The Relationship Between Teamwork and Patient Safety

  • Sallie J. Weaver
  • Lauren E. Benishek
  • Ira Leeds
  • Elizabeth C. Wick


Effective teamwork and communication are central to successful, timely surgical care that is safe, of high quality, and patient centered. Effective teaming in the operating room and across the perioperative care continuum is related to clinical patient outcomes, patient perceptions of their care experience, care costs, and provider outcomes like burnout and job satisfaction. This chapter synthesizes core definitions of teams and teamwork, describes core models of team performance, presents practical principles for effective teaming, and highlights current evidence concerning interventions designed to develop and support effective teaming in surgery.


Patient care team Teamwork Communication Interdisciplinary team Crew resource management Patient safety Quality improvement 


  1. 1.
    Richardson WC, Berwick DM, Bisgard C, Bristow L, Buck CR, Coye J, et al. To Err is human: building a safer health system. Washington, DC: Institute of Medicine; 2000.Google Scholar
  2. 2.
    Centers for Disease Control and Prevention. Inpatient Surgery. Atlanta; 2015.Google Scholar
  3. 3.
    Healey MA, Shackford SR, Osler TM, Rogers FB, Burns E. Complications in surgical patients. Arch Surg. 2002;137(5):611–7; discussion 617–8.CrossRefPubMedGoogle Scholar
  4. 4.
    Mishra A, Catchpole K, McCulloch P. The Oxford NOTECHS system: reliability and validity of a tool for measuring teamwork behaviour in the operating theatre. Qual Saf Health Care. 2009;18(2):104–8.CrossRefPubMedGoogle Scholar
  5. 5.
    McCulloch P, Mishra A, Handa A, Dale T, Hirst G, Catchpole K. The effects of aviation-style non-technical skills training on technical performance and outcome in the operating theatre. Qual Saf Health Care. 2009;18(2):109–15.CrossRefPubMedGoogle Scholar
  6. 6.
    Wiegmann DA, ElBardissi AW, Dearani JA, Daly RC, Sundt TM. Disruptions in surgical flow and their relationship to surgical errors: an exploratory investigation. Surgery. 2007;142(5):658–65.CrossRefPubMedGoogle Scholar
  7. 7.
    Schraagen JM, Schouten A, Smit M, van der Beek D, Van de Ven J, Barach P. A prospective study of paediatric cardiac surgical microsystems: assessing the relationships between non-routine events, teamwork and patient outcomes. BMJ Qual Saf. 2011. doi: 10.1136/bmjqs.2010.048983.
  8. 8.
    Mazzocco K, Petitti DB, Fong KT, Bonacum D, Brookey J, Graham S, et al. Surgical team behaviors and patient outcomes. Am J Surg. 2009;197(5):678–85.CrossRefPubMedGoogle Scholar
  9. 9.
    Gawande AA, Studdert DM, Orav EJ, Brennan TA, Zinner MJ. Risk factors for retained instruments and sponges after surgery. N Engl J Med. 2003;348(3):229–35.CrossRefPubMedGoogle Scholar
  10. 10.
    Seiden SC, Barach P. Wrong-side/wrong-site, wrong-procedure, and wrong-patient adverse events: are they preventable? Arch Surg. 2006;141(9):931–9.CrossRefPubMedGoogle Scholar
  11. 11.
    Stewart DE, Tlusty SM, Taylor KH, Brown RS, Neil HN, Klassen DK, et al. Trends and patterns in reporting of patient safety situations in transplantation. Am J Transplant. 2015;15(12):3123–33.CrossRefPubMedGoogle Scholar
  12. 12.
    Rogers SO, Gawande AA, Kwaan M, Puopolo AL, Yoon C, Brennan TA, et al. Analysis of surgical errors in closed malpractice claims at 4 liability insurers. Surgery. 2006;140(1):25–33.CrossRefPubMedGoogle Scholar
  13. 13.
