Anne van Dalen

132 I Chapter 4 DISCUSSION This structured analysis of 35 laparoscopic cases using audio-visual data from the MDR outcome report revealed that both resilience support events and safety threats most frequently originate from interactions between persons, and are not so much related to organization or environment. During the multidisciplinary debriefing sessions the team most often discussed events related to communication and situational awareness, also both factors associated with persons according to the SEIPS model. 15 Effective communication is a strong predictor of good teamwork. 9 38 The results of this studymay once again highlight the importance of clear communication in theOR. 5 9 39 These results are in line with the other studies that used video recording in theOR, also demonstrating that in most cases communication was the root-cause of adverse events. 26 40 41 Debriefing in surgery appears to be vital, as it was only during the postoperative debriefings that the teammembers realized the important impact of miscommunication. The debriefing discussions showed that safety threats regarding miscommunication were often caused by incorrect assumptions between the OR team members. Indeed, it has been demonstrated that team debriefing can drive the quality improvement process by identifying, and most importantly, addressing recurring, new or unrecognized safety issues. 42 43 Moreover, especially those who work in a hectic environment, might be the ones who benefit from regular feedback on their work. Because without feedback, improvement will not occur. 42 44 Traditionally, OR teams are hierarchical and divided by role which often discourage team members to speak up to or confront a surgeon. 45 46 Yet, participants in this study indicated that debriefing provided them with the opportunity to “speak up” more easily. Other factors perceived to prevent a person from speaking up have been examined in many fields outside of healthcare, including psychology, business, and aviation. 47 Cultural, professional, and organizational factors predispose people to avoid speaking up, and is often the final barrier to an adverse event in the making. 47-49 Speaking up to raise concerns about a perceived safety threat or behavior may therefore have a direct and preventive effect on adverse outcomes. 48 50