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 Today we face many problems. Some are created

essentially by ourselves based on divisions due to

ideology, religion, race, economic status, or other

factors. Therefore, the time has come for us to think

on a deeper level, on the human level, and from that

level we should appreciate and respect the sameness of

others as human beings.

—Dalai Lama

In the current healthcare environment, there is an

increasing focus on providing high quality patient

care at ever lower costs while patients rightly expect

excellent outcomes. Cardiac surgery in particular is

dependent on several disciplines working together

closely and having a good appreciation of the chal-

lenges facing each one. High quality outcomes are

dependent upon a wide array of factors, ranging from

patient specific issues, to provider acumen and tech-

nical skills, to ancillary support systems and increas-

ingly to organizational factors.

Successful healthcare organizations understand

the importance of using teams efficiently to accom-

plish difficult and complex tasks. Teams are assem-

bled with a central, unifying objective in mind and

specific roles are assigned to each member in order to

achieve this goal. This allows members to play to their

individual skill set and operate within their comfort

zone. Advanced technology, streamlined techniques,

and improved science, much of which is outlined in

the chapters of this text, have no doubt improved

practitioner skills and enhanced care. Importantly, a

shared mental model gives what would otherwise be a

group of skilled individuals working in isolation the

ability to successfully tackle increasingly complex

tasks together. Teams generally provide a purpose

and a broader sense of meaning to each member,

creating a sense of mutual support which can bind

individuals together.

Teams are especially critical for avoiding errors

and for responding to unexpected events that can

result in catastrophic complications if not managed

appropriately. The elite cardiac operating room rep-

resents a delicate symphony of quick decision-

making, refined technical skill and sound judgment

by each member of a large multidisciplinary team

consisting of perfusionists, surgeons, anesthesiolo-

gists, fellows, residents, nurses, surgical technologists

and other highly trained, capable healthcare

providers.

A hallmark feature of successful teams is effective

and open communication. The cardiac operating

room is a high stakes environment where small break-

downs in communication and teamwork can have

significant consequences on safe patient care and

outcome. With that in mind, organizations that

accredit healthcare providers, such as The Joint

Commission in the United States, have pinpointed

teamwork as being critical to thriving healthcare

organizations that provide optimal patient care and

minimize medical error.

Error

Before we understand teams, we must understand the

root cause of error. It is increasingly recognized that

most medical errors are avoidable. Rather than being

related to a lapse of technical skill, poor medical

decision-making, inadequate knowledge or subopti-

mal training, they are more commonly the result of a

breakdown in effective communication, in teamwork

or during transition of care. Addressing system-based

issues, breakdowns in cognitive networks and advan-

cing team-based approaches are essential to high

quality care.

The famous human factors engineer, James

Reason, described all systems as containing both

active and latent failures. Active failures represent

 errors made by individuals at the service delivery end

(the operating room team); latent failures are organ-

izational deficiencies (hospital wide, governmental,

manufacturers, etc.) that are lurking in the back-

ground contributing to active failures. Latent failures

can be thought of as the holes in the Swiss cheese.

When errors occur, the majority of healthcare

organizations focus on the active failures, the most

obvious of failures, through investigations like root

cause analyses or Morbidity & Mortality conferences.

Questions typically asked are: “who made mistakes?”

or “who didn’t follow the rules?.” This type of think-

ing with an emphasis on the negative has been coined

“Safety 1.” Safety 1 seeks to find the errors, the flaws,

the vulnerabilities. An alternative perspective, how-

ever, has emerged called “Safety 2.” In delivering

complex, complicated healthcare we do a lot of good

and most times, we do it correctly. We manage to do

this despite operating in increasingly complex

systems, with ever changing providers and more and

more demanding patients. The reason things go right

is not that people behave as they are supposed to but

because people adapt to the conditions they work in

to make outcomes better. Understanding how people

and the systems they work in adjust in order to

provide great care is how “Safety 2” is framed. Safety

2 embraces the variability in the healthcare delivery

system and seeks to understand it. For example: Sally,

a perfusionist, is sought-after for complicated cases.

She is talented clinically, communicates well, shares

what she is thinking, makes good decisions and is

steady under pressure. Sally’s resilience serves the

team well and, when Sally is there, it performs better.

Rather than punishing people for making poor deci-

sions (Safety 1), Safety 2 seeks to understand what

Sally does well and how this can be transferred to

other situations.

The two different perspectives are best summar-

ized in Table 1.1.