    Singh H, Thomas EJ, Petersen LA, Studdert DM. Medical errors involving trainees: a study of closed malpractice claims from 5 insurers. Arch Intern Med. 2007;167(19):2030–6. Health Policy and Quality Program, Houston Center for Quality of Care and Utilization Studies, Houston.CrossRefPubMedGoogle Scholar
  14. 14.
    The Joint Commission. Sentinel Event Data: Root Causes by Event Type. Oakbrook Terrace, IL; 2015.Google Scholar
  15. 15.
    Catchpole K, Mishra A, Handa A, McCulloch P. Teamwork and error in the operating room: analysis of skills and roles. Ann Surg. 2008;247(4):699–706.CrossRefPubMedGoogle Scholar
  16. 16.
    van Veen-Berkx E, Bitter J, Kazemier G, Scheffer GJ, Gooszen HG. Multidisciplinary teamwork improves use of the operating room: a multicenter study. J Am Coll Surg. 2015;220(6):1070–6.CrossRefPubMedGoogle Scholar
  17. 17.
    Bitter J, van Veen-Berkx E, van Amelsvoort P, Gooszen H. Preoperative cross functional teams improve OR performance. J Health Organ Manag. 2015;29(3):343–52.CrossRefPubMedGoogle Scholar
  18. 18.
    Lederer W, Kinzl JF, Trefalt E, Traweger C, Benzer A. Significance of working conditions on burnout in anesthetists. Acta Anaesthesiol Scand. 2006;50(1):58–63.CrossRefPubMedGoogle Scholar
  19. 19.
    Sharma A, Sharp DM, Walker LG, Monson JRT. Stress and burnout among colorectal surgeons and colorectal nurse specialists working in the National Health Service. Colorectal Dis. 2008;10(4):397–406.CrossRefPubMedGoogle Scholar
  20. 20.
    Nurok M, Sundt TM, Frankel A. Teamwork and communication in the operating room: relationship to discrete outcomes and research challenges. Anesthesiol Clin. 2011;29(1):1–11.CrossRefPubMedGoogle Scholar
  21. 21.
    Hull L, Arora S, Aggarwal R, Darzi A, Vincent C, Sevdalis N. The impact of nontechnical skills on technical performance in surgery: a systematic review. J Am Coll Surg. 2012;214(2):214–30.CrossRefPubMedGoogle Scholar
  22. 22.
    Hu Y-Y, Parker SH, Lipsitz SR, Arriaga AF, Peyre SE, Corso KA, et al. Surgeons’ leadership styles and team behavior in the operating room. J Am Coll Surg. 2015;222(1):41–51.CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    Timmel J, Kent PS, Holzmueller CG, Paine L, Schulick RD, Pronovost PJ. Impact of the Comprehensive Unit-based Safety Program (CUSP) on safety culture in a surgical inpatient unit. Jt Comm J Qual Patient Saf. 2010;36(6):252–60.CrossRefPubMedGoogle Scholar
  24. 24.
    Salas E, Sims DE, Burke CS. Is there a “big five” in teamwork? Small Group Res. 2005;36(5):555–99.CrossRefGoogle Scholar
  25. 25.
    Weaver SJ, Wildman J, Salas E. How to build expert teams. In: Cooper CL, Burke RJ, editors. The peak performing organization. Oxford: Taylor & Francis; 2008. p. 129–56.Google Scholar
  26. 26.
    Salas E, Rosen MA. Building high reliability teams: progress and some reflections on teamwork training. BMJ Qual Saf. 2013;22(5):369–73.CrossRefPubMedGoogle Scholar
  27. 27.
    Weaver SJ, Dy SM, Rosen MA. Team-training in healthcare: a narrative synthesis of the literature. BMJ Qual Saf. 2014;23:359–72.CrossRefPubMedPubMedCentralGoogle Scholar
  28. 28.
