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GMS Current Topics in Otorhinolaryngology - Head and Neck Surgery

Deutsche Gesellschaft für Hals-, Nasen-, Ohrenheilkunde, Kopf- und Halschirurgie e.V. (DGHNOKHC)

ISSN 1865-1011

Safe patient care – safety culture and risk management in otorhinolaryngology

Review Article

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GMS Curr Top Otorhinolaryngol Head Neck Surg 2013;12:Doc09

doi: 10.3205/cto000101, urn:nbn:de:0183-cto0001011

Published: December 13, 2013

© 2013 St. Pierre.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( You are free: to Share – to copy, distribute and transmit the work, provided the original author and source are credited.


Safety culture is positioned at the heart of an organization’s vulnerability to error because of its role in framing organizational awareness to risk and in providing and sustaining effective strategies of risk management. Safety related attitudes of leadership and management play a crucial role in the development of a mature safety culture (“top-down process”). A type marker for organizational culture and thus a predictor for an organization’s maturity in respect to safety is information flow and in particular an organization’s general way of coping with information that suggests anomaly. As all values and beliefs, relationships, learning, and other aspects of organizational safety culture are about sharing and processing information, safety culture has been termed “informed culture”. An informed culture is free of blame and open for information provided by incidents. “Incident reporting systems” are the backbone of a reporting culture, where good information flow is likely to support and encourage other kinds of cooperative behavior, such as problem solving, innovation, and inter-departmental bridging. Another facet of an informed culture is the free flow of information during perioperative patient care. The World Health Organization’s safe surgery checklist” is the most prevalent example of a standardized information exchange aimed at preventing patient harm due to information deficit. In routine tasks mandatory standard operating procedures have gained widespread acceptance in guaranteeing the highest possible process quality.

Technical and non-technical skills of healthcare professionals are the decisive human resource for an efficient and safe delivery of patient care and the avoidance of errors. The systematic enhancement of staff qualification by providing training opportunities can be a major investment in patient safety. In recent years several otorhinolaryngology departments have started to incorporate stimulation based team trainings into their curriculum.

Keywords: safety culture, risk management, incident reporting, standard operating procedures, team training

1 Organizational culture and safety culture

Every private practice, department, or hospital is characterized by a certain manner of how people act and react and how the balance between patient care and economic interests, innovation, efficacy, and human attention is found. This distinctive property, “the way how we do it, how we think about certain things and how we feel” is summarized in the literature as organizational culture. Organizational culture includes all characteristics that make an organization (and this means already a private practice with a few people working there) unique as a stable social system and that makes it different from other organization. The attitudes and values of this culture can be described by means of “artifacts” (e.g. explicit rules, dress codes, designing of the practice or the wards etc.) but also by observed behavioral patterns [1]. Asking an organization about its aims regarding safety, is equivalent to asking it about its safety culture. Thus safety culture is one aspect of the organizational culture and can be defined as pattern of common attitudes regarding safety. It must be considered on three levels:

The most obvious level, i.e. the outer layer, is the observed behavior of people working in the organization. Their actions protect or jeopardize patient safety. The second level includes the conscious and thus also communicable attitudes of the colleagues regarding the value of safety in their organization. They may be congruent or discordant with the official statements of the hospital or the practice. The deepest level of those general attitudes regards the basic conviction and values that reflect the “spirit of the house” and that represent the aims of the stake holder or the practice organization. If those aims are focused on economic aspects, also the basic attitudes have an impact on patient safety. Generally the people are not conscious of those attitudes that are thus not communicable, but they influence the other two levels in a significant way. In this sense the conception of safety culture includes observable indicators as well as psychological aspects [2].

2 Safety culture: the DNA of safety

Safety culture and risk management can be compared to the genotype and phenotype of an organization: the safety culture as DNA of patient safety determines in the decisive way how high the priority of safe patient care can be “expressed” in the individual co-worker and which measures of risk management are taken to make the organization as a whole safer. In contrast to the definition, according to the Duden dictionary that defines “safety” as the “condition of being safe”, the term of safety in the context of patient care is not a static final state. Moreover, safety should be understood as a “dynamic non-event” [3]. “Non-event” means that safety cannot be defined as a permanent property but as a non-occurrence of undesired events. “Dynamic” in this context means that this state can never be lasting but it has to be achieved again every day. In this daily process of achieving safety, the staff members play a very important role.

The term of “safety culture” as a specific aspect of organizational culture was first used in 1986 by the International Atomic Energy Agency (IAEA) in a public report about the GSA (greatest supposed accident) of Chernobyl [4]. In this context the IAEA defined safety culture globally as properties and attitudes of an organization determining that safety as highest priority is paid special attention to. Beside this term of safety culture, also the concept of “safety climate” can be found in organizational literature. Both conceptions belong together, but they have different meanings [5].

  • Safety climate describes a changeable, because individual, perception of the organizational staff. If staff members are asked, their reply will always be a snap-shot of the current attitudes, convictions, and perceptions on safety and risk shared at a certain time. The safety climate of a practice or department can thus be measured and is generally inquired by means of questionnaires.
  • Safety culture is more complex and describes properties that are present for a longer time and that cannot be changed easily. Assessing the actual safety culture of the individual ENT department or practice directly is nearly impossible and requires a deep analysis of the organization including also how staff members and management interact in order to find common perceptions of safety.

