiency of
surgery by rectifying frequent problems.
Figure 2 shows the failure source model, which links
observable minor failures with common systemic causes
(bold type).10
The researchers found that in events that
resulted in increased duration or difficulty of surgery, risks to
the patient and demands for resource were frequent.10
Distractions, equipment management problems, safety
consciousness and coordination problems were the most
common failures. Errors related to decision making and
Patient threats
Task threats
Technical error
Equipment, workspace
and resource threats
Organisational
and cultural threats
Patient sourced
procedural difficulties
Psychomotor related surgical
Procedure related error
Fault resolution failure
Planning failure
Equipment/workspace
management failure
Equipment configuration
failure
Equipment failure
External
resource failure
Safety consciousness/
awareness
Distraction
Abscence
Resource management
failure
Team conflict
Awareness failure
Communication/
coordination failure
Decision related surgical error
Psychomotor error
Expertise/skill failure
Preoperative failure
of diagnosis
Unintended effects
on patients
Non-technical error
Figure 2. The failure source model.3
A method for diagnosing the likely source of threats and errors in the operating theatre
ª 2016 Royal College of Obstetricians and Gynaecologists 311
K Suzanne Jackson

4. diagnostic errors were the least common, thus reflecting the
skill and competence of the teams studied. The variability of
the failures in a relatively stable team suggests that failures
must have their source in variable systemic conditions rather
than individuals.
Reducing tolerance for distraction and reduced safety
consciousness – the Sterile Cockpit
A second step which can be put in place is to build in safety
measurements to reduce or prevent error, such as checklists
(the surgical pause being the obvious example), reminder
systems and other ways to optimise performance. Catchpole’s
work3,10
suggests that the opportunity and tolerance for
reduced safety consciousness is high, for example, talking
during the team briefing or failure to observe protocols.
Disruptions are also common, and Wiegmann et al.11
found
that interruptions in the surgical process such as
communication failures or equipment problems increase
surgical errors. The presence of noise and music in the
operating theatre is also common; Moorthy et al.12
exposed
anaesthetists to noise levels similar to those in the operating
theatre and found that their mental performance deteriorated
after exposure to the noise. Likewise, Miskovic et al.13
found
that trainee surgeons reached peak performance at a
laparoscopic task without music.
In aviation, the Sterile Cockpit Rule is a Federal Aviation
Association (FAA) regulation requiring pilots to refrain from
nonessential activities during critical phases of flight,
normally below 10 000 feet.14
Flight attendants are given
specific guidance about what type of information merits
contacting flight crew members during the sterile period of
take-off and landing, when to make the calls, how to call and
what to call. Similarly, controlling the use of mobile phones
and the conduction of messages in the operating theatre,
together with reinforcing safety procedures are simple and
direct solutions that should be applied across the board.
Failures to control distraction and safety are a reflection of
the impact of culture on surgical quality, and the underlying
cause should be considered at all levels, including the
national policy.
Implementing teamwork
Finally, training and teamwork could help individuals to
handle the remaining error-prone situations better. One way
of understanding optimum teamwork is to ask what happens
already on our ‘best days’. Based on this ‘Safety 2’ approach,
teamwork should be measured by sharing knowledge
between one another, trust, flow understanding,
anticipation, mutual support and satisfaction; qualities that
are built up over years. However, the reality is that most of
the time, clinicians and healthcare workers work in busy
units with a high rotation of staff. In these situations,
teamwork and the ability of the team to adapt can be
achieved by supportive structural and social actions that help
the team as a whole to develop mutual knowledge and trust.
This collaborative (or compassionate) care model is based on
the idea that healthcare and teamwork are essentially
correlated. This includes weekly team meetings that help
build trust and knowledge through interaction and
relationally based experiences, which has been shown to be
highly successful in individual units.15
Putting behavioural markers to work
An essential factor in successful problem solving is
establishing shared mental models. The abilities of clinicians
to express problem solving and team coordination in
communication widely differ, particularly in the
formulation of explicit mental models and situation
awareness, i.e. the manner in which a situation is likely to
unfold and organisation of action. These specific skills and
tasks can be learned and developed through education,
experience and guidance. Regular theoretical training in non-
technical skills for individuals and teams, and reinforcement
with behavioural marker systems such as Non-Technical Skills
for Surgeons (NOTSS)16
(a validated educational system for
rating observed non-technical skills in surgery) may be useful
in this regard.2,5
NOTSS was originally developed as a
reflective practice tool for consultants and could still be
used in this regard, or indeed to support revalidation. NOTSS
has been adapted for the obstetrics and gynaecology specialty
and is now available as a formative supervised learning event
on the Royal College of Obstetricians and Gynaecologists
(RCOG) ePortfolio. Information on its use has previously
been reported2
and it is also available on the RCOG
ePortfolio. A copy of the skill taxonomy is shown in
Appendix S1.
