Role of the surgeon in quality and safety in the operating room environment.

Medical errors in the OR can result in substantial morbidity, poor functional outcomes and mortality. They are associated with significant increases in direct and indirect healthcare costs. In addition, errors in the OR associated with harm often have a profound negative impact on the patient, their family, and the medical providers' psychological and social well being. The majority of medical errors are believed to be preventable. Rarely, an error is the result of an isolated single failure in the delivery of care. More commonly, multiple linked processes contribute to the error. Poorly designed systems of care delivery, poor information and knowledge transfer, ambiguous communication between providers and poor coordination of care are frequently identified as the underlying drivers of errors. Solving the problem is as complex as the causes. Raising awareness that an error is more than an individual's problem or behavior is the first step toward a solution. Thoughtful planning in developing systems of care delivery through optimizing and leveraging the knowledge of the team members that provide care is the single most important defense against medical errors. Surgeons play an important role in facilitating the development of and empowering the teams they work through their active participation and effective leadership within the operating room team.