3 Characteristics of safety culture

Although safety culture cannot be directly measured, there are often properties of this culture that can be associated. Those are among others [1]:

  • Self-conception (has the practice/department an explicit and written statement?)
  • Values, norms, and general principles of action
  • Traditional patterns of behavior (“We treat our patients in this certain way.”)
  • The way of interprofessional and interdisciplinary behavior (staff members, nurses, physicians in hospitals, surgical team)
  • The way of learning within the organization (in particular learning from mistakes and incidents)

This means that safety culture implies that all structures and processes within an organization, all workplaces and devices, the qualification of the staff and their relationships are designed in that way that safe action and interaction is possible at any time and at any workplace [6]. So it becomes obvious that an efficient safety culture is not delegated to single responsible staff members (e.g. safety or quality representatives) but rather that all staff members want to live the safety culture in their daily routine.

The better the safety culture is in a practice or a hospital, the less undesired events occur [7], [8], [9] and the more staff members contribute actively to the assessment of errors or undesired events [10], [11]. Safety culture cannot be changed “quite simply” and a strong safety culture does not come over night into a hospital. Changes of values need time and motivation, therefore safety culture develops based on an adaptation to economic (e.g. “Can we afford this kind of safety?”) and social (e.g. “Do we want to achieve a serious assessment of errors?”) conditions and as a reaction on success and failure (e.g. “What can we learn from a severe incident that happened last week?”). Regarding the development of a safety culture, the safety-related attitudes of the hospital management and practice owners play a decisive role (“top-down process”). Safety culture is a task to be fulfilled by the management. Efforts undertaken for changes that are only supported by particularly motivated staff members and that have to be enforced against the existing culture are generally not successful.

Looking for positive characteristics that promote a safety culture, especially the following factors are important [6]:

  • Handling of safety-critical information: In the literature, “safety culture” is often used as synonym of “informed culture” [12] so that one major characteristic for a mature safety culture and a decisive approach for changes is the handling of safety-relevant information. If an incident or accident with patient damage occurs, important safety-related information comes up unsolicited. Traditional attitudes and procedures of a department or practice are probably questioned. Further, this information can also be collected systematically and assessed which is the sense of reporting and learning systems (“incident reporting systems”) and morbidity & mortality boards. Based on a series of key aspects regarding the handling of safety-related information, different degrees of maturity of the safety-culture can be described. They will be further explained in the following.
  • Systemic thinking: It is no longer the staff member at the “sharp end” [13] having been the last one to treat the patient who is in the focus of the interest. Instead, attention is paid to the interaction of different factors concerning the people, the general conditions under which the incident has happened, and other influencing factors that might have been introduced probably several years before and that suddenly become relevant for the development of the incident. Seen from the systemic perspective, it is rarely a false action that leads to the undesired event. Moreover the basic conditions and actions on all levels of an organization make a system “vulnerable” that one single safety-endangering action is sufficient that an incident occurs. In a “vulnerable system”, similar circumstances cause similar errors, independent from the people being involved in the actions. The systemic perspective does not reduce the assessment of damages to the alternative “people or system” but postulates the complementary “people in the system” [14].
  • Justice (“Just culture”) [14], [15], [16]: The systemic approach determines that the assessment of a severe incident does not focus on assignment of guilt to a person but on the analysis of systemic factors. Just culture in this context, however, does not mean that staff members are not personally liable, as it could be understood from the frequently used term of “no blame culture”. A culture where everything is allowed and everything is forgiven would be beyond belief and risky in the eyes of the staff and so a (just) safety culture does not accept a general amnesty for failures. Because the personal responsibility of the individual is not denied, all staff members know that certain patterns of behavior endanger the safety and are thus inacceptable.
  • The human factor as risk and resource: Human factors render the action of the staff in the health sector unsafe and contribute mainly to the jeopardisation of patients. At the same time, however, the human factor is the decisive resource helping to realize patient hazard and to successfully avert the risk. Every time when an attentive person recognizes a critical situation or an error, finds a correct diagnosis and introduces corrections, human factors play a role. A strong safety culture knows that the human factor must never be equated only with a “risk factor”, and so it promotes the human factor competences of the staff (“non-technical skills”, e.g. finding decisions, communication, teamwork, stress management).
  • Orienting based on the theory of high reliability organizations (HRO) [17]: Big organizations of other economic sectors with comparably complex structures as hospitals can work without incidents and thus reliably and safe [3]. Supposing that an attentive organizational design and management can generally achieve safety and reliability of the processes, HRO exist according to certain principles:
    • Assessment of failures: Generally there is skepticism towards persisting and quiet phases of success because success bears the risk of an attitude of self-satisfaction and carelessness. HRO staff always expects the unexpected – they “hope the best and expect the worse”. That is why the staff focuses very much on failures and incidents. Since little deviations may indicate problems in the system, they are considered as cost-free opportunities to learn.
    • Caution against simplifying suppositions: Skepticism is shown towards simplifying suppositions and interpretations of events. In order to understand the complexity of the system environment differentiated and complex models and conceptions about internal and external events are preferred.
    • Sensitivity for operational processes: Operational processes and normal routine are analyzed carefully with regard to their weaknesses and their potential for errors.
    • Respect of expertise: Decisions are made case-by-case at the point where the highest professional expertise for the problem is located. This high respect of professional expertise generally allows separating functional decisions from the formal hierarchy.
    • Aspiration for flexibility and resilience: Staff members of reliable organizations know that undesired surprises may always occur. That is why the strive for flexibility on one hand in order to discover errors early and on the other hand in order to make the system more resistant by flexible adaptation in case of the occurrence of failures.
    • Intensive communication about deviations: In reliability organizations the staff members are explicitly invited to discuss actual states, deviations, individual intended actions, minimal events, and failures. Frequent reflection of decisions avoids that staff members start to accept deviating behavior, and little violation of rules as “normal” actions.

