Original Investigation | Surgery

Clinicians’ Perspectives on Proactive Patient Safety Behaviors

in the Perioperative Environment
Caoimhe Duffy, MD, MSc; Neil Menon, MD; David Horak, BS; Geoffrey D. Bass, MD, MBA; Ruchika Talwar, MD; Cara Lorenzi, BSN, RN, CCRN;
Christina Taing Vo, MSN, CRNP; Chienhui Chiang, MSN, CRNP; Justin B. Ziemba, MD, MSEd

Abstract Key Points

Question What are the behavioral
IMPORTANCE The perioperative environment is hazardous, but patients remain safe with a
categories that support perioperative
successful outcome during their care due to staff adaptability and resiliency. The behaviors that
staff adaptability and resilience to
support this adaptability and resilience have yet to be defined or analyzed. One Safe Act (OSA), a tool
deliver individual and team-based safe
and activity developed to capture self-reported proactive safety behaviors that staff use in their daily
care in the perioperative environment?
practice to promote individual and team-based safe patient care, may allow for improved definition
and analysis of these behaviors. Findings This qualitative thematic
analysis of self-reported proactive safety
OBJECTIVE To thematically analyze staff behaviors using OSA to understand what may serve as the behaviors included a convenience
basis for proactive safety in the perioperative environment. sample of perioperative staff from a
tertiary care academic medical center
DESIGN, SETTING, AND PARTICIPANTS This qualitative thematic analysis included a convenience who participated in a facilitated activity
sample of perioperative staff at a single-center, tertiary care academic medical center who during a 6-month period in 2021. A total
participated in an OSA activity during a 6-month period in 2021. All perioperative staff were eligible of 147 unique behaviors were identified,
for inclusion. A combined deductive approach, based on a human factor analysis and classification which were categorized into 8
framework, as well as an inductive approach was used to develop themes and analyze the self- non–mutually exclusive themes.
reported staff safety behaviors.
Meaning The set of behavioral themes
identified in this analysis may serve as
EXPOSURES Those selected to participate were asked to join an OSA activity, which was conducted
the basis for individual and team-based
in-person by a facilitator. Participants were to self-reflect about their OSA (proactive safety behavior)
practices of resilience and adaptability
and record their experience as free text in an online survey tool.
that promote patient safety.

MAIN OUTCOME AND MEASURES The primary outcome was the development and application of
a set of themes to describe proactive safety behaviors in the perioperative environment. + Invited Commentary
RESULTS A total of 140 participants (33 nurses [23.6%] and 18 trainee physicians [12.9%]), which
+ Supplemental content
Author affiliations and article information are
represented 21.3% of the 657 total perioperative department full-time staff, described 147 behaviors.
listed at the end of this article.
A total of 8 non–mutually exclusive themes emerged with the following categories and frequency of
behaviors: (1) routine-based adaptations (46 responses [31%]); (2) resource availability and
assessment adaptations (31 responses [21%]); (3) communication and coordination adaptation (23
responses [16%]); (4) environmental ergonomics adaptation (17 responses [12%]); (5) situational
awareness adaptation (12 responses [8%]); (6) personal or team readiness adaptation (8 responses
[5%]); (7) education adaptation (5 responses [3%]); and (8) social awareness adaptation (5
responses [3%]).

CONCLUSIONS AND RELEVANCE The OSA activity elicited and captured proactive safety behaviors
performed by staff. A set of behavioral themes were identified that may serve as the basis for
individual practices of resilience and adaptability that promote patient safety.

JAMA Network Open. 2023;6(4):e237621. doi:10.1001/jamanetworkopen.2023.7621

Open Access. This is an open access article distributed under the terms of the CC-BY License.

