Preventing Error in the Operating Room: Five Teaching Strategies for High-Stakes Learning

Background: Effective communication in the operating room between the attending and resident surgeon is necessary to prevent surgical errors. Yet, existing studies do not describe what successful intraoperative teaching looks like and how it prevents errors. Our objective was to identify strategies for successful intraoperative teaching by comparing perspectives of the learner and teacher for the same moments. Material and methods: We conducted a naturalistic inquiry by filming five live surgical teaching cases and analyzing more than 250 teaching exchanges, centered on steps with high likelihood for error. We interviewed each attending and resident, who separately viewed cued video clips, and asked how they made their teaching more visible. We compared answers, looking for common understandings of the same moment. Answers were coded, compared to each other, refined, and combined into larger themes. Results: We identified five successful strategies for communicating avoidance of intraoperative errors: augmenting verbal instruction with small physical actions, pausing the surgical procedure to explain the larger picture, querying the residents' knowledge about specific steps, creating memorable coined names, and issuing highly specific commands. Strikingly, we found a significant example of miscommunication between the attending surgeon and resident that was a near-miss uterine perforation during a dilation and curettage. Conclusions: Attending surgeons are strategic in their intraoperative communications with learners, resulting in a scarcity of surgical errors when the resident is operating. We present real examples of five successful intraoperative teaching strategies. Successful intraoperative teaching relies heavily on tacit information, necessitating that attending and resident share a common understanding about the next step of the case. (C) 2018 Elsevier Inc. All rights reserved.