The properties described here for high reliability organizations can be understood as encouragement for the development in otorhinolaryngology. A simple transfer of this “model for success” to health care is nearly impossible because of the difference of the systems so that certain skepticism towards an easy requirement to transfer the model without adapting it is appropriate [18].

4 Levels and development of safety culture

Culture develops and changes, and so at a certain time within an organization there may be attitudes regarding safety of different intensity and changes may occur during time. This circumstance is taken in account by Diane Parker who described the model of maturity degrees of safety culture (Figure 1 [Fig. 1]). This model shows the dynamism and multidimensionality of safety culture and its possibilities of development over five levels [19]. The increasing maturity of the safety culture leads to the fact that self-protecting and suppressing views become less important and that attitudes and actions focus on safety:

  • Pathologic (“Who cares as long as no one sees us?”)
  • Reactive (“We work on safety: each time when an incident occurred.”)
  • Calculative (“We have created systems which allow us to control the risk.”)
  • Proactive (“We work on problems we notice.”)
  • Generative (“Safety? Everything we do focuses on safety!”)

Based on the phases and corresponding aspects described in Table 1 [Tab. 1] the degree of maturity of the safety culture in the individual practice or department can be assessed and stimulation for future development can be retrieved.

5 Risk management

Beside the influence of the safety culture, patient safety can be impaired by a series of other factors that lie in the severity of the disease, the risk potential of the therapy, and in the different interfaces of patients’ care. The objectives of risk management in medical services with regard to the patients should aim at

  • avoiding each endangering of the treatment purpose as well as
  • achieving the highest possible patient satisfaction and in relation to the staff members and the hospital
  • ensuring the highest possible security of the processes,
  • low costs and financial stability as well as
  • preserving a good reputation.

So risk management in medical services focuses on all factors resulting from the control process and the performance processes of patients’ treatment. “Risk management” describes a dynamic process that includes all measures for systematic identification, analysis, assessment, surveillance, and control of risks. An effective risk management should not start only after the evaluation of an incident but it should start at a time when failure can still be avoided and damage can be prevented. In the context of risk management, an iterative process (e.g. PDCA cycle) identifies and eliminates safety-endangering conditions and processes so that the process of patients’ care becomes safer – independently from the treating staff members. Since in many manuals all aspects of risk management in medical services are described exhaustively, the following paragraphs will only describe some important measures as examples that are relevant for a future improvement of the safety culture in otorhinolaryngology. As the organizational safety correlates with its management of information, in particular

  • learning and reporting systems (“incident reporting”),
  • checklists for perioperative interfaces: safe-surgery checklist of WHO, and
  • standardized patients’ care (SOPs)

allow an improvement of patients’ safety. A second and very important pillar of a strong safety culture that will have to be implemented in otorhinolaryngology is the significance of good teamwork for a higher patient safety. ENT departments often focus on

  • formal team training and
  • simulation trainings

for strengthening communication and team competences. First published results in this context seem to be promising.

6 Reporting and learning systems (“Incident Reporting Systems”; IRS)

6.1 Aims of an incident reporting system

Safety culture is “informed culture” and its degree of maturity is reflected in the management of safety-relevant information. This information based on observed or experienced incidents, failures, or process deviations can be collected by staff members and transferred to the organization. Synonymous terms to describe this kind of reporting system are error reporting system, (critical) incident reporting system, or reporting and learning system. Every incident should be reported that leads to a risk for patients, independently from the aspect if the incident could have been avoided or not and if it was based on misbehavior of the medical staff or not. Because of this functional description the term of error reporting system (– not all safety-related incidents are caused by human errors –) and the term of critical incident reporting system (CIRS) (– not all reported incidents are potentially critical for the patients –) are not really appropriate. Based on a historical background, however, the term of CIRS has been coined so that it will further be used.

An analysis of the information contained in the reports can be used to detect potential sources of errors and up to that time unidentified systemic weaknesses.

Those error-enhancing conditions (formerly also called latent errors) can then be defused so that they do not become relevant at another time in combination with other factors. A second significant function of information can be an organization learning process [20]. If the report is made available beyond the individual practice or department to the public (e.g. via; see below), learning processes in other departments or in the special medical associations can be initiated.