Sufficient spoken communication serves to solve the
problems related to regulation of activity and coordination
of the team. In aviation, Helmreich and Sexton17
found that
specific language variables are moderately to highly
correlated with individual performance, error rates and
communication ratings. They found that frequent use of
the first person plural (we, us, our) tends to correlate with a
reduction in error. In an investigation of communication
during operations,8
a high correlation was observed between
the quality of clinical management and communication, as
measured with behavioural markers. Good communication
alone cannot produce a good surgeon, but it helps in finding
strategies for problem solving in critical situations. Such
situations are all underpinned by the effective use of
authority and assertiveness by the surgeon, which involves
creating an appropriate balance between challenging others,
inviting challenge and participation, and being assertive
enough to apply authority to complete a task safely.5
However, surgeons should be mindful to communicate
respectfully with colleagues and refrain from dismissive or
312 ª 2016 Royal College of Obstetricians and Gynaecologists
Improving patient safety in the operating room

5. intimidating behaviour and inappropriate language,
including swearing. They should be ready to challenge
counterproductive behaviour in colleagues constructively,
objectively and proportionately.5
Challenges: how to ensure that trained
safety behaviours persist
The Royal College of Surgeons has stated that all surgeons
should create a culture of safety by surfacing and mitigating
issues that might be detrimental to the patient.5
However,
creating and sustaining such an environment depends on the
nature of the context in which the local environment exists. It
is important to understand that collaborative models of
working may threaten traditional organisational
management, and while decision makers generally want
hard evidence before resources are directed at team training
courses, the evidence for crew resource management (CRM)
or non-technical skills training remains limited. In addition,
there are still situations where a reluctance to do the right
thing is reported. The World Health Organization surgical
pause is a good example. Although it serves as a tool to
communicate expectations between team members, share
brief potential contingency plans and clarify or share the
team’s mental model of what is going to happen, i.e. basic
CRM, and has been embraced enthusiastically in some
centres, difficulties in implementing the pause effectively are
still common. Problems with engagement continue and
scepticism in relation to checklists prevails. Shaping
checklists or programmes that are more effective and more
likely to be perceived as effective in the environment in which
they are introduced is the present-day challenge.
Conclusion
There is (generally) no such thing as a bad apple. Surgery relies
on teamwork and errors are usually the result of non-technical
or systems failures. Small recurrent problems are common in
the operating theatre and are usually mitigated through the
team’s ability to adapt. Studying these problems may help us to
reduce the number of error-prone situations. Patient safety
initiatives in the workplace must be supported and there
should be zero tolerance for needless distraction or protocol
violation. A ‘good’ team will be able to facilitate this through
structural and social actions that encourage effectiveness.
In future, improved healthcare quality is likely to focus
significantly on teamwork training, with a focus on ensuring
that processes and systems work effectively. Moreover, the
surgeon should focus on setting direction, motivating others
and ensuring that the operational elements are safely and
efficiently delivered. Behavioural marker systems are likely to
be the key to such programmes, and an improved team safety
culture will help them take root and establish.
Disclosure of interests
KSJ co-adapted and piloted NOTSS for the RCOG. She is the
Deputy Chair of the Health Education North East Human
Factors Group and a member of the RCOG Human Factors
Working Group.
Contribution to authorship
This paper was the sole work of KSJ.
Ethics approval
Not required
Acknowledgements
I thank Dr Dave Murray, Consultant Anaesthetist, James
Cook University Hospital, Middlesbrough and Chair of the
Health Education North East Human Factors Group, for
his comments.
Supporting Information
Additional supporting information may be found in the
online version of this article at http://wileyonlinelibrary.
com/journal/tog
Appendix S1. The Non-technical Skills for Surgeons form
and skill taxonomy. The form allows feedback of observed
behaviours in key non-technical skills domains.
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