    Kozlowski SWJ, Bell BS. Work groups and teams in organizations. In: Borman WC, Ilgen DR, Klimoski RJ, editors. Handbook of psychology. New York: Wiley; 2003. p. 333–75.Google Scholar
  29. 29.
    Salas E, Dickinson TL, Converse SA, Tannenbaum SI. Toward an understanding of team performance and training. In: Swezey RW, Salas E, editors. Teams: Their Training and Performance. Norwood, NJ: Ablex; 1992. p. 3–29.Google Scholar
  30. 30.
    Schraagen JM, Schouten A, Smit M, van der Beek D, Van de Ven J, Barach P. Improving methods for studying teamwork in cardiac surgery. Qual Saf Health Care. 2010;19:1–6. doi: 10.1136/qshc.2009.040105.
  31. 31.
    Lemieux-Charles L. What do we know about health care team effectiveness? A review of the literature. Med Care Res Rev. 2006;63(3):263–300.CrossRefPubMedGoogle Scholar
  32. 32.
    Andreatta PB. A typology for health care teams. Health Care Manage Rev. 2010;35(4):345–54.CrossRefPubMedGoogle Scholar
  33. 33.
    Leach LS, Myrtle RC, Weaver FA, Dasu S. Assessing the performance of surgical teams. Health Care Manage Rev. 2009;34(1):29–41.CrossRefPubMedGoogle Scholar
  34. 34.
    Sundstrom E, de Meuse KP, Futrell D. Work teams: applications and effectiveness. Am Psychol. 1990;45(2):120–33.CrossRefGoogle Scholar
  35. 35.
    Kolbe M, Burtscher M, Manser T, Kunzle B, Grote G. The role of coordination in preventing harm in healthcare groups: research examples from Anaethesia and an integrated model of coordination for action teams in healthcare. In: Boos M, Kolbe M, Kappeler PM, Ellwart T, editors. Coordination in human and primate groups. Heidelberg: Springer; 2011. p. 75–92.CrossRefGoogle Scholar
  36. 36.
    Barach P, Johnson J. Safety by Design: Understanding the dynamic complexity of redesigning care around the clinical microsystem. Qual Saf Health Care. 2006; 15 Suppl 1:i10–6.Google Scholar
  37. 37.
    Mathieu JE, Marks MA, Zaccaro SJ. Multiteam systems. In: Anderson N, Ones DS, Sinangil H, Viswesvaran C, editors. International handbook of work and organizational psychology. London: Sage; 2001. p. 289–313.Google Scholar
  38. 38.
    Zaccaro SJ, Marks MA, DeChurch LA. Multiteam systems: an introduction. In: Zaccaro SJ, Marks MA, DeChurch LA, editors. Multiteam systems: an organizational form for dynamic and complex environments. New York: Taylor & Francis; 2011. p. 3–32.Google Scholar
  39. 39.
    Hinsz VB, Betts KR. Conflict in multiteam systems. In: Zaccaro SJ, Marks MA, DeChurch LA, editors. Multiteam systems: an organizational form for dynamic and complex environments. New York: Routledge; 2012. p. 289–322.Google Scholar
  40. 40.
    Mathieu JE, Maynard MT, Rapp T, Gilson L. Team effectiveness 1997–2007: A review of recent advancements and a glimpse into the future. J Manage. 2008;34(3):410–76.Google Scholar
  41. 41.
    Cannon-Bowers JA, Bowers CA. Team development and functioning. In: Zedeck S, editor. APA handbook of industrial and organizational psychology. Washington: American Psychological Association; 2010. p. 597–630.Google Scholar
  42. 42.
    Arrow H, McGrath JE, Berdahl JL. Small groups a scomplex systems: formation, coordination, development, and adaptation. Thousand Oaks: Sage; 2000.Google Scholar
  43. 43.
