Use training tactics proven successful by surgeons, soldiers, police officers, firefighters,

pilots and wilderness rescuers. This book will help you and your team

to prepare to face your next defining moment!



Book Endorsement:

The book, Crisis Management Leadership in the Operating Room, by Kenneth A. Lipshy, M.D., F.A.C.S., provides an excellent review of human cognitive errors, causes of errors, role of systems in preventing and mitigating errors, and education and training of surgical teams.  National imperatives that necessitate focus on these domains are articulated well and examples from other high-reliability organizations are helpful in considering different strategies to improve safety in surgery.  Topics of crisis management and effective leadership in the Operating Room environment are handled well. The key messages are succinctly articulated throughout the book.


This book should be a valuable resource to surgical leaders, practicing surgeons, surgery residents, and members of surgical teams.  It should help in underscoring and extending further national efforts currently underway to deliver surgical care of the highest quality and promote safety. It should also be valuable to surgical educators as they design and introduce new training programs to address gaps in this field to harness the myriad opportunities ahead.


Ajit K. Sachdeva, M.D., F.R.C.S.C., F.A.C.S.

Director, Division of Education American College of Surgeons


Disclaimer: The opinions expressed in this Foreword are those of the author and do not necessarily represent the official position of the American College of Surgeons.


by Kenneth A. Lipshy, M.D. FACS

• System Safety Net Development

• Causes of Human Error

• Adaptive and Maladaptive Behavior

• Panic Avoidance Under Stress

• Effective Team Leadership

Has your team training included:

IN THE OPERATING ROOM with Training To Survive The Critical Moment
Now Included $45.95 plus NC sales tax and shipping and handling
Please allow 2-3 weeks delivery.
Training To Survive
The Critical Moment
New 3rd Edition $22.95 plus NCsales tax and shipping and handling
Please allow 2-3 weeks delivery.

• Effective Team Followership

• Effective Team Communication

• Effective Risk Assessment

• Effective Risk Management Execution

• Debriefing

CRISIS MANAGEMENT LEADERSHIP: Training To Survive The Critical Moment now in the 3rd Edition provides a synopsis of crisis leadership styles and advice from Medical, Military, Aviation, Fire, Police and Wilderness Rescue leadership professionals (full list found under acknowledgements). This guide translates skills used in many high risk professions to methods that are adaptable to the medical field. It is a quick and easy reference to all too common but frightening events encountered during daily life in the hospital or anywhere. After years of training residents and students on how to manage the unexpected threat, this supplement provides visual memory cues to remember and practice. It continues as a supplement to the main text as an excellent review of human cognitive errors, causes of errors, role of systems in preventing and mitigating errors, and education and training of surgical teams. Topics of crisis management and effective leadership in the Operating Room environment are handled well.

About the Book:

Medical adverse events, patient safety concerns, disasters, and catastrophes are frequently attributed to human cognitive error or problematic system safety cultures.  While Crew Resource Management (CRM) and Medical Team Training (MTT) are steadily becoming the mainstay, the medical field lags significantly behind the aviation industry in terms of preparedness for a crisis.  Literature has proven that patient safety measures, including this training, improve overall patient care, yet Operating Room (O.R.) teams do not routinely engage in simulation training.  Crises in the O.R. are typically associated with cognitive error or system problems, but often are the results of unforeseen internal or external problems.  Crisis management leadership in the operating room must progress beyond the typical CRM and MTT exercises and accept that use of checklists work when the threat to the patient and team are fully recognized. Maladaptive behavior control and effective team leadership only occur when the principles utilized in this book are mastered.  After reading this book surgical leaders should be capable of: Recognizing how human error contributes to and perpetuates adverse events, Understanding how system deficiencies can allow a simple error to progress to a catastrophe or how the system can be prepared to mitigate a mistake, Understanding cognitive functions during normal and abnormal circumstances, and Effectively lead their team through the risk management and definitive action process. While the surgeons and other O.R. team members typically self-profess an exemplary response to any threatening event, second hand observer assessment usually reveals significant bias in the ability of team members to handle a crisis appropriately.  Dr. Kenneth Lipshy uses personal firsthand experience as well as instructions from military and first responders as to how any organization should respond to a crisis, to guide leaders toward a successful program in O.R. crisis management.

More About the Book:

As noted in our recent publication, “Operating room crisis management leadership training: Guidance for surgical team education”, OR teams need to be proficient in preparedness for any crisis they may encounter by integrating the steps noted in this book (see October 2013 edition of the Bulletin of the American College of Surgeons at

Book Resources:

Flow of a Crisis
Goals of Book
© Copyright 2014 Crisis Management Leadership. All Rights Reserved.

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).

© Copyright 2014 Crisis Management Leadership. All Rights Reserved.


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


© Copyright 2014 Crisis Management Leadership. All Rights Reserved.

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

I wish to express my gratitude to the following individuals:

• Bradley Lipshy, for his additional drawings.

• Jarrod Lipshy, for his additional editing skills.

• Genesis Lipshy, for her photography skills.

• Dr. Byers Bowen MD, resident EVMS, for his close attention to the details of the guide during his editing.

In addition, I am in gratitude for the individuals listed below for their informative and encouraging conversations, phone calls, and emails leading me in the right direction towards completion of this book.