JAMA Network Open. 2023;6(4):e237621. doi:10.1001/jamanetworkopen.2023.7621 (Reprinted) April 11, 2023 1/10

Downloaded from jamanetwork.com by guest on 11/18/2023

 JAMA Network Open | Surgery Clinicians’ Perspectives on Patient Safety Behaviors in the Perioperative Environment

Introduction
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 health care
encounter.1 Despite this, virtually all surgical cases are performed safely and effectively,
demonstrating the resilience of individuals and surgical teams.2
Smith and Plunkett3 have described resilience as the “positive adaptability within systems that
allows good outcomes in the presence of both favorable and adverse conditions.” Understanding this
proactive adaptability and variability is the foundation of the health care Safety-II framework.4 In
Safety-II, the focus is on how work is done at the frontline by health care professionals in real work
conditions (what we refer to as work as done) to generate acceptable, safe outcomes almost
universally (what goes right). This is in contrast to the traditional approach to safety management3
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 health care 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 grow a robust safety culture within an institution, and
to counteract the fact that organizations struggle to gather and learn and promote these
experiences.5
Although the Safety-II framework holds promise to strengthen patient safety, it has yet to be
widely adopted and inculcated among health care professionals and staff, particularly in the
perioperative environment. Available tools such as the Perioperative Staff Safety Assessment6 from
the Agency of Healthcare Research and Quality (AHRQ) and, more recently, the Bedside Learning
Coordinator (BLC)5 from the National Health Service (NHS) rely on the traditional approach, focusing
on what went wrong rather than what goes right.5,7
Therefore, we developed a simple, efficient, and effective tool, termed One Safe Act (OSA),
capable of capturing, cataloging, and highlighting proactive safety behaviors and actions that staff of
any role utilize 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 safety culture. These
staff adaptions and behaviors can then be analyzed to identify common themes that may serve as
the basis for proactive safety in a clinical unit.

Methods
This study was approved by the University of Pennsylvania institutional review board with informed
consent waived as this was deemed to be a quality improvement study. The Standards for Reporting
Qualitative Research (SRQR) reporting guideline were followed for transparency.

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.8 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.8 This learning is context specific, informal, experiential, participatory, and
opportunistic.8 The perioperative environment, particularly an individual operating room, is a unique
example of a small but robust and co-located community of practice where members share similar
behaviors, language, experiences, identities, and practices. It is these characteristics that make the

JAMA Network Open. 2023;6(4):e237621. doi:10.1001/jamanetworkopen.2023.7621 (Reprinted) April 11, 2023 2/10

Downloaded from jamanetwork.com by guest on 11/18/2023

 JAMA Network Open | Surgery Clinicians’ Perspectives on Patient Safety Behaviors in the Perioperative Environment

perioperative environment ripe for learning and growth of health professionals through activities
that influence the sociocultural norms of the community, such as with the OSA activity.

Activity Design
Briefly, in the OSA activity, a local clinical leader serves as the facilitator, gathering an ad hoc group of
multidisciplinary and co-located health professionals (Figure 1). The facilitator provides an example
of their own “one safe act,” defined as an action or behavior that they utilize in their daily practice to
promote individual and team-based safe patient care. A pause occurs for participants to self-reflect
on their own one safe act. Participants record these actions and behaviors in an online survey tool via
their mobile device for cataloging and later thematic analysis. Participants are then required to share
their one safe act 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 one safe acts.
The activity is versatile and can be performed rapidly by any staff member on any clinical unit at
any time. It requires no preparation work or supplies other than a participant’s mobile device. It has
no minimum number or limit on participants. It is designed to be performed within the work
environment during a natural pause in daily events. It can be performed only once or repeatedly,
either as a standalone activity or as part of a larger safety program. 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 the Hospital of the University of
Pennsylvania from December 2020 to July 2021. The Perioperative Department is an
interprofessional and interdisciplinary functional unit responsible for managing the daily operations
of the procedural areas, including the perioperative care units, operating rooms, endoscopy suites,
and interventional cardiology suites.

Study Population
All 657 perioperative staff were eligible for inclusion. This included such roles as preoperative,
operative, and recovery nurse; nurse anesthetist; certified nursing assistant; radiology technicians;
environmental services technicians; instrument storage and processing technicians; and
administrative staff. In addition, all faculty, fellows, and residents from the surgical subspecialties and

Figure 1. One Safe Act Activity Diagram

Assemble
Leader gathers unit staff for
a multidisciplinary participant group

1
Summarize Introduce
Leader summarizes behavioral 6 2 Leader facilitates staff
themes for group learning introductions and presents activity

One Safe Act

Discuss 5 3 Reflect
Participants present and Participants self-reflect on
discuss their safety behaviors personal proactive safety
with the group 4 behaviors

