Circulation 122,210 • Volume 31, No. 3 • February 2017   Issue PDF

Conflict in the Operating Room: Impact on Patient Safety Report from the ASA 2016 Annual Meeting’s APSF Workshop

Mark A. Warner, MD; David J. Birnbach, MD, MPH

The APSF Board of Directors Workshop entitled “Conflict in the Operating Room: Impact on Patient Safety” was held on Saturday, October 22, 2016, at the McCormick Place Convention Center in Chicago, IL. This workshop used six actual case scenarios (Table 1) to trigger discussions and reflections on the very real, negative impact that conflicts between personnel in the perioperative period can have on patient safety. If you are like many of us and enjoy learning from actual cases that have teachable moments, you can find the scripts for these scenarios on the APSF website ( It takes only a simple mouse click to access them from the website (top buttons, far right, “ASA 2016”). We encourage you to read them; each takes only a single minute to read and the script is written in the style of a short stage play. The outcomes for each scenario are provided and include both patient outcomes and medicolegal, institutional (e.g., loss of privileges), and licensure results associated with the conflicts.

The names and locations used in the scenarios are modified for privacy reasons but the stories are real. We served as moderators for the workshop; anesthesiologists Emily E. Sharpe, MD, Bridget P. Pulos, MD, and Amy C. Pearson, MD (each from Mayo Clinic, Rochester, MN), joined us in acting as the characters in the scenarios. As you might expect, surgeons, nurses, and anesthesiologists were key players in the actual scenarios.

Table 1: Conflicts
1. Anesthesia professional refuses to follow institution’s sterile precautions policy during central venous catheter placement; conflict between O.R. nurse and anesthesia professional
2. Surgeon refuses to delay elective procedure of a patient who has multiple co-morbidities, hyperkalemia, and overdue dialysis; conflict between surgeon and anesthesia professional
3. Orthopedist demands to use new bone cement that has not yet been introduced into the medical center; conflict between O.R. nurse and surgeon
4. Surgeon refuses to allow transfusion of a patient who has lost 1 liter of blood; conflict between surgeon and anesthesia professional
5. Surgeon will not return to hospital to re-explore a patient whom the anesthesia professional believes is bleeding profusely into his abdomen; conflict between surgeon and anesthesia professional
6. A high-volume obstetrician demands to perform a weekend elective cesarean section for placenta accreta although it is against medical center policy; conflict between obstetrician, institutional medical director, and anesthesia professional

There is remarkable educational value in reading the scenarios and reflecting on them and the impact that the conflicts in each had on the patients’ outcomes. Here are our observations based on reflections and comments from the 167 workshop participants, each of whom joined discussions with colleagues after the cases were individually introduced:

Outcomes Matter

The first three scenarios, including their outcomes, were presented and discussed in small groups. Participants subsequently asked that the last three of the six scenarios be presented without sharing their outcomes until the small group discussions had occurred. The participants found that knowing the outcomes swayed their opinions and introduced biases into their perspectives on each of the characters. This “hindsight bias” phenomenon has been well known (Psych Bull 1990;107:311-27). It influences many medicolegal and regulatory actions taken against providers. Examples include larger jury awards when harmed patient plaintiffs are present during trials and more significant negative actions by licensing boards when patient outcomes are known at the times of deliberation. Test your own potential hindsight bias by reading several of the workshop’s six scenarios and their outcomes (“Hey, I knew that might happen.”), and then reading several of the scenarios without their outcomes (“Wow! I wouldn’t have thought that would have happened.”). All of us can learn by understanding this phenomenon.

Anesthesia Professionals Matter

In several of the scenarios, anesthesia providers likely had the ability to add positive influences into perioperative conflicts—and failed to provide the reasonable, knowledgeable, and calming influences that they could have. Everyone in the workshop’s audience agreed that proactive avoidance of potential conflicts by pre-event collaborations and discussions was the best approach to preventing perioperative conflicts. However, when they have already occurred and are ongoing, failure to engage and de-escalate building conflicts (e.g., avoidance) and succumbing to biases (e.g., choosing sides and hierarchical influences) result in lost opportunities to resolve or positively impact them. Anesthesia providers have the professional status to promote resolution of perioperative conflicts if they are willing to engage and if they use their interpersonal skills to influence those involved in the conflicts. Societal expectations are that anesthesia professionals should and must protect their patients. This includes protecting them from the potential harm that may result from perioperative interpersonnel conflicts.

Dr. Warner is currently President of the APSF and the Annenberg Professor in Anesthesiology at the Mayo Clinic. He is emeritus Executive Dean of the Mayo Clinic College of Medicine and former Chair of the Department of Anesthesiology at the Mayo Clinic.

Dr. Birnbach is currently a member of the APSF Executive Committee and APSF Board of Directors. He is Vice Provost of the University of Miami and Professor of Anesthesiology, Obstetrics and Gynecology, and Public Health. He is Senior Associate Dean and and the Director of the University of Miami-Jackson Memorial Hospital Center for Patient Safety.

Neither author has any financial conflicts to disclose associated with this article.