    Marks MA, Mathieu JE, Zaccaro S. A temporarily based framework and taxonomy of team process. Acad Manag Rev. 2001;26(3):356–76.Google Scholar
  44. 44.
    Ilgen DR, Hollenbeck JR, Johnson M. Teams in organizations: from input-process-output models to IMOI models. Annu Rev Psychol. 2005;56:517–43.CrossRefPubMedGoogle Scholar
  45. 45.
    Weaver SJ, Feitosa J, Salas E. The science of teams: the theoretical drivers, models, and competencies of team performance for patient safety. In: Salas E, Frush K, editors. Improving patient safety through teamwork and team training. New York: Oxford University Press; 2013. p. 3–26.Google Scholar
  46. 46.
    Reader TW, Flin R, Mearns K, Cuthbertson BH. Developing a team performance framework for the intensive care unit. Crit Care Med. 2009;37(5):1787–93.CrossRefPubMedGoogle Scholar
  47. 47.
    Salas E, DiazGranados D, Klein C, Burke CS, Stagl KC, Goodwin GF, et al. Does team training improve team performance? A meta-analysis. Hum Factors. 2008;50(6):903–33.CrossRefPubMedGoogle Scholar
  48. 48.
    Michalak SM, Rolston JD, Lawton MT. Prospective, multidisciplinary recording of perioperative errors in cerebrovascular surgery: is error in the eye of the beholder? J Neurosurg. 2015;124:1794–804.CrossRefPubMedGoogle Scholar
  49. 49.
    Anderson C, Talsma A. Characterizing the structure of operating room staffing using social network analysis. Nurs Res. 2011;60(6):378–85.CrossRefPubMedGoogle Scholar
  50. 50.
    Baker D, Battles J, King H, Salas E, Barach P. The role of teamwork in the professional education of physicians: current status and assessment recommendations. Jt Comm J Qual Saf. 2005;31(4):185–202.Google Scholar
  51. 51.
    Kozlowski SWJ, Ilgen DR. Enhancing the effectiveness of work groups and teams. Psychol Sci Public Interest. 2006;7(3):77–124.CrossRefPubMedGoogle Scholar
  52. 52.
    Manser T. Teamwork and patient safety in dynamic domains of healthcare: a review of the literature. Acta Anaesthesiol Scand. 2009;53(2):143–51.CrossRefPubMedGoogle Scholar
  53. 53.
    Barach P, Cosman P. Teams, team training, and the role of simulation. In: Barach P, Jacobs J, Laussen P, Lipshultz S, editors. Outcomes analysis, quality improvement, and patient safety for pediatric and congenital cardiac disease. New York, NY: Springer Books; 2014. ISBN 978-1-4471-4618-6.Google Scholar
  54. 54.
    Salas E, Lazzara EH, Benishek L. On being a team player: evidence-based heuristic for teamwork in interprofessional education. Med Sci Educ. 2014;23(3S):524–31.Google Scholar
  55. 55.
    Salas E, Shuffler ML, Thayer AL, Bedwell WL, Lazzara EH. Understanding and improving teamwork in organizations: a scientifically based practical guide. Hum Resour Manage. 2015;54(4):599–622.CrossRefGoogle Scholar
  56. 56.
    Thomas-Hunt MC, Phillips KW. Managing teams in the dynamic organization: the effects of revolving membership and changing task demands on expertise and status in groups. In: Peterson S, Mannix EA, editors. Leading and managing people in the dynamic organization. Mahwah: Lawrence Erlbaum; 2003. p. 115–34.Google Scholar
  57. 57.
    Arrow H, McGrath JE. Membership dynamics in groups at work: a theoretical framework. In: Staw BM, Cummings LL, editors. Research in organizational behavior. Greenwich: JAI Press; 1995. p. 373–411.Google Scholar
  58. 58.
    Cassera MA, Zheng B, Martinec DV, Dunst CM, Swanström LL. Surgical time independently affected by surgical team size. Am J Surg. 2009;198(2):216–22.CrossRefPubMedGoogle Scholar
  59. 59.