Document
Participants document
proactive safety behaviors

JAMA Network Open. 2023;6(4):e237621. doi:10.1001/jamanetworkopen.2023.7621 (Reprinted) April 11, 2023 3/10

Downloaded from jamanetwork.com by guest on 11/18/2023

 JAMA Network Open | Surgery Clinicians’ Perspectives on Patient Safety Behaviors in the Perioperative Environment

anesthesiologists were also available for inclusion. When an activity facilitator was available on the
Table 1. Characteristics of Participants
unit, a convenience sample of staff were selected for participation from among those randomly
Participants,
assigned to work that day in support of operating room functions. Staff were potentially able to No. (%)
Role (N = 140)
participate more than once. The activity was conducted during a natural pause in the workflow, such
Nursing, operating room 33 (23.6)
as when equipment was ready, but staff were awaiting patient transport to the room.
Physician, trainee 18 (12.9)
Other 13 (9.3)
Data Collection Nursing, prep 12 (8.6)
Free-text narrative descriptions of the behaviors or actions that promote individual and team-based Nursing, recovery 11 (7.9)
safe patient care were self-reported by each participant in an online survey tool (eFigure in Physician, faculty 9 (6.4)
Supplement 1). All responses were captured anonymously. Surgical technician 7 (5.0)
Radiology technician 5 (3.6)

Data Analysis Surgical services assistant 5 (3.6)

9
Free-text narrative responses were examined using thematic analysis. Initially, these responses Transport 5 (3.6)
Certified nurse anesthetist 5 (3.6)
were examined to determine if each participant had described only 1 or more than 1 behavior. If more
Medical student 3 (2.1)
than 1 behavior was described, then each was separated out for individual analysis. Next, a set of
Administration/leadership 3 (2.1)
preliminary codes was developed by the study author (C.D.) based on the human factor analysis and
Unit clerk 3 (2.1)
classification framework.10 Each of these codes were then independently applied to the entire data
Perfusion technician 2 (1.4)
set by 4 study coauthors (C.D., J.Z., N.M., and D.H.). Initially, a total of 3 potential codes were allowed Facilitator 2 (1.4)
to be applied to each narrative response to ensure the full breadth of behaviors were identified. The Service partner 2 (1.4)
group then met to review the primary, and if applicable, the secondary and tertiary codes applied to CRNA 1 (0.7)
each narrative response by each author. During this session, the codes were refined based on group Environmental services 1 (0.7)
consensus and informed by the descriptions themselves via an inductive approach. This process was Anesthesia technician 0
then repeated in an iterative fashion for 6 additional rounds until saturation occurred and stable Instrument processing 0

themes emerged. These themes were informed by the data, but also by the authors training and Pharmacist 0

experience. Biomedical/clinical engineering 0

Abbreviation: CRNA, certified registered nurse

anesthetist.

Results
Of 657 perioperative department full-time staff who were eligible, 140 participants (21.3%)
described 147 behaviors during the study period. Nearly a quarter (33 participants [23.1%]) were
operating room nurses (Table 1).
A total of 8 non–mutually exclusive themes emerged (Table 2). Briefly, these included (1)
routine-based adaptation, defined as ensuring that a routine, repetitive, highly practiced task relating
to procedure, training, or proficiency is completed correctly; (2) resource availability and assessment
adaptation, defined as reviewing and confirming that all required resources are present and
functioning; (3) education adaptation, defined as providing staff with new information that prepares
them with the knowledge to perform a task in a standard or safe way; (4) environmental ergonomics
adaptation, defined as ensuring that the environment and equipment within it are configured
appropriately for user interaction; (5) situational awareness adaptation, defined as assessing
situations for potential errors that could arise, with adjustments to behavior to defend against these
errors from occurring; (6) communication and coordination adaptation, defined as the use of
communication, coordination, teamwork, and planning to prevent errors and enhance safety; (7)
personal or team readiness adaptation, defined as pre-duty or on-duty activities or standard
preparations required to perform optimally; and (8) social awareness adaptation, defined as
attending to the social and emotional needs of others, including patients and staff. These themes
were applied via consensus by the author coding group to each narrative description for
categorization. A primary theme was applied to each with a secondary theme applied when
necessary.
Routine-based adaptations were the most common behaviors at 31% (46 responses) (Figure 2;
Figure 3). For example, a recovery nurse wrote that they “always check Micromedex for compatibility
when giving unfamiliar or infrequently used IV [intravenous] meds” and a surgical technician