6.2 Properties of an incident reporting system (IRS)

With inception of the law of patients’ rights the implementation of an incident reporting system becomes a legal obligation that is also mandatory for otorhinolaryngology. With an isolated process change (“we will implement IRS starting next month”) however neither the intention of the legislator nor the sense of IRS is fulfilled. Moreover, IRS can only be introduced successfully when the basic presuppositions are present:

  • IRS are exclusively meant to avoid future incidents, their purpose it not to clarify questions of guilt or liability. A report is not analyzed under the aspect of “who is guilty?” but with regard to identifiable factors and processes. The property of IRS is to be proactive and solution-oriented.
  • IRS reports represent a subjective summary of an individual person and they do not give an extensive overview of “what had happened”. In order to assess all aspects of the incident other instruments (e.g. the London protocol [21]) have to be applied.
  • IRS are participation programs that can only exist due to the readiness of the staff members to contribute with their knowledge about sources of errors and improvement possibilities in the processes of the hospital.
  • IRS for itself is useless. In order to be effective, they have to be part of an (probably only department-related) system of risk and quality management.

Authors of the international literature mostly agree on the organization of incident reporting systems [22], [23], [24], [25]. The most important properties of an IRS are:

  • Voluntariness: No staff member is obliged to submit reports.
  • Anonymous and confidential reporting: The staff members must be able to rely on absolute confidentiality and anonymity of their reports. Anonymisation or disidentification of the reports must be performed before the public is informed so that only directly concerned people can suppose that the report describes the original incidence.
  • Freedom from sanction: A report must not lead to legal consequences for the staff members. The explicit written confirmation of the medical and nursing direction can be helpful in this context. The possibly applicable criminal responsibility or civil liability, however, is not abrogated by this confirmation.
  • No legally relevant cases: Even if an anonymisation and disidentification of the reports before publication does not allow subsequent reconstruction of the incidents, a reporting of legally relevant cases is not recommended. Since severe incidents are analyzed by other means the information that results from those investigations is at the disposition of the organization.
  • Independent from, but supported by the management: IRS must be introduced and supported by the management. At the same time, the structure of the CIRS team should be independent from the hospital management.
  • System oriented analysis by experts: If the systemic analysis of reports is meant to be systematic and successful, high expertise is required. This expertise can be present on site or imported in form of external analysis.
  • Rapid response about the consequences: The reporting staff members must be able to see the benefit of their reports. If a short-term change is not possible because of the complexity of the problem, a regular report about the current state of realization is helpful.
  • Teaching of the staff members regarding the use of IRS: The staff members must be informed about the philosophy and the operation of an IRS and undergo continuous updating. Some hospitals have made good experience with a kick-off event for introduction of the system.

With respect of the pragmatic organization of an IRS, the following aspects are applied:

  • The questionnaire must contain free-text fields. Since the relevant information is based on a possibly detailed description of the incident and the accompanying circumstances, the focus of the questionnaire should be the possibility of inserting free texts.
  • Since a successful management of the incidents leads to safety-relevant information, also successful strategies for problem solution should be assessed [26].
  • The reporting threshold must be low because not only dramatic incidents are opportunities for improvement but also unimportant deviations from standards and routine procedures.
  • The workload to submit a report must be low so that it can be integrated in the clinical routine that is characterized by time pressure. The most appropriate systems are user-friendly.
  • Reporting systems can be paper-based (“letter box”) or electronic whereas from a practical point of view electronic reporting questionnaires prevail (e.g. local databases, web-based systems).

Which system finally is introduced in a practice or hospitals is not relevant as long as the assessment and analysis of the reports corresponds to the mentioned criteria. Often this decision is anticipated by the hospital owner or the hospital group. Since many systems do not allow an insight for external people, the organizational learning potential is not used by others. In this context the “Netzwerk” (network, offered by the Ärztliches Zentrum für Qualität in der Medizin (ÄZQ, medical center for quality in medical services) on behalf of the BÄK (Bundesärztekammer, German Medical Council), KVB, Deutscher Pflegerat (German Nursing Council), deutsche Krankenhausgesellschaft (German Hospital Association) represents a recommended alternative: practices, departments, and hospitals can use the IRS as an internal reporting system and at the same time make their cases available on a national scale in order to provide experience for other ENT colleagues. Some medical associations (e.g. the German Society for Anesthesiology and Intensive Care; DGAI, Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin) use and recommend as a specific reporting and learning system.

6.3 Working of an incident reporting system

Reports that are introduced in an incident reporting system initiate a cyclical process consisting of report, analysis, measures, response. Beside changes, the report also launches learning processes within an organization (organizational learning). The knowledge about the origin and the remedial action are supposed to remain and be effective in the organization even if the staff members involved in the incident are no longer present (Figure 2 [Fig. 2]).

