Proactive Patient Safety: Focusing on What Goes Right in the Perioperative Environment : Journal of Patient Safety

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Proactive Patient Safety: Focusing on What Goes Right in the Perioperative Environment

Duffy, Caoimhe MD, MSc, FCAI∗,†; Menon, Neil BS; Horak, David BS§; Bass, Geoffrey D. MD, MBA; Talwar, Ruchika MD; Lorenzi, Cara BSN, RN, CCRN; Taing Vo, Christina MSN, CRNP; Chaing, Chienhui MSN, CRNP; Ziemba, Justin B. MD, MSEd†,‡,#

Author Information
Journal of Patient Safety 19(4):p 281-286, June 2023. | DOI: 10.1097/PTS.0000000000001113



Adverse events in the perioperative environment, a potential risk to patients, may be mitigated by nurturing staff adaptability and resiliency. An activity called “One Safe Act” (OSA) was developed to capture and highlight proactive safety behaviors that staff use in their daily practice to promote safe patient care.


One Safe Act is conducted in-person in the perioperative environment by a facilitator. The facilitator gathers an ad hoc group of perioperative staff in the work unit. The activity is run as follows: staff introductions, purpose/instructions of the activity, participants self-reflect about their OSA (proactive safety behavior) and record it as free text in an online survey tool, the group debriefs with each person sharing their OSA, and the activity is concluded by summarizing behavioral themes. Each participant completed an attitudinal assessment to understand changes in safety culture perception.


From December 2020 to July 2021, a total of 140 perioperative staff participated (21%, 140/657) over 28 OSA sessions with 136 (97%, 140/136) completing the attitudinal assessment. A total of 82% (112/136), 88% (120/136), and 90% (122/136) agreed that this activity would change their practices related to patient safety, improve their work unit’s ability to deliver safe care, and demonstrated their colleagues’ commitment to patient safety, respectively.


The OSA activity is participatory and collaborative to build shared, new knowledge, and community practices focused on proactive safety behaviors. The OSA activity achieved this goal with a near universal acceptance of the activity in promoting an intent to change personal practice and increasing engagement and commitment to safety culture.

The perioperative environment is complex, dynamic, and error prone, with patients more likely to experience preventable harm during perioperative care than any other type of healthcare encounter.1 Despite this, virtually all surgical cases are performed safely and effectively, demonstrating the resilience of individuals and surgical teams.2–4

Resilience describes the “positive adaptability within systems that allows good outcomes in the presence of both favorable and adverse conditions.”5 Understanding this proactive “adaptability” and variability is the foundation of the healthcare Safety-II framework.6 In Safety-II, the focus is on how work is done at the frontline by healthcare professionals in real work conditions (“work as done”) to generate acceptable, safe outcomes almost universally (“what goes right”). This is in contrast to the traditional approach to safety management5 that relies on a conceptualized (“work as imagined”) model of how work should be performed for later comparison after an adverse event (“what went wrong”).

Assessing “what goes right” begins by connecting with frontline healthcare professionals because these are the individuals who understand the unique demands, concerns, and risks in their clinical areas. Their experience gives them rich insight and solutions across a range of ever-evolving clinical and organizational situations to which they continually adapt to deliver optimal care. These insights are essential to enhance safe care further and growing a robust safety culture within an institution, but organizations struggle to gather and learn and promote these experiences.7

Although the Safety-II framework holds promise to strengthen patient safety, it has yet to be widely adopted and inculcated among healthcare professionals and staff, particularly in the perioperative environment. Available tools such as the Perioperative Staff Safety Assessment8 from the Agency of Healthcare Research and Quality and, more recently, the Bedside Learning Coordinator7 from the National Health Service rely on the traditional approach, focusing on “what went wrong” rather than “what goes right.”7,9

Therefore, we developed a simple, yet efficient tool termed “One Safe Act” (OSA) capable of capturing, cataloging, and highlighting proactive safety behaviors and actions that staff of any role use in their daily practice to promote individual and team-based safe patient care. We hypothesized that this activity would contribute to situated learning among staff whereby they gain comfort identifying and acknowledging “what goes right” in their clinical work environment through socialization, participation, and collaboration with their colleagues to reinforce perceptions of safety culture.