JAMA Network Open. 2023;6(4):e237621. doi:10.1001/jamanetworkopen.2023.7621 (Reprinted) April 11, 2023 4/10

Downloaded from jamanetwork.com by guest on 11/18/2023

 JAMA Network Open | Surgery Clinicians’ Perspectives on Patient Safety Behaviors in the Perioperative Environment

commented, “Making sure the patient belt is on the patient once the patient gets on the bed.”
Resource availability and assessment adaptations accounted for the next most frequent behaviors at
21% (31 responses). These behaviors included examples like “wrapping transport pulse oximeter to
supplemental nasal cannula used for transport” as described by a trainee physician, or “checking all
the monitors in my recovery pod to make sure all alarms are on and the monitors are working before
the start of my shift,” as suggested by a recovery nurse. Communication and coordination adaptation
represented 16% of the behaviors (23 responses). These behaviors included such actions as “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,” which was described by a faculty
physician, or, “I make sure I know who the covering provider is and where to find the phone
numbers,” which was submitted by a recovery nurse. Environmental ergonomics adaptation
accounted for the final large category of behaviors with 12% (17 responses). This category consisted
of behaviors such as “make sure all my lines (IV lines, monitor cords, O2, chest tubing) are clear before

Table 2. Proactive Safety Behavior Thematic Classification Scheme

Name Description
Routine-based adaptation Ensuring a routine, repetitive, highly practiced task relating to procedure, training, or
proficiency is completed correctly. Failure to do this task (eg, checklist completion,
checking allergies, using a certain piece of equipment every time a specific process is
performed) could result in an unsafe situation
Resource availability and Reviewing and confirming that all required resources (including equipment, controls, and
assessment adaptation staffing) are present and functioning correctly (eg, checking that an ultrasound machine
is available, ensuring that additional team members are available to assist). This can be an
ongoing process
Education adaptation Providing staff with new information that provides them with the knowledge to perform
a task in a standard or safe way (eg, new defibrillator training)
Environmental ergonomics Ensuring that the environment and equipment within it are configured appropriately for
adaptation user interaction (eg, placing mats on floor to cover cable, ensuring that machines are
adjusted to the correct settings). This can be an ongoing process
Situational awareness Assessing situations for potential errors that could arise, adjusting behavior to defend
adaptation against potential errors from occurring (eg, holding the door open for staff pushing a
stretcher, recognizing a risk posed by beds being left unlocked, ensuring no equipment is
hanging off the side of the bed while in transport, ensuring anesthetized patient safety)
Communication and Refers to the use of communication, coordination, teamwork, and planning to prevent
coordination adaptation errors and enhance safety. This includes provider-provider interactions (eg, using closed
loop communication, practicing read-back, calling for help, assessing staff mix when
assigning roles) and patient-provider interactions (eg, confirming laterality or procedure
to be performed)
Personal or team readiness Refers to pre-duty or on-duty activities or standard preparations required to perform
adaptation optimally on the job such as adequate sleep (eg, review of appropriate medical/technical
knowledge or patient-specific knowledge like chart or imaging review)
Social awareness Attending to the social and emotional needs of others, including patients and junior
adaptation colleagues (eg, putting patients at ease by showing empathy, helping patients feel more
comfortable by offering to answer their questions)

Figure 2. Frequency of Proactive Safety Behavioral Categories in Primary Assigned Theme

Routine-based adaptation

Resource availability and

Proactive safety behavior category

assessment adaptation
Communication and
coordination adaptation

Environmental ergonomics adaptation

Situational awareness adaptation

Personal or team readiness adaptation

Social awareness adaptation

Education adaptation

0 5 10 15 20 25 30 35
Categorization frequency, %

JAMA Network Open. 2023;6(4):e237621. doi:10.1001/jamanetworkopen.2023.7621 (Reprinted) April 11, 2023 5/10