6.4 Introduction of an incident reporting system

The German Coalition for Patient Safety (Aktionsbündnis Patientensicherheit, APS) has formulated recommendations for actions that describe the planning and implementation of an IRS in seven steps [22] and that can be adapted to the local circumstances. Those steps are:

  • Decision phase
  • Planning phase
  • Introduction of CIRS
  • Realization of evaluation and analysis
  • Organization of improvement measures in the risk management
  • Assessment of feedback
  • Evaluation of experiences with the IRS

With the submission of a report by a staff member, the real work starts and so the decisive factor for acceptance and long-term implementation of IRS is based on the action resulting from reports. If IRS reports do not lead to visible changes the system will soon peter out. Since some reports touch very basic problems, their analysis and correction requires probably a long time and therefore regular communication about the current status of the management of those problems is important. Staff members want to know that their reports are being read, taken seriously, and serve as inducement for changes.

7 Safe surgery checklist

An informed culture knows about the safety relevance of an information loss at the perioperative interfaces: insufficient communication and unsatisfactory team work result in the largest part of safety-relevant incidents and complications in the perioperative medical services. This is mainly due to the loss of important information associated with the communication deficit [27]. A standardized information transmission in form of structured briefings is most common in high risk sectors and has also the potential in perioperative medical services to improve teamwork and the quality of results [28], [29]. In order to make the quality of the processes and the results independent from the individual user, the introduction of checklists turned out to be useful. With the purpose to systematically address the aspects that are prone to errors of diagnosis or treatment, serial checklists were suggested for the different areas in perioperative medical services [30].

The most common and safety-relevant perioperative checklist seems to be the “Surgical Safety Checklist” conceived by the World Health Organization (WHO). In an innovating study, the effect of this WHO checklist for avoiding errors in the process of surgical interventions was evaluated and a significant reduction of the operatively caused lethality (by 47%) and severe complications (by 36%) was observed [31]. The WHO divided the Surgical Safety Checklist into three parts: the part before anesthesia (“sign in”), before skin incision (“time out”), and immediately after the end of the surgery (“sign out”). This segmentation is meant to prove that at exactly defined times the treating team assesses the significant safety-relevant information about the patient and in cases of “time out” communicates this information to everybody in a clearly audible way. A direct transfer and unchanged acceptance of the original checklist is neither desired nor useful. Moreover, it should be adapted to the local circumstances according to certain rules [32] in order to guarantee the patient safety at the interfaces of the perioperative phases mostly extensively. Independently from the aspect which modifications are performed, it is important to guarantee the objective of a structured communication about the most important contents within the team.

A German journal entitled Deutsches Ärzteblatt recently published a review article [33] in which the authors describe extensively the current literature with regard to the effect of the surgical safety checklist of the WHO on the complication rate and the interdisciplinary communication, focusing especially on the changes of the safety culture in the surgery phase resulting from the application of the checklist. Because the description in the mentioned publication is very extensive, the authors only want to indicate this publication instead of discussing it at this point.

8 Implementation of standard operating procedures (SOP)

If there is an accepted best procedure for a repeatedly occurring task, this procedure should be applied by all staff members. The desired high similarity of the processes is achieved by standardization. Standardization (e.g. standards for surgeries, conservative treatments, diagnostic pathways) can be performed within a hospital or crossing departmental boundaries (e.g. guidelines of the German ENT Society). A type of standards that is very specific for practices or departments is the local definition of standard procedures (standard operating procedures, SOP). An SOP is the detailed written description of a desired procedure that is meant to standardize the accomplishment of certain tasks. The advantage of those standard procedures for the individual is that they stipulate successful treatment concepts for many situations and thus the basic process quality allows a high quality of the results. In the context of the team of the operating room, SOPs offer the advantage that all people involved know about the necessary treatment steps and their sequence and in this way the creation of common mental models is facilitated. First results indicate that the treatment results can be improved by an introduction of standardized treatment processes. Standardization causes for example that the hospital stays could be shortened which led to a reduction of the costs [34], [35].

The general acceptance of standard procedures contrasts with the fact that medical challenges or problems can be dealt with by means of several secure treatment alternatives and in the particular situation where a decision must be found, the preservation of the user’s medical (and thus personal) therapeutic freedom may have a high priority for him or her. While the non-compliance of SOPs represents a punishable default in certain high-risk technologies (e.g. aviation) the non-compliance cannot be considered as negligence or carelessness in medical services. Moreover it reflects the medical self-conception of a free profession and of the medical “culture”. However, if the medicine wants to find a way to an “ultra-safe system”, the question of a cultural re-orientation must be asked [36] only systems where the professional autonomy is given up for obligatory standards have a realistic chance to significantly increase their operative safety. This is why the operative medicine had to answer the question whether it might be ready to replace a tradition based on “creative craftsmen” [36] by a system of qualitatively equivalent (and exchangeable) team players [“equivalent actors” [36]) in order to increase the reliability.

9 Team work and patient safety

Qualified staff members are a decisive resource for safety-conscious working and for avoiding failures. However, the focus of this qualification should not only be placed on the acquaintance of medico-technical knowledge and technical skills but also on learning non-technical skills [37], [38], [39]. Communication, teamwork, and decision-making competence should be associated with medico-technical contents as part of medical and nursing competences. Especially in the medical field expert knowledge, clinical algorithms, and practical skills had been trained up to now without considering the fact that the treatment of patients is generally performed in the context of a team. In the clinical routine it is taken for granted that communication and cooperation within a team go smoothly without any problem [40].

