Tunnel vision kills in the operating room. It is a team problem, and the whole team has to own it.
The near miss that changed our theatre
Two decades ago, a venous clamp slipped during a laparoscopic nephrectomy (keyhole surgery to remove a kidney). Metal clips resulted in this near miss, and the renal vein, the large vein draining the kidney, was at risk.
The scrub staff called for backup before anyone asked them to. Another surgeon came, venous control was achieved, and there was no catastrophe. That incident changed how we run our OR.
Bringing the whole team into the discussion
We started involving the entire team in perioperative discussions (the planning and review around an operation), including the nurses and everyone else in the room besides the surgeons. We ran crew resource management sessions.
We also asked nursing staff to share their own near-miss stories. One described stopping a liver surgeon mid-case because the cautery blade had drifted. She raised her concern, and damage was avoided.
Permission to interrupt
The shift is cultural. Surgeons have to tell staff explicitly: “You are allowed to interrupt me.”
Fixation bias, where you lock onto one explanation and stop seeing others, and the bystander effect, where everyone assumes someone else will speak up, are real cognitive traps. Hierarchy makes both worse.
A simple framework, used under pressure
We use a structured decision framework, the French mnemonic POuRDÉCider, to move through problem identification, option mapping, risk comparison and execution checks. It is simple and repeatable under pressure.
After morbidity and mortality events, a cognitive autopsy closes the loop. We go back over how the decisions were made, as well as what happened.
When OR staff feel responsible for the patient as well as for their own task, error rates fall.