Downloaded from jamanetwork.com by guest on 11/18/2023

 JAMA Network Open | Surgery Clinicians’ Perspectives on Patient Safety Behaviors in the Perioperative Environment

moving the patient to and from the stretcher and or throughout the halls,” as said by a transport
technician.
The remaining 4 themes each contained a relatively small number of responses, yet still
highlighted important behaviors. For example, situational awareness adaptation included “checking
on patient when alarms are going off even when they’re not my own,” as said by a recovery nurse;
or personal or team readiness adaptation, such as “during patient check in, pulling up and reviewing
relevant imaging prior to skin marking,” as described by a trainee physician; or education adaptation
like “schedule education of new equipment for the nursing staff,” from an operating room nurse; or,
finally, social awareness adaptation like “asking patients if they have any questions or concerns
before the procedure,” also from an operating room nurse. Additional examples of proactive safety
behaviors with their associated categorization are available in eTable in Supplement 1.

Discussion
The OSA activity was participatory and collaborative by design to reinforce the sociocultural nature
of situated learning and to 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 dialogue and discussion.
Thematic analysis revealed that the majority of staff report proactive safety behaviors that focus on
either routine-based tasks or ensuring appropriate resource availability. However, reported
behaviors were still quite varied, also covering dimensions such as communication, ergonomics, and
situational awareness. Individual reported behaviors were observed to be frequently cross-
functional and applicable to more than a single staff role.
Patient safety should be characterized not only by the absence of accidents but also by the
frequency with which intended outcomes are achieved.11 OSA enhances the ability of participants
and leadership to recognize positive, proactive safety initiatives already present but previously
unnoticed. 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 health care’s
slow pace of innovation adoption12 and can also lead to staff dissatisfaction and disengagement.5
OSA 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 (ie, 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 (ie, staff working in anesthesia talking only with
anesthesia colleagues), which is too often the case in a clinical work unit. OSA is a starting point that

Figure 3. Frequency of Proactive Safety Behavioral Categories in Secondary Assigned Theme

Situational awareness adaptation

Communication and
Proactive safety behavior category

coordination adaptation
Personal or team readiness adaptation

Environmental ergonomics adaptation

Situational awareness adaptation

Resource availability and

assessment adaptation

Routine-based adaptation

Education adaptation

0 5 10 15 20 25 30 35 40
Categorization frequency, %

JAMA Network Open. 2023;6(4):e237621. doi:10.1001/jamanetworkopen.2023.7621 (Reprinted) April 11, 2023 6/10

Downloaded from jamanetwork.com by guest on 11/18/2023

 JAMA Network Open | Surgery Clinicians’ Perspectives on Patient Safety Behaviors in the Perioperative Environment

enables staff to focus on interdependence, creating commonality between groups, as well as an

