Every year, the Anesthesia Patient Safety Foundation (APSF) reviews existing and emerging patient safety issues and publishes its list of highest patient safety priorities (asamonitor.pub/3y7gGuD). For many years, “Safety Culture” has been featured prominently near the top of the list, in recognition of the important role it plays in optimizing teamwork, supporting a learning (versus punishing) work culture, and ultimately helping individuals and teams bring their very best to the care of patients. During the unprecedented time of the COVID-19 pandemic, we have seen front line workers think outside the box: navigating various work roles and workflow and system changes while maintaining patient quality standards and supporting colleagues. This type of resiliency is very much dependent on safety culture.

Key components to creating a culture of safety

Safety culture is a complex, multi-faceted concept. The Agency for Healthcare Research and Quality (AHRQ) has identified four key components to creating a healthy safety culture: 1) acknowledgement of the high-risk nature of an organization's activities and the determination to achieve consistently safe operations, 2) a blame-free environment where individuals are able to report errors or near-misses without fear of reprimand or punishment, 3) encouragement of collaboration across ranks and disciplines to seek solutions to safety problems, and 4) organizational commitment of resources to address safety concerns (asamonitor.pub/3ffGFaV).

Establishing trust and having psychological safety allows us to speak up about concerns and communicate in a timely way, without fear of retribution. Positive relationships impact our ability to address challenges and to flex, adapt, and innovate during times of uncertainty (J Management Studies 2003;40:1419-51). Thus, critical and respectful communication in the perioperative setting both supports and is a marker for a strong safety culture. Deliberately optimizing how our communication affects our relationships is a vital and effective patient safety strategy.

Subtle lapses in professionalism

Overt conflict between surgeons and anesthesiologists has been experienced or witnessed by almost everyone who has worked in an OR. While we have come a long way since the times when instruments would be thrown and weaponized, it is not uncommon to see microaggressions in the form of brief indignities that reflect negative attitudes (including eye-rolling, foot tapping, disrespectful or dismissive language, or passive-aggressive behavior). Quiet microaggressions or reluctance to communicate are maladaptations that can also result from imperfect working relationships. Overt or not, lapses in professionalism erode the psychological safety of the entire perioperative team and have been shown in studies to negatively impact information sharing, adherence to safety protocols, individual performance of clinical tasks, and team performance during critical events (J Clin Anesth 2007;19:152-8; Pediatrics 2003;112:553-8; Am J Surg 2005;190:770-4; AACN Clin Issues 2004;15:182-95; Ann Intern Med 2002;136:826-33; Physician Exec 2002;28:8-11; Pediatrics 2015;136:487-95).

Disruptive interactions in the perioperative arena also come with indirect costs such as decreased worker morale and productivity and increased disability and workforce turnover (J Clin Anesth 2007;19:152-8; AACN Clin Issues 2004;15:182-95; Ann Intern Med 2002;136:826-33; BMC Med Educ 2016;16:229; Curr Opin Crit Care 2007;13:732-6; J Am Coll Surg 2007;204:533-40).

On the other hand, positive interactions that enhance information sharing and shared mental models are likely effective in promoting optimal safety (Med Educ 2002;36:728-34; Qual Saf Health Care 2004;13:330-4; Simulation & Gaming 2001;32:175-193; JAMA 2010;304:1693-700).

