“Teamwork may be just as hard in certain lines of work. Under conditions of extreme complexity, we inevitably rely on a division of tasks and expertise – in the operating room, for example, there is a surgeon, the surgical assistant, the scrub nurse, the circulating nurse, the anesthesiologist, and so on. They can each be technical masters at what they do. That's what we train them to be, and that alone can take years. But the evidence suggests we need them to see their job not just as performing their isolated set of tasks well but also as helping the group get the best possible results. This requires finding a way to ensure that the group lets nothing fall between the cracks and also adapts as a team to whatever problems might arise.” (The Checklist Manifesto: How to Get things Right. 1st ed, 2009)

–Atul Gawande

Teamwork is a hallmark of patient safety. This term has been defined in many different ways. Eduardo Salas, an industrial and organizational psychologist and expert in studying teams in aviation, medicine, and other industries, popularized a definition of a team in a publication written with colleagues: “[A team is] a distinguishable set of two or more people who interact, dynamically, interdependently, and adaptively toward a common and valued goal/objective/mission, who have each been assigned specific roles or functions to perform, and who have a limited lifespan of membership” (Teams: Their Training and Performance. 1992). Thinking more longitudinally, the concept of a team has also been defined in the medical literature as “a group of diverse clinicians who communicate with each other regularly about the care of a defined group of patients and participate in that care” (JAMA 2004;291:1246-51). Regardless of the precise definition that one uses when thinking of teamwork in the perioperative arena, there are some fundamental themes pertaining to teamwork that can enable safer care in the OR.

Communication is relevant for interactions both between anesthesiology colleagues and interprofessionally across disciplines.

Closed-loop communication, a practice where the sender and receiver of information interact to confirm information has been received correctly and tasks have been completed, has been promoted by multiple organizations involved in patient safety (Anesth Analg 2023;137:1302-5; Anaesth Crit Care Pain Med 2023;42:101262; Anaesthesia 2023;78:458-78).

“Both within and beyond the field of medicine, tests of selective attention have been developed to educate how one can succumb to a loss of situational awareness and overt inattentional blindness, particularly when an environment is complex with multiple sensory inputs.”

Leadership, which has been described as the provision of “directions, assertiveness, and support among team members,” can include principles such as role clarity, delegation of tasks, and decision-making (Comprehensive Healthcare Simulation: Anesthesiology. 1st ed, 2019; World J Surg 2014;38:305-13).

Situational awareness is a concept that includes perception of the information in one's environment, comprehension of its relevance, and anticipation of its implications (Anaesthesia 2023;78:479-90). Both within and beyond the field of medicine, tests of selective attention have been developed to educate how one can succumb to a loss of situational awareness and overt inattentional blindness, particularly when an environment is complex with multiple sensory inputs (Psychol Sci 2013;24:1848-53; asamonitor.pub/4aMwrtC). There is also ongoing research surrounding the use of technology to aid in situational awareness (Hum Factors 2022;64:269-77).

Safety checklists, which have been designed for both routine and emergency perioperative scenarios, can foster principles of teamwork while also reviewing processes of care (N Engl J Med 2009;360:491-9; N Engl J Med 2013; 368:246-53). When performing a handover or transition of care to other team members, the use of structured handover tools and protocols may lead to improved care and patient outcomes (Anesthesiology 2024;140:387-98; BMJ Qual Saf 2021;30:513-24). After a critical event, there is value in looking out for your teammates and considering whether a debriefing can provide a check-in for colleagues, an opportunity for education, and confirmation that any remaining acute patient care matters are being addressed (ASA Monitor 2021;85:42-3).

There are many ways to continue perioperative clinician education in teamwork and incorporate lessons into daily practice to improve patient safety:

  • Team training via medical simulation may offer the opportunity to practice teamwork principles in a hands-on fashion (Ann Surg 2014;259:403-10).

  • ASA has offered patient safety educational and CME offerings for many years, including a dedicated module on the Fundamentals of Patient Safety (asamonitor.pub/3VRpraA).

  • TeamSTEPPS is a framework of evidence-based tools to foster improved teamwork, communication, and improved patient outcomes (asamonitor.pub/49zsyr1).

Teamwork is a multifaceted concept that can be leveraged toward the safer care of patients perioperatively and beyond.

ASA Patient Safety Editorial Board contributors: Alexander F. Arriaga, MD, MPH, ScD, Jonathan B. Cohen, MD, Jeffrey A. Green, MD, MSHA, FASA, Keith J. Ruskin, MD, Senthilkumar Sadhasivam, MD, MPH, MBA, FASA, Scott C. Watkins, MD, Deborah Schwengel, MD, MEHP (Editor-in-Chief).