appreciation and awareness of the teamwork that occurs every day. Ideally, it is just one activity that
can be continuously utilized within the context of a larger safety education and practice program at
the unit, department, or institutional level to highlight and reinforce resilience within perioperative
health care teams. Specifically, collected and categorized behaviors can be further strengthened in
high-performing units or disseminated for learning and application in low-performing units.
The identified themes of staff adaptations around routines, resource availability and
assessments, education, environmental ergonomics, situational awareness, communication and
coordination, personal or team readiness, and social awareness represent a new method of
categorizing proactive safety behaviors by perioperative health care professionals. These themes are
largely congruent with the only other prior analysis of operating room staff assessing safety through
a work as done lens.13 In this qualitative interview analysis of 17 staff consisting of only operating
room nurses, registered nurse anesthetists, and surgeons, Göras13 identified only 3 universal
categories: preconditions and resources, planning and preparing for the expected and unexpected,
and adapting to the unexpected. Additional universal subcategories were identified—including
coordinating and reaffirming information, creating a plan for the patient and undergoing mental
preparation, and prioritizing and solving upcoming problems—but the remainder were occupation
specific.13 Nevertheless, there are several similarities to our responses and themes. For example, the
preconditions and resources category is equivalent to our resource availability and assessments
adaption theme and the coordinating and reaffirming information category is congruent with our
communication and coordination theme. Although further evaluation is necessary across other
populations and settings, this suggests that a core, universal set of actions may underlie safe
perioperative care.
Assessing how work is done is a relatively new lens with which to understand operating room
safety. Traditionally, safety improvement processes have relied on a deficit-based model, which
focused on engineering environments after an event to reduce or eliminate harm.14 However, this
focuses only on the very small fraction of care that results in harm. It misses understanding and
learning from the conditions that lead to success.14 Instead, utilizing a resilience engineering model,
which hypothesizes that acceptable outcomes can be maintained under expected and unexpected
conditions alike (ie, resilience), it is possible to focus on the system as a whole, learning from the
failures, everyday successes, and exceptional successes.14
Previous attempts to capture this information in the operating room have occurred, most
notably with black box technology.15,16 In a prior analysis of a single operating room with this
equipment installed, general laparoscopic surgery of only 4 surgeons was assessed to capture
potential resilient, proactive safety behaviors.15,16 In a given surgical case, a median of 12 resilient
supports were identified per case, most commonly in the person or organization category.15
Although this begins to provide insight into resilient, proactive safety behaviors in the operating
room, it focuses only on the surgical case itself, is limited to the staff in the room, and is technically
challenging to implement. However, the Resilience Engineering Tool to Improve Patient Safety
(RETIPS), which is an incident reporting structure to elicit narrative descriptions of clinical scenarios
where safe, successful care was present to capture positive adaptations, is a more flexible
approach.17 In the evaluation of the tool, a total of 9 anesthesia residents provided narrative
examples, which were later thematically evaluated. The key themes identified in the recalled
scenarios were variability in routines, preparedness, communication and coordination, and safety-
efficiency relationships.17
However, the OSA activity can deliver similar assessments across perioperative clinical (and
nonclinical) areas without the need for specialized equipment. Furthermore, our analysis is unique in
that it relied on open-ended and self-reported concrete, specific actions solicited from those in the
midst of active, presumably safe clinical care. This allows for a real-time, leading indicator of
resilience and eliminates the potential for recall bias, such as with the RETIPS narrative submissions,17
or the hypothetical bias that can occur with generic scenarios about safety care planning or dealing

JAMA Network Open. 2023;6(4):e237621. doi:10.1001/jamanetworkopen.2023.7621 (Reprinted) April 11, 2023 7/10

Downloaded from jamanetwork.com by guest on 11/18/2023

 JAMA Network Open | Surgery Clinicians’ Perspectives on Patient Safety Behaviors in the Perioperative Environment

with uncertainty. In addition, unlike traditional studies, the OSA activity can continuously provide
updated proactive safety behavior analysis through repeated administration for ongoing refinement
of these thematic categories and subsequent learning.
Finally, unlike black boxes or the RETIPS tool, which are individualistic reviews, OSA provides an
opportunity to introduce positivity into the perioperative environment as it focuses on constructive
actions and behaviors within a community of practice. 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.18 OSA allows staff to foster positive emotions and participate in
collective reflection, which are recognized methods in assisting individuals develop resilience.19
Individuals who cultivate positive factors can use them to cope with negative emotions.18 An analogy
between OSA can be drawn with Three Good Things, an intervention used as an intentional activity
to cultivate positive cognitions and emotions.20 Similarly, further studies could focus on whether
OSA has similar long-term positive psychological outcomes, particularly on reduction of staff
burnout, and through thematic analysis of the narrative responses, which can unlock the behaviors
that support the capability of health care teams to almost universally deliver safe care.

Limitations
This study had several limitations. First, this was a programmatic evaluation of OSA that did not
measure the acquisition of new proactive safety behaviors or changes in clinical practice to facilitate
safe care. There was no correlation of patient or clinical outcomes as a result of participation in OSA.
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 major
paradigm shift in how health care professionals think and act with regards to patient safety.
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 currently
practiced behaviors were selected as a primary outcome with a focus on understanding what actions
may support safe care. Future iterations of this activity will allow for the assessment of new or
changed proactive safety behaviors as a result of participation, and application of these behavioral
themes to self-reported or observed behaviors of health care staff in other clinical environments will
be necessary to validate these findings.

Conclusion
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 an
opportunity to highlight and understand behaviors that align with the Safety-II principle to focus on
what goes right in perioperative settings. This has revealed a set of behavioral themes that may serve
as the basis for individual and team-based practices of resilience and adaptability that promote
patient safety.

ARTICLE INFORMATION
Accepted for Publication: February 24, 2023.
Published: April 11, 2023. doi:10.1001/jamanetworkopen.2023.7621
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2023 Duffy C
et al. JAMA Network Open.