Theoretical Framework

Situated learning theory surmises that individual learning occurs within a sociocultural context through legitimate peripheral participation of activities within a community of practice.10 In this scenario, novice members begin learning how to behave, act, and identify through social interactions with more senior members around activities customary or connected to the practices of the community.10 This learning is context specific, informal, experiential, participatory, and opportunistic.10 The perioperative environment, particularly the operating room itself, is a unique example of a small, but robust and colocated community of practice where members share similar beliefs, behaviors, language, experiences, identities, and practices. It is these characteristics that make the perioperative environment ripe for learning and growth of individual health professionals and cultural transformation of how work is done by teams through activities that influence the sociocultural norms of the local community, such as with the “OSA” activity.

Activity Design

In the “OSA” activity, a local clinical leader serves as the facilitator, gathering an ad hoc group of multidisciplinary and colocated health professionals. There was no standard method for or time to gather staff, which was by design to allow for flexibility in initiating and organizing the activity. Instead, facilitators harnessed natural pauses that occur in routine workflow when staff were awaiting a patient and had all preparation completed. The facilitator explains the rationale and commences with participant introductions to promote socialization. The facilitator provides an example of their own “OSA,” which is an action or behavior that they use in their daily practice to promote individual and team-based safe patient care. A brief pause with the length determined by the facilitator occurs for participants to self-reflect on their own “OSA.” Participants record these actions and behaviors in an online survey tool (Qualtrics, Inc, Seattle, WA, via their own personal mobile device for cataloging and later thematic analysis. Participants are then required to share their “OSA” to reinforce socialization and build shared, potentially new knowledge and community practices focused on proactive safety behaviors. The facilitator concludes the activity with a thematic summary of the presented “OSAs” (Fig. 1).

Key steps involved in conducting OSA.

The activity is versatile and can be performed rapidly (5–10 minutes) by any staff member on any clinical unit at any time. There is no specialized training required before facilitation. It requires no prework or supplies other than a participants’ mobile device. It has no minimum number or limit on participants. It can be performed within the work environment during a routine pause in daily events. By using these natural pauses in the routine workflow, this exercise does not impact or interrupt patient care. It has no risk management concerns as it is not associated with discussing or disclosing adverse events. Documented proactive safety behaviors can be immediately disseminated via discussion during the activity or provide institutional learning later via thematic analysis.

Setting and Context

This study was conducted within the perioperative department of a large academic tertiary care referral center in the Northeastern United States from December 2020 to July 2021. This study was approved by the institutional review board of the university affiliated with the large academic tertiary care referral center. Informed consent was waived as this was deemed quality improvement. Patients or the public were not involved in the conduct of this study. Facilitators included an attending surgeon, attending anesthesiologist, and a senior nurse, all of whom were members of the perioperative quality and safety committee with an extensive background in patient safety. All facilitators selected the day that they were scheduled to be present in the operating room for their clinical duties to complete at least one OSA activity during that shift, which further decreased the barrier to activity organization, and also allowed them to make use of the naturally occurring pauses in their personal (and the staff around them) workflow processes. As there were 3 facilitators typically working on different days and/or shifts, this allowed the majority of the days of the week to be covered with at least 1 OSA activity. Perioperative and hospital safety leadership were supportive and encouraged activity participation.

Study Population

All perioperative staff were eligible for inclusion (N = 657). When an activity facilitator was available on the unit, a convenience sample of staff were selected for participation from among those randomly assigned to work that day in support of operating room functions. Only staff actively engaged in patient care at the bedside were excluded from participation. Staff were eligible to participate in the activity more than once over the 6-month study period.

Data Collection

Free-text narrative descriptions of the behaviors or actions that promote individual and team-based safe patient care were self-reported by each participant in the online survey tool (Fig. 2). All participants self-identified their role and primary work unit and completed a 4-question attitudinal assessment (strongly agree to strongly disagree) (see supplement for full survey instrument, All responses were captured anonymously, with an optional field for participants to provide their names and consent for later internal publication of their responses.

Online survey tool used to conduct the activity and collect data.

Data Analysis

The free-text narrative responses were cataloged for later review. This analysis focuses on the responses from each of the attitudinal assessment questions (Fig. 2), which were converted to percent positive (strongly agree + somewhat agree). The primary outcome was a strongly positive intent to change practice related to patient safety.


A total of 140 staff participated in 28 OSA activity sessions during the study period. This represented 21% of the total perioperative department full-time staff (140/657). Nearly a quarter of the participants (33/140, 23%) were operating room nurses with the remaining characteristics of the cohort outlined in Table 1. Staff could potentially participate in this activity more than once, as data were collected anonymously. Table 2 includes examples of the OSA free-text narrative responses (proactive safety behaviors) submitted by participants.

