Anne van Dalen

266 I Summary and General Discussion that prevent a person from speaking up have been examined in many fields outside of healthcare, including psychology, business, and aviation. 11 Cultural, professional, and organisational factors predispose people to avoid speaking up, and is often the final barrier to a safety threat. 11-13 Speaking up to raise concerns about a perceived safety threat or behaviour has therefore a direct and preventive effect on adverse events. The OR team members also indicated that participating in the debriefings made them feel “more valuable” and “part of the team”, which has a positive impact on the personal well-being of the team members, job satisfaction, and organisational commitment. 15-17 Promoting these human factors is hence very important when it comes to improving team performance and thus the safety culture. The evidence on the impact of the team’s non-technical skills on patient outcomes is still limited, as it is difficult to analyse these factors with traditional research methods. 89 92 Just describing adverse events and reporting their frequency does not adequately capture the complex, independent factors surrounding intra-operative events. Explicit clarification is necessary and objective multisource data, as provided by the Black Box, are hence needed. 89 92 Video recording surgical procedures using a Black Box has consequently multiple benefits, as the complex interactions between the clinicians and their environment can be captured at a level of detail that exceeds the capability of human observers, and surpasses their level of objectivity. 27 72 Human factors in the operating room The OR is a unique and high-stress environment, where professionals from various specialties, disciplines and level of seniority are required to work closely together as a team. As emphasized, it is important to ensure that a shared mental model is perceived by all members of the OR team. 38 45 Highly cohesive teams support the expression of individual opinions, which promotes identification of an active or latent unsafe acts. 33 Unsafe acts need to be identified and managed pro-actively, in order to mitigate peri- operative errors, as these are often the result of a cumulation of minor aberrations resulting from different factors in the OR. 12 Pro-active error management requires a supportive and safe environment in which the entire OR team is able and willing to speak