JAMA Network Open. 2023;6(4):e237621. doi:10.1001/jamanetworkopen.2023.7621 (Reprinted) April 11, 2023 8/10

Downloaded from jamanetwork.com by guest on 11/18/2023

 JAMA Network Open | Surgery Clinicians’ Perspectives on Patient Safety Behaviors in the Perioperative Environment

Corresponding Author: Justin B. Ziemba, MD, MSEd, Division of Urology, Department of Surgery, Perelman
School of Medicine, University of Pennsylvania, Perelman Center for Advanced Medicine, 3rd Floor W, 3400 Civic
Center Blvd, Philadelphia, PA 19104 ([email protected]).
Author Affiliations: Department of Anesthesiology & Critical Care, Perelman School of Medicine at the University
of Pennsylvania, Philadelphia (Duffy); Department of Perioperative & Procedural Services, Hospital of the
University of Pennsylvania, Philadelphia, PA (Duffy, Lorenzi, Ziemba); Division of Urology, Department of Surgery,
Hospital of the University of Pennsylvania, Perelman School of Medicine, University of Pennsylvania, Philadelphia,
Pennsylvania (Menon, Talwar, Ziemba); Department of Biological Sciences, University of Delaware, Newark
(Horak); Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
(Bass, Taing Vo); Division of Pulmonary, Allergy, and Critical Care Medicine, Perelman School of Medicine at the
University of Pennsylvania, Philadelphia (Bass); Division of Transplant Surgery, Department of Surgery, Hospital of
the University of Pennsylvania, Philadelphia (Chiang); Department of Clinical Effectiveness and Quality
Improvement, Hospital of the University of Pennsylvania, Philadelphia (Ziemba).
Author Contributions: Dr Ziemba had full access to all of the data in the study and takes responsibility for the
integrity of the data and the accuracy of the data analysis.
Concept and design: Duffy, Bass, Talwar, Lorenzi, Taing Vo, Chiang, Ziemba.
Acquisition, analysis, or interpretation of data: Duffy, Menon, Horak, Bass, Chiang, Ziemba.
Drafting of the manuscript: Duffy, Menon, Horak, Bass, Lorenzi, Ziemba.
Critical revision of the manuscript for important intellectual content: Duffy, Menon, Bass, Talwar, Taing Vo,
Chiang, Ziemba.
Statistical analysis: Duffy.
Administrative, technical, or material support: Duffy, Menon, Bass, Chiang, Ziemba.
Supervision: Duffy, Bass, Talwar.
Conflict of Interest Disclosures: None reported.
Data Sharing Statement: See Supplement 2.
Additional Contributions: We would like to thank all the staff within the Hospital of the University of
Pennsylvania’s Department of Perioperative Services for their willingness to participate in the One Safe Act activity
and to Dr Jennifer Myers, MD, for her mentorship throughout the project.

REFERENCES
1. Weinger MB. Time out! rethinking surgical safety: more than just a checklist. BMJ Qual Saf. 2021;30(8):613-617.
doi:10.1136/bmjqs-2020-012600
2. Vincent C, Moorthy K, Sarker SK, Chang A, Darzi AW. Systems approaches to surgical quality and safety: from
concept to measurement. Ann Surg. 2004;239(4):475-482. doi:10.1097/01.sla.0000118753.22830.41
3. Smith AF, Plunkett E. People, systems and safety: resilience and excellence in healthcare practice. Anaesthesia.
2019;74(4):508-517. doi:10.1111/anae.14519
4. Ham DH. Safety-II and resilience engineering in a nutshell: an introductory guide to their concepts and
methods. Saf Health Work. 2021;12(1):10-19. doi:10.1016/j.shaw.2020.11.004
5. Shand J, Allwood D, Lee N, et al. Systematically capturing and acting on insights from front-line staff: the
‘Bedside Learning Coordinator’. BMJ Qual Saf. 2021;30(6):509-512. doi:10.1136/bmjqs-2020-011966
6. Agency for Healthcare Research and Quality. Perioperative Staff Safety Assessment. Reviewed December 2017.
Accessed November 22, 2022. https://www.ahrq.gov/hai/tools/surgery/tools/applying-cusp/perioperative-
asst.html
7. Ray-Sannerud BN, Leyshon S, Vallevik VB. Introducing routine measurement of healthcare worker’s well-being
as a leading indicator for proactive safety management systems based on resilience engineering. Procedia Manuf.
2015;3:319-326. doi:10.1016/j.promfg.2015.07.163
8. Kaufman DM. Teaching and learning in in medical education: how theory can inform practice. Understanding
Medical Education: Evidence, Theory, and Practice. Wiley-Blackwell; 2018.
9. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3:77-101. doi:10.1191/
1478088706qp063oa
10. Hoffman RB, Segal CG, Foster JA, Rhoads LC. Adaptation of the human factors analysis and classification
system to patient safety studies. Proceedings of the International Symposium on Human Factors and Ergonomics in
Health Care. 2013;2(1):108-113. doi:10.1177/2327857913021021

