The natural process of heuristics that can lead to our mistakes is increased to a dangerous level when we encounter an unfamiliar threat / scenario and are distracted or fatigued. We are most prone to making an error when we are fatigued but are also at risk when we are less wary (i.e. in the vacation state of mind).

After reading this book surgical leaders should be capable of teaching to their O.R. team to:

1. Recognize how human error contributes to and perpetuates adverse events

2. Understand how system deficiencies can allow a simple error to progress to a catastrophe or how the system can be prepared to mitigate a mistake

3. Understand cognitive functions during normal and abnormal circumstances

4. Recognize that during a crisis the team will proceed through successful or self-destructive pathways determined by their ability to:

a. Control panic and dissociation

b. Establish clear lines of leadership and followership

c. Communicate effectively

d. Maintain situational awareness

e. Perform effective risk management strategies

George C. Velmahos, MD, PhD, MSEd, John F. Burke Professor of Surgery, Harvard Medical School, Chief—Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital

This book is invaluable not only for its content but also for the way it passes the information. In a technically masterful fashion Dr. Lipshy uses a direct style of language, representative figures and diagrams, and appropriate evidence to make the text flow naturally and easy to read.

The case about cohesive team building and leadership through crisis is made effectively, and practical solutions are given. I must admit that the book was an eye-opener to me in so many ways. ~ George C. Velmahos

*****

John A. Weigelt, MD, DVM, MMA Department of Surgery, Trauma Division/CC Medical College of Wisconsin

Milt and Lidy Lunda Aprahamian Professor of Surgery, Associate Dean of Clinical Quality, Medical College of Wisconsin

Editor in Chief, Journal of Surgical Education

Healthcare providers are constantly being told that we need to improve safety within our healthcare system. Multiple suggestions are made regarding how to achieve a safer environment, but are these principles of a highly reliable organization reaching the front lines of surgical practice? Dr. Lipshy has taken many of the basic principles of safety, teamwork, performance improvement, and crisis management and put them together for the operating room environment.

This book helps us understand how problems occur in the operating room. It suggests how methods from other disciplines can be used to control, mitigate, and possibly avoid these crisis situations. The book is well written. Its scenarios will be readily recognized by surgeons and anesthesiologists. Given the emphasis on safety and quality within our training programs, I suggest it might even appear on a required reading list for surgical trainees and teams. ~ John A. Weigelt

*****

Jeffrey S. Young, MD, MBA, Professor of Surgery, Director, Trauma Center, and Chief Patient Safety Officer, University of Virginia Health System

Patient care at the bedside has been neglected in the patient safety revolution in favor of metrics and colored dots. This book tries to bring this imbalance back into equilibrium. It is the critical decisions and teamwork around the operating table that save lives during un-expected events, and this book provides a fantastic framework for improving clinicians’ abilities to act intelligently in those situations. I recommend it to doctors, residents, nurses, and anyone who is involved in direct patient care. A must read. ~ Jeffrey S. Young

*****

Alexander L. Eastman, MD, MPH, FACS, Lieutenant, Dallas Police Department (SWAT), Interim Medical Director,
The Trauma Center at Parkland (UT Southwestern Medical Center)

In my experiences on SWAT, they don’t pay us to get ready, but to always be ready. This book is an excellent resource to prepare the young surgeon to respond to inevi-table intraoperative crises. Ken Lipshy’s Crisis Management Leadership In The Operating Room should help harden any operative team against compounding crisis through further error.* ~ Alexander L. Eastman

* Disclaimer: These statements represent the views of the endorser and do not necessarily express the views or policies of the Dallas Police Department.

*****

Chair, Saint Agnes Hospital, Associate Professor of Surgery, Johns Hopkins Medicine, Baltimore, Maryland

This is truly a remarkable book for it delivers important concepts from a wide array of disciplines in a concise, readable format. It manages to put in perspective the real-world situations clinical practitioners actually face daily. Through realistic examples, this book explains why we behave the way we do in a crisis and how leaders can turn maladaptive behaviors to adaptive behaviors when it really counts. It lays out a framework useful for any safety-critical team to prepare for and prevent sudden adverse events and includes key references for the reader to pursue topics further.

~ Juan Sanchez

Click to read full list of endorsements here.