Anne van Dalen

Six Sigma in surgery I 239 9 The operating theatre is a high-performance and high-stress environment, and an environment where a culture of blame andshame is stillprevalent. 1 This,despite the fact that errors are rarely the result of individual failure, but are the consequence of an uninterrupted chain of multiple and multifactorial events. Safe delivery of surgical care is complex and co-dependent of many organisational and environmental factors, including patient, task and technology, individual and teamfactors. 1 Human factors are known to have a major impact on surgical outcome. 1 Multiple strategies aim at improving surgical safety and can therefore be categorised into two routes; technological/managerial/engineering related or non- technical/human factors related. 2 The first involves the higher levels in an organisation and the latter is at the workers’ level, including job satisfaction, motivation, and attitudes, all influencing safety behaviour. Both routes, however, impact the same outcomes and influence or even complement each other. Safety culture combines the technical, social, and scientific dimensions of safetymanagement, which encompasses all ideas, beliefs, and habits that affect how safety is managed at different organisational levels. 1,2 Organisations with a positive safety culture are characterised by communications founded on mutual trust, shared perceptions of the importance of safety, and by confidence in the efficacy of preventive measures. 1 Safety culture is hence a very broad and inclusive high-order construct, founded on the individual attitudes and values of everyone involved. 1,2 This editorial highlights the importance of improving safety culture and discusses an innovative strategy to reach a higher safety level in the operating theatre. Six Sigma safety level Before the COVID-19 pandemic, more than 100 000 flights a day were safely executed. The risk of an airplane being involved in a fatal accident is one in 16 million flights. Key to this success has been the implementation of a system approach, in which ‘errors’ are addressed without blame, yet proactively, to diminish the consequences before they escalate into serious adverse events. 3 Causes are searched for within the system rather than blaming one individual. As a result, safety improvement gaps within the system and their consequences can be identified and resolved. 4 Using this approach, aviation was able