JAMA Network Open. 2023;6(4):e237621. doi:10.1001/jamanetworkopen.2023.7621 (Reprinted) April 11, 2023 9/10

Downloaded from jamanetwork.com by guest on 11/18/2023

 JAMA Network Open | Surgery Clinicians’ Perspectives on Patient Safety Behaviors in the Perioperative Environment

11. Raben DC, Bogh SB, Viskum B, Mikkelsen KL, Hollnagel E. Learn from what goes right: a demonstration of a
new systematic method for identification of leading indicators in healthcare. Reliab Eng Syst Saf. 2018;169:
187-198. doi:10.1016/j.ress.2017.08.019
12. Green LW, Ottoson JM, García C, Hiatt RA. Diffusion theory and knowledge dissemination, utilization, and
integration in public health. Annu Rev Public Health. 2009;30:151-174. doi:10.1146/annurev.publhealth.031308.
100049
13. Göras C, Nilsson U, Ekstedt M, Unbeck M, Ehrenberg A. Managing complexity in the operating room: a group
interview study. BMC Health Serv Res. 2020;20(1):440. doi:10.1186/s12913-020-05192-8
14. Plunkett A, Plunkett E. Positive approaches to safety: Learning from what we do well. Paediatr Anaesth. 2022;
32(11):1223-1229. doi:10.1111/pan.14509
15. Adams-McGavin RC, Jung JJ, van Dalen ASHM, Grantcharov TP, Schijven MP. System factors affecting patient
safety in the OR: an analysis of safety threats and resiliency. Ann Surg. 2021;274(1):114-119. doi:10.1097/SLA.
0000000000003616
16. Kolodzey L, Trbovich P, Kashfi A, Grantcharov TP. System factors affecting intraoperative risk and resilience:
applying a novel integrated approach to study surgical performance and patient safety. Ann Surg. 2020;272(6):
1164-1170. doi:10.1097/SLA.0000000000003280
17. Hegde S, Hettinger AZ, Fairbanks RJ, et al. Qualitative findings from a pilot stage implementation of a novel
organizational learning tool toward operationalizing the Safety-II paradigm in health care. Appl Ergon. 2020;82:
102913. doi:10.1016/j.apergo.2019.102913
18. Rippstein-Leuenberger K, Mauthner O, Bryan Sexton J, Schwendimann R. A qualitative analysis of the Three
Good Things intervention in healthcare workers. BMJ Open. 2017;7(5):e015826. doi:10.1136/bmjopen-2017-
015826
19. Jackson D, Firtko A, Edenborough M. Personal resilience as a strategy for surviving and thriving in the face of
workplace adversity: a literature review. J Adv Nurs. 2007;60(1):1-9. doi:10.1111/j.1365-2648.2007.04412.x
20. Sexton JB, Adair KC. Forty-five good things: a prospective pilot study of the Three Good Things well-being
intervention in the USA for healthcare worker emotional exhaustion, depression, work-life balance and happiness.
BMJ Open. 2019;9(3):e022695. doi:10.1136/bmjopen-2018-022695

SUPPLEMENT 1.
eFigure. One Safe Act Activity Survey Tool
eTable. Examples of Proactive Safety Behaviors Submitted by Participants

SUPPLEMENT 2.
Data Sharing Statement

JAMA Network Open. 2023;6(4):e237621. doi:10.1001/jamanetworkopen.2023.7621 (Reprinted) April 11, 2023 10/10

Downloaded from jamanetwork.com by guest on 11/18/2023