Anne van Dalen

244 I Chapter 9 by the team are consequently controlled and prepared for implementation. In this ‘circle of safety’, suggested improvements may be tested in a simulation setting and then applied in the real world. The focus of this last step is process standardisation and optimisation. Indeed, Six Sigma focusses on reducing process variability, yet we ought to accept that healthcare is different from the aviation and car industries, as human variability plays a much bigger role. Resilience results in good outcomes in the presence of adverse conditions by positive adaptability within systems, and to this end human variability is essential. 23 However, by using an objective data monitoring system such as the Operating Room Black Box and following the above-mentioned DMAIC approach, variability in the safety of healthcare can be reduced, which may ulti- mately result in a higher Six Sigma safety level. 6,11 Conclusions While it is laudable that healthcare professionals accept responsibility for their actions, their behaviour resonates with and results from the context, organisation and culture in which they act. In most operating environments, even if the atmosphere is constructive, identifying and acknowledging error is difficult. More transparency concerning error management and shared belief that engagement leads to safety improvement are of utmost importance. To reduce the incidence of errors in the operating theatre, quality and safety improvement initiatives ought to involve the entire team, promoted and supported by the organisation. The use of innovative analytical platforms such as anOperating Room Black Box should therefore be embraced, as they may support process optimisation and help healthcare organisations reach the level of a progressive, sustainable, and Six Sigma safety culture in the operating theatre.