A study based on a survey measuring attitudes toward the
work environment in the operating room reveals that
surgeons exhibit the lowest level of teamwork and nurses
The survey, called the Safety Attitudes Questionnaire, was
adapted from an airline industry questionnaire and applied
to the health care environment. Developed by a Johns
Hopkins-led team, the SAQ contains 65 questions in six
areas relating to safety, including teamwork climate,
safety climate, job satisfaction, perceptions of
management, stress recognition and working conditions.
Results appear in the May issues of the Annals of
Surgery and the Journal of the American College of
Only 65 percent of OR personnel thought surgeons exhibited
a high or very high level of teamwork. In contrast, 83.5
percent of those surveyed believed general surgical nurses
exhibit a high or very high level of teamwork, and 85
percent rated certified registered nurse anesthetists, or
CRNAs, as showing a high or very high level of teamwork.
Anesthesiologists rated third at 79 percent.
"The SAQ provides hospitals with an accurate method for
rating safety in the OR because it asks frontline
caregivers about the OR work environment," said lead
researcher Martin Makary, an assistant professor in the
Department of Surgery at the School of Medicine.
"Results — like those telling us that surgeons rate
poorly in teamwork — help target areas for improved
communication and provide a benchmark for rating strategies
aimed at improving patient safety."
Makary said that other questions, such as ones directly
asking OR team members if they would feel comfortable being
operated on in their own hospitals, send a clear message
regarding patient safety concerns in the OR.
"The bottom line is, you wouldn't want to fly with a pilot
or co-pilot who wasn't happy with his working environment,
and the same applies to the OR," he said.
The SAQ was adapted from the Flight Management Attitudes
Questionnaire and its predecessor, the Cockpit Management
Attitudes Questionnaire, both of which were developed to
address accidents in the airline industry. The theory
behind all these surveys is that improving work-area issues
improves safety, said co-researcher J. Bryan Sexton, an
assistant professor of
anesthesiology and critical care medicine at Johns
Hopkins. The survey is not limited to the OR. Variations of
the SAQ have been used to analyze work environments
throughout the hospital, he said.
"We found that using frontline caregiver assessments of
patient safety can give you a valid and reliable consensus
on how things are going in a particular patient care area,
and that this is related to important outcomes like
hospital-acquired infections, length of stay and nurse
turnover," Sexton said.
Reports by the Institute of Medicine regarding safety in
the OR, rising malpractice costs and the demonstrated
vulnerability and devastation hospitals face after public
exposure of deaths due to OR errors have all drawn
attention to the importance of developing sound hospital
systems to reduce OR errors. As a result, the Joint
Commission on Accreditation of Healthcare Organizations
will require all hospitals to measure their culture
beginning in 2007.
Wrong site/wrong procedure surgeries, retained sponges,
unchecked blood transfusions, mismatched organ transplants
and overlooked allergies are examples of potentially
catastrophic events that, in certain circumstances, can be
prevented by improved communication and safer hospital
The team fine-tuned the SAQ by reviewing the literature on
patient safety, asking OR health care providers to review
the survey and conducting focus groups.
These SAQ questions were presented to all OR caregivers in
a Catholic health system comprising 60 hospitals in 16
states during July and August 2004. Results were gathered
from 222 surgeons, 1,058 OR nurses, 564 surgical
technicians, 170 anesthesiologists and 121 CRNAs. On each
question on teamwork, participants were asked to rate
themselves and their peer groups on a scale of 1 (very low)
to 5 (very high). The overall response rate was 77.1
"The results have already led to improvements in the OR,"
Makary said. "Before every operation, we now require a
pre-surgery checklist similar to what pilots do before
take-off. This not only minimizes errors but also improves
Makary said 700 hospitals are already using the survey, and
he expects to see more adapting it in the near future.
This study was conducted with a grant from the Agency for
Healthcare Research and Quality.
Other Johns Hopkins investigators involved in the study are
Julie A. Freischlag, chief of Surgery, SoM; Peter J.
Pronovost, professor, and Christine Holzmueller, senior
research program coordinator, Department of Anesthesiology
and Critical Care Medicine, SoM; E. Anne Millman, research
associate, Bloomberg School of Public Health; and Lisa
Rowen, Surgical Nursing director, JHH. David B. Pryor,
senior vice president for clinical excellence at Ascension
Health Systems in St. Louis, Mo., also contributed to the