Beside the mentioned educational deficit, the open dialogue within a treatment team is often difficult because of rigid hierarchical structures. Sometimes the significance of a hint or a warning does not depend on the logical nature of the argument but on the professional group, the professional status, or the position within the hospital hierarchy. In extreme cases an atmosphere comes up where a whole professional group (e.g. the nursing staff) or hierarchic levels (e.g. residents) is denied the competence and the authorization to express their concerns regarding safety or risks [41]. In a recently published simulation study only 28% of the staff members dared to contact their senior physician regarding their concerns about the safety of a planned measure while the other staff members remained silent hoping for a spontaneous solution of the conflict. In nearly 90% of the cases the silence led to the situation that a possibly lethal dose of a drug was given [42].[Tab. 2]

Meanwhile it can be considered as a fact that poor up to non-existent teamwork is one of the key factors for insufficient patient care and for the occurrence of incidents [43], [44]. However, upon reversion it could be shown that effective communication and good teamwork allow improvement of the quality of the patient care regarding conservative as well as operative medicine and that the frequency of failures and incidents can be reduced [43], [45], [46], [47].

10 Team training in otolaryngology

The systematic teaching of non-technical skills and the team training play an important role in the context of patient safety and mature safety culture. Training measures may include frontal teaching with interactive elements such as role playing games, case studies, and discussions [48] and also units with patient simulators (“full-scale simulators”). All social and interpersonal skills that are necessary for teamwork can be systematically achieved through those training programs. Since the non-technical skills that are significant in one field cannot be transferred from one environment to another (for example from civil aviation to the ENT operating room), behavioral marker systems were developed and validated for the surgical disciplines (NOn Technical Skills for Surgeons; NOTSS [38] or for teams of an operating room (Observational Teamwork Assessment for Surgical teams, OTAS [49]). Those behavioral markers describe which behavior patterns may strengthen the teamwork during surgical interventions and thus should be specifically trained. Table 2 [Tab. 2] and Table 3 [Tab. 3] give an overview of the categories and elements of behavioral marker systems.

After the majority of simulation-based team trainings had been performed for a long time in the classical acute care disciplines (e.g. anesthesiology, intensive care, emergency care), in pediatrics and obstetrics (overview see [50]), the simulation training is more and more often found in otorhinolaryngology. In particular the dynamic environment of the ENT-specific outpatient clinic where the staff members are confronted with high-risk emergency cases such as obstruction of the airways, bleedings, and allergic reactions is appropriate for teaching basic skills of teamwork [51], [52], [53].


Competing interests

The author declares that he has no competing interests.