    Pisano G, Bohmer RMJ, Edmondson AC. Organizational differences in rates of learning: evidence from the adoption of minimally invasive cardiac surgery. Manage Sci. 2001;47(6):752–68.CrossRefGoogle Scholar
  60. 60.
    Regans R, Argote L. D B. Individual experience and experience working t ogether: predicting learning rates from knowing who knows what and knowing how to work together. Manage Sci. 2005;51(6):869–81.CrossRefGoogle Scholar
  61. 61.
    Xu R, Carty MJ, Orgill DP, Lipsitz SR, Duclos A. The teaming curve: a longitudinal study of the influence of surgical team familiarity on operative time. Ann Surg. 2013;258(6):953–7.CrossRefPubMedGoogle Scholar
  62. 62.
    Cannon-Bowers J, Tannenbaum S, Salas E, Volpe C. Defining competencies and establishing team training requirements. In: Guzzo R, Salas E, editors. Team effectiveness and decision making in organizations. San Francisco: Jossey-Bass Publishers; 1995. p. 333–80.Google Scholar
  63. 63.
    Weaver SJ, Rosen MA, Salas E, Baum KD, King HB. Integrating the science of team training: guidelines for continuing education. J Contin Educ Health Prof. 2010;30(4):208–20.CrossRefPubMedGoogle Scholar
  64. 64.
    Weaver SJ, Rosen MA. Team-training in health care: brief update review. In: Making health care safer II. An updated critical analysis of the evidence for patient safety practices. Rockville; 2013.Google Scholar
  65. 65.
    Young-Xu Y, Neily J, Mills PD, Carney BT, West P, Berger DH, et al. Association between implementation of a medical team training program and surgical morbidity. Arch Surg. 2011;146(12):1368–73.CrossRefPubMedGoogle Scholar
  66. 66.
    Neily J, Mills PD, Young-Xu Y, Carney BT, West P, Berger DH, et al. Association between implementation of a medical team training program and surgical mortality. JAMA. 2010;304(15):1693–700.CrossRefPubMedGoogle Scholar
  67. 67.
    Armour Forse R, Bramble JD, McQuillan R. Team training can improve operating room performance. Surgery. 2011;150(4):771–8.CrossRefPubMedGoogle Scholar
  68. 68.
    Hughes AM, Gregory ME, Joseph DL, Sonesh SC, Marlow SL, Lacerenza CN, Benishek LE, King HB, Salas E. Saving lives: a meta-analysis of team training in healthcare. J Appl Psychol. 2016;101(9):1266–304. doi:  10.1037/apl0000120.
  69. 69.
    Carney BT, West P, Neily JB, Mills PD, Bagian JP. Improving perceptions of teamwork climate with the Veterans Health Administration medical team training program. Am J Med Qual. 2011;26(6):480–4.CrossRefPubMedGoogle Scholar
  70. 70.
    Carney BT, West P, Neily J, Mills PD, Bagian JP. Changing perceptions of safety climate in the operating room with the Veterans Health Administration medical team training program. Am J Med Qual. 2011;26(3):181–4.CrossRefPubMedGoogle Scholar
  71. 71.
    Moffatt-Bruce SD, Hefner JL, Mekhjian H, McAlearney JS, Latimer T, Ellison C, et al. What is the return on investment for implementation of a crew resource management program at an Academic Medical Center? Am J Med Qual. 2015Google Scholar
  72. 72.
    Salas E, Weaver SJ, Gregory ME. Team training for patient safety. In: Carayon P, editor. Handbook of human factors and ergonomics in health care and patient safety. 2nd ed. Boca Raton: CRC Press; 2012. p. 627–48.Google Scholar
  73. 73.