The power of teamwork

Good teamwork is important for safe, high-quality perioperative care. The impact of surgeon-anesthesiologist relationships on the quality of our work was highlighted by Dr. Jeffrey Cooper in his 2018 paper published concurrently in Anesthesiology and the Journal of the American College of Surgeons and summarized in the Anesthesia Patient Safety Foundation Newsletter (Anesthesiology 2018;129:402-5; J Am Coll Surg 2018;227:382-6; APSF Newsletter 2020;35:8-9). We don't know the incidence of poor outcomes in the OR that are precipitated specifically by poor interactions between anesthesiologists and surgeons. Personal anecdotes about the OR and published studies on ICU interactions suggest the incidence of conflict is significant and that, therefore, this is an important area for study and improvement (J Clin Anesth 2007;19:152-8; Am J Surg 2005;190:770-4; J Nurs Scholarsh 2010;42:40-9). There is little research about this specific OR dyad relationship, what works well and not well, and what can be done to optimize it; APSF is currently supporting a research grant on this topic (APSF Newsletter 2021;36:28-29). We do know from existing literature that optimizing teamwork improves the patient experience and improves quality outcomes (such as length of hospital stay and mitigating harm from errors and intraoperative adverse events). (JAMA 2010;304:1693-700; J Nurs Scholarsh 2010;42:40-9; Med Care 2000;38:807-19; J Serv Res 2002;4:229-311).

‘Relational coordination’

The Institute of Medicine (IOM) has called for increased trust, respect, and transparency in communication to improve the quality of care (J Nurs Manag 2010;18:926-37; Keeping Patients Safe: Transforming the Work Environment of Nurses. 2004). Several studies have investigated the impact of “relational coordination” within health care teams (Med Care 2000;38:807-19; J Nurs Manag 2010;18:926-37). These have demonstrated that optimizing communication and having shared mental models and mutual respect can be associated with improved patient outcomes (BMC Med Educ 2016;16:229; BMJ Qual Saf 2015;24:458-67; Surgery 2011;150:771-8; Am J Obstet Gynecol 2009;200:492.e1-8; Ann Intern Med 1986;104:410-8; Heart Lung 1992;21:18-24). According to relational coordination theory, colleagues can collaborate best when there is high-quality communication (frequent, timely, accurate, and problem-solving), which is enhanced by high-quality relationships (shared goals, shared knowledge, and mutual respect) (Human Resource Management Journal 2001;18:154-70).

Work in ORs is characteristically complex and requires that skilled workers are both independent and interdependent. It is not hard to imagine how such a communication framework could facilitate rapid dissemination of critical information during a perioperative crisis and promote collaborative problem-solving that is well received even by colleagues who are in the thick of a clinical challenge. Many of us have had a personal experience where we wished a colleague had spoken up about a concern they noticed before we did. For this reason, we have encouraged leaders to model inclusive behaviors and to invite relational coordination at our institution. It is becoming more common for a surgery or anesthesiology attending to say in a huddle, “this is a challenging case... please speak up if you notice a problem or have information that may be helpful....” We find from personal experience that such invitations help lower barriers to speaking up, perhaps because “being helpful” comes more easily to us and thus lowers the personal risk that can lead to self-censorship. Having an expectation that there will be timely, important, and respectful communication also seems to help us hear it when we are on the receiving end. This behavior has become more hardwired when leaders thank team members for input, even when the input was off-base or a false-alarm.

Relational coordination impacts worker wellness as well as patient safety. Working within a framework of mutual support has been shown to improve resiliency and to be an antidote to clinician burnout (Human Resource Management Journal 2001;18:154-70; J Nurs Adm 2012;42:418-25). Now, more than ever, deliberate efforts to help providers feel connected, valued, and supported is an important patient safety and clinician wellness strategy. Wouldn't it be great if, someday, “Safety Culture” was no longer identified as a safety vulnerability on the APSF list of top safety priorities and in perioperative care?


Dr. Pian-Smith is a member of the APSF Board of Directors.

May C. M. Pian-Smith, MD, MS, Member, APSF Board of Directors, Associate Professor of Anesthesia, Harvard Medical School, and Chief, Division of Quality & Safety, Department of Anesthesia, Critical Care & Pain Medicine, Massachusetts General Hospital, Boston.

May C. M. Pian-Smith, MD, MS, Member, APSF Board of Directors, Associate Professor of Anesthesia, Harvard Medical School, and Chief, Division of Quality & Safety, Department of Anesthesia, Critical Care & Pain Medicine, Massachusetts General Hospital, Boston.