Bellabarba J. Zum Konzept der Unternehmenskultur in Krankenhäusern. In: Hoefert H, editor. Führung und Management im Krankenhaus. Göttingen: Verlag für Angewandte Psychologie; 1997. p. 99-108.
Büttncher T, Fahlbruch B, Wilpert B. Sicherheitskultur. Heidelberg: Asanger; 1999.
Weick KE. Das Unerwartete managen. Wie Unternehmen aus Extremsituationen lernen. Stuttgart: Klett-Cotta; 2003.
International Nuclear Safety Group. Summary report on the post-accident review meeting on the Chernobyl accident. Vienna: International Atomic Energy Agency; 1986. (INSAG Series; 1).
Mearns KJ, Flin R. Assessing the state of organizational safety – culture or climate? Curr Psychol. 1999;18(1):5-17. DOI: 10.1007/s12144-999-1013-3 External link
St Pierre M, Hofinger G, Buerschaper C. Organisation und Fehler. In: St Pierre M, Hofinger G, Buerschaper C, editors. Notfallmanagement Human Factors und Patientensicherheit in der Akutmedizin. Heidelberg: Springer; 2010. p. 231-47.
Singer SJ, Gaba DM, Falwell A, Lin S, Hayes J, Baker L. Patient safety climate in 92 US hospitals: differences by work area and discipline. Med Care. 2009 Jan;47(1):23-31. DOI: 10.1097/MLR.0b013e31817e189d External link
Naveh E, Katz-Navon T, Stern Z. Treatment errors in healthcare. A safety climate approach. Management Science. 2005;51(6):948-60. DOI: 10.1287/mnsc.1050.0372 External link
Hofmann DA, Mark B. An investigation of the relationship between safety climate and medication errors as well as other nurse and patient outcomes. Pers Psychol. 2006;59(4):847-69. DOI: 10.1111/j.1744-6570.2006.00056.x External link
Cohen MM, Kimmel NL, Benage MK, Hoang NC, Burroughs TE, Roth CA. Implementing a hospitalwide patient safety program for cultural change. Jt Comm J Qual Patient Saf. 2004 Aug;30(8):424-31.
Gandhi TK, Graydon-Baker E, Huber CN, Whittemore AD, Gustafson M. Closing the loop: follow-up and feedback in a patient safety program. Jt Comm J Qual Patient Saf. 2005 Nov;31(11):614-21.
Reason J. Managing the risks of organizational accidents. Aldershot: Ashgate; 1997.
Reason J. The contribution of latent human failures to the breakdown of complex systems. Philos Trans R Soc Lond B Biol Sci. 1990 Apr 12;327(1241):475-84.
Dekker S. Just culture. Balancing safety and accountability. Burlingon: VT. Ashgate; 2007.
Weiner BJ, Hobgood C, Lewis MA. The meaning of justice in safety incident reporting. Soc Sci Med. 2008 Jan;66(2):403-13. DOI: 10.1016/j.socscimed.2007.08.013 External link
Frankel AS, Leonard MW, Denham CR. Fair and just culture, team behavior, and leadership engagement: The tools to achieve high reliability. Health Serv Res. 2006 Aug;41(4 Pt 2):1690-709. DOI: 10.1111/j.1475-6773.2006.00572.x External link
Weick K. The reduction of medical errors through mindful interdependence. In: Rosenthal MM, Sutcliffe KM, editors. Medical Error: What do we know? What do we do? San Francisco: Jossey Bass; 2002. p. 177-99.
Thomas EJ, Helmreich RL. Will airline safety models work in medicine? In: Rosenthal MM, Sutcliffe KM, editors. Medical Error: What do we know? What do we do? San Francisco: Jossey Bass; 2002. p. 217-34.
Parker D, Lawrie M, Hudson P. A framework for understanding the development of organizational safety culture. Safety Science. 2006;44(6):551–62. DOI: 10.1016/j.ssci.2005.10.004 External link
Argyris C, Schön DA. Organizational learning II. Theory, method, and practice. Reading, Mass.: Addison-Wesley; 1996.
Vincent C, Taylor-Adams S, Stanhope N. Framework for analysing risk and safety in clinical medicine. BMJ. 1998 Apr 11;316(7138):1154-7. DOI: 10.1136/bmj.316.7138.1154 External link
Aktionsbündnis Patientensicherheit – Arbeitsgruppe „CIRS im Krankenhaus“. Empfehlung zur Einführung von CIRS im Krankenhaus. Witten: Aktionsbündnis Patientensicherheit; 2006. Available from: External link
Leape LL. Reporting of adverse events. N Engl J Med. 2002 Nov;347(20):1633-8. DOI: 10.1056/NEJMNEJMhpr011493 External link
Mahajan RP. Critical incident reporting and learning. Br J Anaesth. 2010 Jul;105(1):69-75. DOI: 10.1093/bja/aeq133. External link
Johnson CW. Failure in safety-critical systems: a handbook of accident and incident reporting. Glasgow, Scotland: University of Glasgow Press; 2003.
Rall M, Martin J, Geldner G, Schleppers A, Gabriel H, Dieckmann P, Krier C, Volk T, Schreiner Hechltjen JL, Möllemann A. Charakteristika effektiver Incident-Reporting-Systeme zur Erhöhung der Patientensicherheit. Anästhesiol Intensivmed. 2006;47:S9-19.
Sutcliffe KM, Lewton E, Rosenthal MM. Communication failures: an insidious contributor to medical mishaps. Acad Med. 2004 Feb;79(2):186-94. DOI: 10.1097/00001888-200402000-00019 External link
Makary MA, Holzmueller CG, Thompson D, Rowen L, Heitmiller ES, Maley WR, Black JH, Stegner K, Freischlag JA, Ulatowski JA, Pronovost PJ. Operating room briefings: working on the same page. Jt Comm J Qual Patient Saf. 2006 Jun;32(6):351-5.
Hofinger G. Sicherheitskultur im Krankenhaus: Vortrag. Rahmenkongress Medizintechnik und Patientensicherheit MEK, Münster, März 2008. Available from: External link
Källberg AS, Göransson KE, Östergren J, Florin J, Ehrenberg A. Medical errors and complaints in emergency department care in Sweden as reported by care providers, healthcare staff, and patients - a national review. Eur J Emerg Med. 2013 Feb;20(1):33-8. DOI: 10.1097/MEJ.0b013e32834fe917 External link
Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AH, Dellinger EP, Herbosa T, Joseph S, Kibatala PL, Lapitan MC, Merry AF, Moorthy K, Reznick RK, Taylor B, Gawande AA; Safe Surgery Saves Lives Study Group. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009 Jan;360(5):491-9. DOI: 10.1056/NEJMsa0810119 External link
Weiser TG, Haynes AB, Lashoher A, Dziekan G, Boorman DJ, Berry WR, Gawande AA. Perspectives in quality: designing the WHO Surgical Safety Checklist. Int J Qual Health Care. 2010 Oct;22(5):365-70. DOI: 10.1093/intqhc/mzq039 External link
Fudickar A, Hörle K, Wiltfang J, Bein B. „Surgical Safety Checklist“ der Weltgesundheitsorganisation: Auswirkungen auf Komplikationsrate und interdisziplinäre Kommunikation [The effect of the WHO Surgical Safety Checklist on complication rate and communication]. Dtsch Arztebl Int. 2012;109(42):695-701. DOI: 10.3238/arztebl.2012.0695 External link
Hasibeder WR. Does standardization of critical care work? Curr Opin Crit Care. 2010 Oct;16(5):493-8. DOI: 10.1097/MCC.0b013e32833cb84a External link
Krimsky WS, Mroz IB, McIlwaine JK, Surgenor SD, Christian D, Corwin HL, Houston D, Robison C, Malayaman N. A model for increasing patient safety in the intensive care unit: increasing the implementation rates of proven safety measures. Qual Saf Health Care. 2009 Feb;18(1):74-80. DOI: 10.1136/qshc.2007.024844 External link
Amalberti R, Auroy Y, Berwick D, Barach P. Five system barriers to achieving ultrasafe health care. Ann Intern Med. 2005 May;142(9):756-64. DOI: 10.7326/0003-4819-142-9-200505030-00012 External link
Fletcher GC, McGeorge P, Flin RH, Glavin RJ, Maran NJ. The role of non-technical skills in anaesthesia: a review of current literature. Br J Anaesth. 2002 Mar;88(3):418-29. DOI: 10.1093/bja/88.3.418 External link
Yule S, Flin R, Paterson-Brown S, Maran N. Non-technical skills for surgeons in the operating room: a review of the literature. Surgery. 2006 Feb;139(2):140-9. DOI: 10.1016/j.surg.2005.06.017 External link
Reader T, Flin R, Lauche K, Cuthbertson BH. Non-technical skills in the intensive care unit. Br J Anaesth. 2006 May;96(5):551-9. DOI: 10.1093/bja/ael067 External link
Leonard M, Graham S, Bonacum D. The human factor: the critical importance of effective teamwork and communication in providing safe care. Qual Saf Health Care. 2004 Oct;13 Suppl 1:i85-90. DOI: 10.1136/qhc.13.suppl_1.i85 External link
Paula H. Patientensicherheit und Risikomanagement im Pflege- und Krankenhausalltag. Heidelberg: Springer; 2007.
St Pierre M, Scholler A, Strembski D, Breuer G. Äußern Assistenzärzte und Pflegekräfte sicherheitsrelevante Bedenken? Eine Simulatorstudie zum Einfluss des Autoritätsgradienten [Do residents and nurses communicate safety relevant concerns? Simulation study on the influence of the authority gradient]. Anaesthesist. 2012 Oct;61(10):857-66. DOI: 10.1007/s00101-012-2086-1 External link
Barrett J, Gifford C, Morey J, Risser D, Salisbury M. Enhancing patient safety through teamwork training. J Healthc Risk Manag. 2001 Fall;21(4):57-65. DOI: 10.1002/jhrm.5600210410 External link
Morey JC, Simon R, Jay GD, Wears RL, Salisbury M, Dukes KA, Berns SD. Error reduction and performance improvement in the emergency department through formal teamwork training: evaluation results of the MedTeams project. Health Serv Res. 2002 Dec;37(6):1553-81.
Baker DP, Day R, Salas E. Teamwork as an essential component of high-reliability organizations. Health Serv Res. 2006 Aug;41(4 Pt 2):1576-98. DOI: 10.1111/j.1475-6773.2006.00566.x External link
Weaver SJ, Rosen MA, DiazGranados D, Lazzara EH, Lyons R, Salas E, Knych SA, McKeever M, Adler L, Barker M, King HB. Does teamwork improve performance in the operating room? A multilevel evaluation. Jt Comm J Qual Patient Saf. 2010 Mar;36(3):133-42.
Manser T. Teamwork and patient safety in dynamic domains of healthcare: a review of the literature. Acta Anaesthesiol Scand. 2009 Feb;53(2):143-51. DOI: 10.1111/j.1399-6576.2008.01717.x External link
Sundar E, Sundar S, Pawlowski J, Blum R, Feinstein D, Pratt S. Crew resource management and team training. Anesthesiol Clin. 2007 Jun;25(2):283-300. DOI: 10.1016/j.anclin.2007.03.011 External link
Healey AN, Undre S, Vincent CA. Developing observational measures of performance in surgical teams. Qual Saf Health Care. 2004 Oct;13 Suppl 1:i33-40. DOI: 10.1136/qhc.13.suppl_1.i33 External link
St Pierre M, Breuer G, editors. Simulation in der Medizin. Grundlegende Konzepte - Klinische Anwendung. Heidelberg: Springer; 2013. DOI: 10.1007/978-3-642-29436-5 External link
Volk MS, Ward J, Irias N, Navedo A, Pollart J, Weinstock PH. Using medical simulation to teach crisis resource management and decision-making skills to otolaryngology housestaff. Otolaryngol Head Neck Surg. 2011 Jul;145(1):35-42. DOI: 10.1177/0194599811400833 External link
Deutsch ES. Simulation in otolaryngology: smart dummies and more. Otolaryngol Head Neck Surg. 2011 Dec;145(6):899-903. DOI: 10.1177/0194599811424862 External link
Malekzadeh S, Malloy KM, Chu EE, Tompkins J, Battista A, Deutsch ES. ORL emergencies boot camp: using simulation to onboard residents. Laryngoscope. 2011 Oct;121(10):2114-21. DOI: 10.1002/lary.22146 External link