A culture of safety or coping? Ritualistic behaviours in the operating theatre

The creation of a 'safety culture' is a health services priority, yet there is little contemporary research examining the tacit, customary practices that relate to clinical risk. This paper investigates how the ritualistic behaviours of surgeons and anaesthetists serve to normalize risks within the operating theatre, thereby inhibiting organizational learning and enabling such risks to recur.

A two-year ethnographic study in the operating department of a large teaching hospital in the north of England, including observations of the organizational and clinical setting and interviews with 80 members of staff.

Three ritualistic types of behaviour are identified and described. Each illustrates the taken-for-granted assumptions associated with clinical risk in the operating theatre and is characterized by a patterned response to risk, the first being to tolerate and endure risk, the second being to accommodate risk through slight modifications to clinical practice and the third being to innovate or implement unorthodox practices to control for risk.

These ritualistic behaviours normalize risk within the operating theatre leading to the possibility that some threats will escape appropriate attention and may lead to patient harm. These culturally scripted behaviours also encourage a short-term reactive response to risk that emphasizes the importance of individual coping rather than the more systemic forms of learning associated with participation in incident reporting. This research extends and elaborates upon the current policy orthodoxy to better understand the cultural context of patient safety.