Features  |   May 2018
Behaviors That Undermine a Culture of Safety: Let’s Pay Attention
Author Affiliations
  • Michael Block, M.D.
    Committee on Patient Safety and Education
  • Parul Maheshwari, M.D.
    Committee on Patient Safety and Education
  • Donna-Ann Thomas, M.D.
    Committee on Patient Safety and Education
Article Information
Patient Safety / Features
Features   |   May 2018
Behaviors That Undermine a Culture of Safety: Let’s Pay Attention
ASA Monitor 5 2018, Vol.82, 16-18.
ASA Monitor 5 2018, Vol.82, 16-18.
Following induction of anesthesia and intubation of a patient undergoing coronary artery bypass graft surgery (CABG), the anesthesiology resident successfully places a right internal jugular central line under supervision of the attending anesthesiologist. Immediately following, a cuff leak is detected in the endotracheal tube (ETT). The ETT is promptly and successfully exchanged. During this time, the cardiac surgeon enters the O.R. and with his hands in the air asks everyone, “Why is everything taking so long this morning and holding me up?” The nurse explains the situation, and the cardiac surgeon asks to speak to the attending anesthesiologist. During a brief, heated side-conversation away from the patient, the surgeon confronts the anesthesiologist, asking, “What complication just occurred with my patient?” The case proceeds uneventfully. It is remarked by staff in the room that this anesthesiologist and cardiac surgeon “have had words before” and “we are used to this.”
1 Comment
May 9, 2018
Paul Zilberman
Hadassah Medical Center, Jerusalem, Israel
Behavior Problems

It is sad indeed that such events happen. We are all humans, after all, and ups and downs are part of our nature. However, working in such high-stress environments like the O.R. and/or ER or, you name it, puts a heavy burden on our already overstretched "psyche." I am neither sure nor convinced that one protocol or another or - to put it politically correct as "code of conduct" - could replace our basic education received (or not?) in our first years at home. Yet, one way or another we MUST remember that the colleague we are behaving badly toward is, after all, our colleague. Insulting him/her is insulting oursevles in the first place. In the aviation industry there is a term called CRM (Crew/Cabin Resource Management) that addresses exactly such disruptive behaviors if and when they happen. By the way, in the same line of thinking, a pilot has regulated hourd of work/sleep. This may be one of the reasons why civilian air traffic is so safe. Why are we, doctors, behaving differently? Because of that "production pressure"? Because a "mishap" is a rather isolated single case while an air catastrohe takes the lives of several hundred people together? Just thinking... In the meantime, let's cool off and try to make our working environment a place we enjoy to be, not a boxing ring.

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