    Weaver SJ, Lyons R, DiazGranados D, Rosen MA, Salas E, Oglesby J, et al. The anatomy of health care team training and the state of practice: a critical review. Acad Med. 2010;85(11):1746–60.CrossRefPubMedGoogle Scholar
  74. 74.
    Makary MA, Mukherjee A, Sexton JB, Syin D, Goodrich E, Hartmann E, et al. Operating room briefings and wrong-site surgery. J Am Coll Surg. 2007;204(2):236–43.CrossRefPubMedGoogle Scholar
  75. 75.
    Paull DE, Mazzia LM, Wood SD, Theis MS, Robinson LD, Carney B, et al. Briefing guide study: preoperative briefing and postoperative debriefing checklists in the Veterans Health Administration medical team training program. Am J Surg. 2010;200(5):620–3.CrossRefPubMedGoogle Scholar
  76. 76.
    Treadwell JR, Lucas S, Tsou AY. Surgical checklists: a systematic review of impacts and implementation. BMJ Qual Saf. 2014;23(4):299–318.CrossRefPubMedGoogle Scholar
  77. 77.
    Russ S, Rout S, Sevdalis N, Moorthy K, Darzi A, Vincent C. Do safety checklists improve teamwork and communication in the operating room? A systematic review. Ann Surg. 2013;258(6):856–71.CrossRefPubMedGoogle Scholar
  78. 78.
    Hannam JA, Glass L, Kwon J, Windsor J, Stapelberg F, Callaghan K, et al. A prospective, observational study of the effects of implementation strategy on compliance with a surgical safety checklist. BMJ Qual Saf. 2013;22(11):940–7.CrossRefPubMedGoogle Scholar
  79. 79.
    Russ S, Rout S, Caris J, Mansell J, Davies R, Mayer E, et al. Measuring variation in use of the WHO surgical safety checklist in the operating room: a multicenter prospective cross-sectional study. J Am Coll Surg. 2015;220(1):1–11.e4.CrossRefPubMedGoogle Scholar
  80. 80.
    Johnston FM, Tergas AI, Bennett JL, Valero V, Morrissey CK, Fader AN, et al. Measuring briefing and checklist compliance in surgery: a tool for quality improvement. Am J Med Qual. 2014;29(6):491–8.CrossRefPubMedGoogle Scholar
  81. 81.
    Weaver SJ, Rosen MA, DiazGranados D, Lazzara EH, Lyons R, Salas E, et al. Does teamwork improve performance in the operating room? A multilevel evaluation. Jt Comm J Qual Patient Saf. 2010;36(3):133–42.CrossRefPubMedGoogle Scholar
  82. 82.
    Hicks CW, Rosen M, Hobson DB, Ko C, Wick EC. Improving safety and quality of care with enhanced teamwork through operating room briefings. JAMA Surg. 2014;149(8):1–6.CrossRefGoogle Scholar
  83. 83.
    Paull DE, Mazzia LM, Izu BS, Neily J, Mills PD, Bagian JP. Predictors of successful implementation of preoperative briefings and postoperative debriefings after medical team training. Am J Surg. 2009;198(5):675–8.CrossRefPubMedGoogle Scholar
  84. 84.
    Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat A-HS, Dellinger EP, et al. Changes in safety attitude and relationship to decreased postoperative morbidity and mortality following implementation of a checklist-based surgical safety intervention. BMJ Qual Saf. 2011;20(1):102–7.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing Switzerland 2017

Authors and Affiliations

  • Sallie J. Weaver
    • 1
  • Lauren E. Benishek
    • 1
  • Ira Leeds
    • 2
  • Elizabeth C. Wick
    • 2
  1. 1.Department of Anesthesiology and Critical Care MedicineArmstrong Institute for Patient Safety & Quality, Johns Hopkins University School of MedicineBaltimoreUSA
  2. 2.Department of SurgeryJohns Hopkins University School of Medicine, and The Johns Hopkins HospitalBaltimoreUSA

Personalised recommendations