Marlot Kuiper

140 Connective Routines After the time-out, the surgeon leaves the OR to scrub, while the residents, nurse anaesthetists, and scrub nurses prepare the patient for the surgery. When the patient is safe and asleep, the team members are making ‘fun’ with each other while doing their jobs, for example, by squirting water from syringes in each other’s ears. People not only know each other by name, but they also seem to get along quite well and work in a ‘relaxed’ atmosphere. A couple of minutes later, the surgeon is operating the first patient of the day. While he is working, the next patient is already discussed in an informal way. Statements like “what shall we do”, “you tell me!” and “we’ll get there” pass by. Though the ‘plan’ for the next patient is discussed on the spot—comparable to what a briefing stipulates — this conversation is not systematic and moreover, required equipment is not yet resembled and checked at the start at the day, as the checklist prescribes. Two hours later, the operation is finished. While the assistants are cleaning up the OR, the surgeon asks: “Did we do the sign-out?” The other teammembers nod approvingly. “Oh, I missed that. That’s not quite right actually”, he replies. When the next patient is on the table, the surgeon takes the lead in the time-out again. Just like the case before, he checks the identity, intervention and prosthetic devices out of memory. The performance here deviates from the prescribed items on the checklists; some items are not covered, while others (prosthetic devices) are added to tailor the checklist to the needs of this specific context. A few minutes later, when the patient is on the table, and the time-out has just been performed, I start a conversation with the resident in thorax surgery to ask him about the briefing. The observation note covers the short conversation. I: “Do you also have a team briefing?” Resident in surgery: “This was the briefing” I: No, this was the time-out, the last check right before incision of the skin..” Resident in surgery: “Oh, no. We don’t have a briefing then.” Some confusion occurred, since the resident was convinced that they do work with the checklist — they indeed ‘performed’ some deliberation regarding the patient. However, it turned out that this team had altered the checklist through recurring performances in such a way, that it deviated from the artefact as such. In this case, strong connections among teammembers — that thus already exist