On the third day of a surgical sub-internship, a fourth-year medical student is invited by the chair of the department to observe the operative repair of a congenital heart lesion on a 4-year-old girl. A team of multiple providers is present in the operating room, including a surgical scrub nurse, anesthesiologist, and surgical resident. As preparations are made to begin the procedure, a team member places a Foley catheter into the patient. The medical student notices that, unlike what he had seen with adult patients, no sterile precautions are taken prior to placing the catheter. Aware of his status as the most junior member on the team, the student remains silent. The following day, the patient becomes febrile and urine cultures grow Pseudomonas aeruginosa. Which of the following would most likely have encouraged this student to express his concern to the team during the procedure?
Features of effective teams* in health care | |
Safety culture |
|
Collaboration |
|
Psychological safety |
|
Responsiveness |
|
Situational awareness |
|
Transparency |
|
*Poor teamwork is a leading root cause of sentinel events; improved communication reduces medical errors & improves patient/clinical outcomes. | |
Effective teamwork allows each team member, regardless of status, to promote patient safety through vigilance (monitoring for error). However, as this scenario illustrates, perception of steep hierarchy gradients increases fear of speaking up and medical error risk. This student's hesitation to question the lack of sterile procedures prior to Foley catheter placement reflects low psychological safety (eg, comfort expressing safety-related concerns and questions without fear of intimidation), which is common with junior status on a team and inexperience with safety communication.
Team safety debriefings are collaborative discussions encouraging expression of safety-related concerns and actions in a specific situation. They can occur before or after a clinical event. Debriefings are used by high-reliability organizations (organizations with excellent safety records despite high risk, such as aviation) to strengthen safety culture (shared commitment to safety goals) and continuous team learning. Attending team briefings can improve the student's psychological safety, confidence in safety culture, and familiarity with relevant communication skills, increasing likelihood of voicing his concerns during the procedure.
(Choice B) Although rounding in interprofessional teams (eg, teams involving multiple disciplines, such as nursing, pharmacy, social work) can improve the student's communication and familiarity with health care fields, attending safety debriefings is a superior approach that addresses the student's status-based hesitation and specifically builds comfort with safety communication.
(Choice C) Observing roles and communication driven by hierarchy, rather than mutual collaboration and merit, is likely to worsen fear linked to perceived lower status and reduce the student's psychological safety. As seen in high-reliability organizations, team members should be encouraged to openly communicate concerns, regardless of hierarchical position, with team leaders valuing and equally respecting each member's input.
(Choice D) Training in catheter placement techniques would improve the student's understanding of required sterile precautions in both pediatric and adult patients; however, it would not improve psychological safety or status-driven hesitation to speak up in a team setting.
Educational objective:
Psychological safety strengthens safety culture by enabling team members to express questions and concerns without fear and regardless of status. Team-based safety briefings, used by high-reliability organizations (eg, aviation), improve communication skills and psychological safety by encouraging collaborative discussion and monitoring.