TABLE 1 - Characteristics of Participants (N = 140)
Participants % n
Nursing, operating room 23.57% 33
Physician, trainee 12.86% 18
Other 9.29% 13
Nursing, prep 8.57% 12
Nursing, recovery 7.86% 11
Physician, faculty 6.43% 9
Surgical technician 5.00% 7
Radiology technician 3.57% 5
Surgical services assistant 3.57% 5
Transport 3.57% 5
Certified nurse anesthetist 3.57% 5
Medical student 2.14% 3
Administration/leadership 2.14% 3
Unit clerk 2.14% 3
Perfusion technician 1.43% 2
Facilitator 1.43% 2
Service partner 1.43% 2
CRNA 0.71% 1
Environmental services 0.71% 1
Anesthesia tech 0.00% 0
Instrument processing 0.00% 0
Pharmacist 0.00% 0
Biomedical/clinical engineering 0.00% 0
CRNA, certified registered nurse anesthetist.

TABLE 2 - Examples of OSA Free-Text Narrative Responses (Proactive Safety Behaviors) Submitted by Participants
“Always check Micromedex for compatibility when giving unfamiliar or infrequently used IV meds” Recovery nurse
“Wrapping transport pulse oximeter to supplemental nasal cannula used for transport” Trainee physician
“Always ask patients when checking in what side we are doing to verify they understand and are comfortable and I myself know. Then together we mark the correct side” Faculty physician
“Make sure all my lines (IV lines, monitor cords, O2, chest tubing) are clear before moving the patient to and from the stretcher and or throughout the halls” Transport technician
“Make sure a patient gets to their car safe… after they are discharged from the PACU” Medical assistant
“Asking patients prior to the OR what their true allergies are and reactions and editing their chart appropriately so they can receive penicillin and other antibiotics in the future if listed allergies are actually known side effects” Preoperative nurse
“Protecting patient during positioning. Making sure legs are aligned correctly while in yellow fins, arms are secured, checking shoulders and fingers.” Operating room nurse
“Check every single connection on the [ECMO] circuit” ECMO/perfusion technician
IV, intravenous; ECMO, extracorporeal membrane oxygenation; PACU, postanesthesia care unit.

The attitudinal questions were completed by 136 participants (136/140, 97%) and showed a strongly favorable response (strongly agree + somewhat agree) to participation. A total of 82% (112/136) agreed that this activity would change their practices related to patient safety, and 90% (n = 122/136) agreed that this activity would enhance their ability to contribute to patient safety in the future. Similarly, 90% (122/136) agreed that this activity demonstrated their colleagues’ commitment to patient safety, and 88% (120/136) agreed that this activity will improve their work unit’s ability to deliver safe care.


The OSA activity is participatory and collaborative by design to reinforce the sociocultural nature of situated learning, and build shared, potentially new knowledge and community practices focused on proactive safety behaviors within the perioperative environment. The OSA activity achieved this goal by eliciting and capturing these behaviors used by perioperative team members in their daily practice to ensure or promote patient safety through group dialog and discussion. The attitudinal responses also confirmed a near universal acceptance and value of the activity in prompting an intent to change personal practice and similarly increasing engagement and commitment to local safety culture.

Patient safety should be characterized not only by the absence of accidents but also by the frequency with which intended outcomes are achieved.11 Qualitative insights from frontline staff are seldom part of routine data capture. Failure to capture frontline knowledge and then enact local operational change contributes to healthcare’s slow pace of innovation adoption12 and can also lead to staff dissatisfaction and disengagement.7 One Safe Act uniquely enables access to precious frontline knowledge, gathering data on “work as done,” while simultaneously engaging with the larger perioperative community to begin the transformation into the practice of focusing on “what goes right” (Safety-II) to build even greater resilience. It provides frontline staff with a psychological safe environment to engage with members of the community of practice beyond just those with a similar role (i.e., anesthesia talking only with anesthesia colleagues), which is too often the case in a clinical work unit. One Safe Act is a starting point that enables staff to focus on interdependence, creating commonality between groups, as well as an appreciation and awareness of the teamwork that occurs every day.

