Captain Rick Saber at the controls. He is a leader in the field of aviation safety and how “Black Box Thinking” can make medicine safer.
Courtesy of David Nelson, MD, FAAOS


Published 3/24/2021
David Nelson, MD, FAAOS

Patient Safety Scenario: Protocol Communication Failure

Editor’s note: Originally published by the American Society for Surgery of the Hand (ASSH) in the March 2018 issue of the ASSH Perspectives newsletter, this article was authored by David Nelson, MD, FAAOS, a member of the ASSH Ethics and Professionalism Committee.

A comparison of safety in aviation and medicine is frightening: Aviation disasters are investigated and written up, and every pilot has access to the lessons learned. In medicine, medical errors are investigated, written up, and buried so deeply that no one learns anything. Surgeons have to repeat every error on their own—with their own patients. In aviation, there is one accident every 2.4 million flights, whereas medical errors kill between 44,000 and 98,000 patients per year, according to two studies reported in a 1999 Institute of Medicine report, “To Err is Human.” This is the equivalent of crashing a 747 every other day. Would you be willing to fly if this was aviation’s safety record? Yet, according to several studies, this is our safety record in medicine. Medicine needs to develop “Black Box Thinking,” defined in a book of the same name as “the willingness and tenacity to investigate the lessons that often exist when we fail. … It is about creating systems and cultures that enable organizations to learn from errors rather than being threatened by them.”


An OR management committee decided to discontinue the use of sterile, disposable handles for the overhead lights in favor of metal, sterilizable light handles. Several weeks after this protocol was implemented, a surgeon was performing a case. The surgeon adjusted the lights using the metal light handle. Gene, a transport technician walking outside the room looked in, saw the surgeon using the metal handle, and burst into the room, yelling, “Dr. Blank, stop!”

The surgeon was quite surprised, both at this outburst and the fact that the transport tech was telling him what to do, and asked, “Gene, what did I do?” His reply: “Didn’t they tell you? Those light handles aren’t sterile anymore!”

The surgeon was then belatedly instructed by the scrub tech and the circulating nurse that the protocol had changed and that the metal light handles were no longer sterilized. The scrub tech had forgotten to put on the sterile plastic cover. The surgeon thanked the scrub tech and changed gloves. Later, he again personally thanked the transport tech, wrote him up for a compliment that went into his personnel file, and spoke to both the head nurse and the OR director about the failure to disseminate this change in policy and how it almost resulted in a disaster. Interestingly, compliments in this OR got written up so rarely that the head nurse said no one had done this as long as he had been there.


This scenario is an example of good teamwork and how it can save the patient and surgeon from a disaster. The transport tech, who is rather low on the hierarchy of the OR and has no responsibility for the sterile field, felt empowered to challenge the surgeon when he perceived that a violation of OR protocol had occurred. In this instance, because he felt he needed to act quickly in order to stop the surgeon before he contaminated the field (it would take only a second to drop that contaminated hand into the field), he felt empowered not only to challenge the surgeon, but to do it in a sharp and forceful way. The surgeon had a close and respectful relationship with his OR team and the transport tech (he always addressed the transport tech by name). Because of this team relationship, the surgeon responded, “Gene, what did I do?” and not with, “Who the hell do you think you are, telling me what to do?” The key here was clearly the comfort level of the tech in feeling authorized to speak up. Understanding that safety supersedes any other concerns in the OR is important for maintaining an environment where everyone will speak up. It is not a natural thing for people lower on the power hierarchy of the OR to speak up; it needs to be taught and encouraged.

Root-cause analysis

Studies have shown that 70 percent of errors have their foundation in communication failures. The previously described example had several communication failures, including:

  • Communication failure 1: Failure of the OR director, OR head nurse, and entire OR management team to disseminate to the surgeon the fact that there had been a change in protocol that directly affected surgeons and sterility.
  • Communication failure 2: Failure of the OR team that day to make sure that the surgeon knew of the change in protocol.
  • Communication failure 3: Failure of the OR management to post a sign, either in the room or on the light handle, to warn the staff of a change in protocol.
  • Communication failure 4: Failure of the OR team that day to manage the sterile field, place a sterile cover on the light handle, observe that the surgeon had contaminated himself, and institute corrective action.
  • Communication failure 5: Failure of the surgeon to do a “check-in” with the OR team that day; such a “check-in” might have alerted him to a change in protocol that he was unaware of.


Good teamwork has many positive results: a safer OR, a more enjoyable work environment, faster procedures and room turnover, lower turnover of staff, etc. A good leader knows all of the team members, personally if possible, or at least treats them all with respect, and enlists their active involvement in all aspects of the case. In the airline industry and others, this aspect of team interaction is called Crew Resource Management. Captains of commercial airlines are supposed to do a “check-in” with their flight crews and, particularly if the captain is senior and the first officer (copilot) is junior or they have not worked together before, actively solicit challenges if the first officer suspects a violation of safety. It is common for the captain to say to the first officer and flight engineer, “If you see something I do that makes you feel uncomfortable, I want you to speak up, OK?” Pilots are often appalled that surgeons do not routinely encourage their teams to speak up. Maintaining a collegial relationship with all OR staff, no matter their position, is necessary to create a high-reliability environment.

Writing up the transport tech for a compliment that went into his personnel file was a great way to reinforce the idea of teamwork. It is a good management strategy to recognize and praise good teamwork more often than you write up people for bad behavior. It is good at times to do it formally, asking that it be added to the personnel file. Word gets around the OR that you praise more than you criticize, which only helps you. When you do criticize, do so only for serious violations of protocol. The fact that no one had written anyone up for a compliment before shows a serious deficit in the management style of that OR.

The take-home message is to be sure to speak to your OR team the next time you are in the OR and encourage them to speak up for patient safety if they feel uncomfortable. They will be shocked, but you will have started the journey to teamwork in the OR.

David Nelson, MD, FAAOS, is an orthopaedic hand surgeon in private practice in San Francisco and chair of the Patient Safety Subcommittee of the Ethics and Professionalism Committee of the American Society for Surgery of the Hand.