• CAPT Frank K. Butler, Jr., MC USN Retired US Navy ophthalmologist, diving medical Officer, Director of Biomedical Research for the Naval Special Warfare Command. Platoon commander Navy Underwater Demolition and SEAL (Sea/Air/Land commando) teams. Diving Medical Research Officer, Navy Experimental Diving Unit. Chief of Ophthalmology - Naval Hospital Pensacola. Naval Special Warfare Command. Ophthalmic consultant to the Divers Alert Network

• Rorke Denver former head of basic and advanced SEAL training and author of- DAMN FEW: making the modern day seal warrior. 2012.

• Lt.Col Dave Grossman former Ranger, paratrooper and West Point Psychology Staff; Author of On Killing and On Combat.

• Col Thomas Kolditz, author of In Extremist Leadership; founding director West Point Leadership Center.

• Dr. Edward Kosik DO, University Oklahoma Dept Anesthesia, Simulation Center


• Col. Patrick Sweeney, Former battalion commander in 101st airborne, former director Eisenhower Leader Development program, West Point.

• Michael D. Matthews, former law enforcement officer, professor of engineering psychology, West Point, Past president of American Psychological Asso. Society for Military Psychology. Fellow, Strategic Services Office of the Chief of Staff of the Army.

• Lev Zhuravsky   RCpN, BSN, PGCert(CritCare), PGDip(HealMgt), MHealSc(HealMgt), AFACHSM Christchurch Hospital,Christchurch,New Zealand


Others who provided guidance during the construction of the textbook:

• Brigetta D. Craft, RN, MSN, DNP, Contract Patient Safety Program Manager/TeamSTEPPS Healthcare Team Training, AFMOA/SGHQ, Lackland AFB, TX

• Robert F Dees; Major General U.S. Army Retired; Author Resilient Warriors, Resilient Leaders and Resilient Nations

• Dr. Gene Deisinger, Ph.D. Deputy Chief of Police and Director of Threat Management- Virginia Tech, Blackburg, Virginia

• Dr. Alan Diehl Ph.D. Author "Air Safety Investigators: using science to save lives-- one crash at a time"

• Gordon Dupont, Aviation Safety Expert, CEO System Safety Services

• Dr. Mica R. Endsley, PhD, PE, Chief Scientist US Air Force Pentagon

• Bob Figlock, Ph.D. Navy Post Graduate School; Advanced Survey Design, LLC, Monterey, CA

• Darren P. Gibbs, Colonel, USAF; Chief, Readiness & Emergency Mgt Division (A7CX)

• Gordon Graham; Graham Research Consultants; Long Beach, CA

• Laurence Gonzales, Author, “Deep Survival”

• Billy Jackson; Detective, retired, Newport News, Virginia, Police Dept.

• William L Johnson, retired CG Commander (O-5) Ardent Sentry / Vigilant Shield Lead Planner JS J7 Joint Training / Joint Exercise Division

• Bob Hahn, Associate Director, School of Aviation Safety. Naval Aviation Schools Command

• Robin L. Homolak RN; OR Manager VA Long Beach Medical Center

• Dr. Anthony LaPorta MD, FACS Colonel Retired, US Army, Professor of Surgery, Rocky Vista University School of Medicine

• Representative Thomas Lubanau II BS JD; Wyoming State Legislature; Retired Fire Service Wyoming; Author "Crew Resource Management For the Fire Service 2002"

• CDR Mitch Morrison, PhD; Chief, Aviation Safety Division; COMDT (CG-1131); U.S. Coast Guard Headquarters

• Dr. Douglas E. Paull, M.D. Director, Patient Safety Curriculum National Center for Patient Safety

• Dr. Peter J. Pronovost, MD, PhD, FCCMSr. Vice President for Patient Safety and Quality,Director of the Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine

• Dr. Matthew Seeger PhD, Professor Dean of the College of Fine, Performing and Communication Arts and Professor of Communication, Wayne State University

• Bruce Siddle; CEO Human Factor Research Group; Author Sharpening the Warrior’s Edge: The Psychology and Science of Training

• Dr. Mark W. Scerbo, Ph.D., FHFES; Professor, Human Factors; Department of Psychology; Old Dominion University

• Dr. Mathew Sharps, Ph.D. Author of Processing Under Pressure—Stress, Memory and Decision Making in Law Enforcement

• Michael Spinks, Aircraft Safety Systems Specialist, commentator on:

• John Tippett, Deputy Chief of Operations, City of Charleston Fire Dept.  Steven Venette, Associate Professor University of Southern Mississippi, Speech Communication

• David S. Wade, M.D., FACS, Chief Medical Officer, Federal Bureau of Investigation

About the Author
Kenneth A. Lipshy, M.D. FACS

Kenneth A. Lipshy MD, FACS (Fellow American College of Surgeons) has been an active surgical leader in the Veterans Administration Health Care System.  Prior to federal service he was in private practice for eight years. His private practice career was preceded by a three-year surgery oncology fellowship at Virginia Commonwealth University. His surgical education began during an internship at Ben Taub Hospital – Baylor College of Medicine Houston, TX and was followed by completion of his surgery residency at Marshall University Huntington WV.


His interest in surgical error and its relationship to crises was sparked during his training while serving in over two dozen medical centers during his career.  However, his true interest flourished while serving as assistant scoutmaster in a local troop where he recognized a correlation between wilderness misadventures and O.R. disasters.  This, combined with close associations with local members of all branches of the armed services as well as first responders, opened the door to a wealth of information on these topics as they relate to fields that are constantly at risk of facing crises.

© Copyright 2014-2017 Crisis Management Leadership. All Rights Reserved.

Unauthorized duplication for any purpose strictly forbidden by law.