The results of our attitudinal questionnaire showed that staff felt this exercise to be beneficial and positively impact their view of patient safety. One Safe Act provides an opportunity to introduce positivity into the perioperative environment as it focuses on constructive actions and behaviors. Focusing on these proactive actions can aid engagement, pleasure, and a sense of meaning in the workplace for staff, which are all linked to positive organizational outcome.13 One Safe Act allows staff to foster positive emotions and participate in collective reflection, which are recognized methods in assisting individuals develop resilience.14 Individuals who cultivate positive factors can use them to cope with negative emotions.13 An analogy between OSA can be drawn with “Three Good Things,” a positive intervention used as an intentional activity to cultivate positive cognitions and emotions.15 Similarly, OSA enhances participants’ ability and leadership’s ability to recognize positive safety initiatives already present but previously unnoticed. Next steps will focus on whether OSA has similar long-term positive psychological outcomes, particularly on reduction of staff burnout, and thematic analysis of the narrative responses, which can unlock the behaviors that support the capability of healthcare teams to almost universally deliver safe care.

Limitations and Next Steps

Limitations of this study include a programmatic evaluation of “OSA” that did not measure changes in the frequency of safety event reports or the acquisition of new proactive safety behaviors or changes in clinical practice or outcomes or association with other metrics of safety culture. This was by design as focusing on proactive safety behaviors to build system resilience rather than the traditional approach of retrospective analysis of a safety event to initiate change is a shift in how healthcare professionals think and act with regard to patient safety. The use of sociocultural learning theory as the framework for activity development helps explain why objective outcomes such as behavioral change was not assessed because staff are novices just beginning a cultural transformation. Therefore, at this stage, the objective is to increase awareness, comfort, and acceptance of focusing on proactive safety behaviors among staff within the clinical environment, which is why an attitudinal outcome was selected. Furthermore, any change in clinical outcomes based on participation in this activity would be hard to ascribe to the activity itself given the complexity of caring for the perioperative patient. However, future iterations of this activity, including comparisons with a control group, will allow for the association of participation with more traditional metrics of safety culture and assessment of acquisition of new or changed proactive safety behaviors to increase resilience as a result of participation. Finally, the study only included 21% of eligible staff as participants, which was a result of balancing facilitator and staff availability with the realities and constraints of staffing models of the perioperative department. This relatively low participation rate could have resulted in a biased attitudinal outcome if those who participated have vastly different reactions to those who did not. This seems unlikely given the overwhelming majority favoring the activity across all dimensions, and the randomness of staff selected to participate. Staff were only invited to participate if they were not actively involved in bedside patient care, which may have impacted the inclusion of some staff members, although this was rare that a natural pause could not be identified for inclusion of all staff. However, awaiting a natural pause in clinical activity meant that it could only be run sporadically. Similarly, staff could potentially participate more than once, and in future iterations, we would anticipate that staff would be exposed to this activity on a routine basis to nurture resilience and foster community building. In addition, this OSA activity could be used to develop or reinforce specific proactive behaviors known to increase safe care on a unit if centered around a particular safety theme, such as medication safety after an adverse event or hand hygiene after observations of decreased compliance. The participation in these theme-directed OSA activities could then be correlated to changes in adverse events around that safety theme or improvements in traditional safety data streams such as hand hygiene compliance over time and against other units who may not have participated in an OSA activity. Future will work will also focus on demonstrating the effectiveness of this intervention by assessing staff reported changes in proactive safety behavior, in frequency and type of adverse event reports, and in clinical outcomes of patients. Finally, this OSA activity is being used as one tool to support a health system-wide educational program into high reliability principles and practice for all staff, which will allow for future assessment of this activity in other clinical work environments, and continued advocacy of this work by local and senior leaders. This alignment of the OSA activity with the institutional priority and simultaneous cultural change to focus on proactive safety under the principles of high reliability will support the expansion of this OSA activity by encouraging those in other units to become champions and facilitators and also help to ensure the sustainability of it in the perioperative environment.


The OSA activity elicited and captured proactive safety behaviors performed by staff within the perioperative environment through a participatory and collaborative design to reinforce the sociocultural nature of situated learning, and build shared, potentially new knowledge and community practices to promote safety in their work setting. The key benefits of this approach are ease of administration, high engagement, and commitment to local safety culture that aligns with the Safety-II principles to focus on “what goes right.”


The authors thank all the staff within the Hospital of the University of Pennsylvania’s Department of Perioperative Services for their willingness to participate in the OSA activity and to Dr Jennifer Myers for her mentorship throughout the project.


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patient safety; safety management; organizational culture; perioperative care; interprofessional education

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