Measuring Sense-making Activity
in the Operating Room
during Crisis Situations

To err is human…

In 1999, the Institute of Medicine (IOM) released a report titled “To Err Is Human” in which medical error was cited as the eighth leading cause of death in the United States (more than motor vehicle accidents, breast cancer, or AIDS), responsible for as many as 98,000 deaths annually(1). The healthcare community was starting to become aware of the significance of organizational and human factors. In France, the Ministry of Health conducted a national survey on ‘serious unwanted events related to healthcare delivery in 2004 and 2009. It was found that in hospitals, 60% of such events could be connected to poor teamwork, especially ‘insufficient supervision,’ ‘insufficient communication,’ and ‘lack of quality culture’(2).

Since then, many studies have examined the non-technical skills of caregivers and have shown that poor communication and supervision were general features, as in French studies. Progressively, they also highlighted other traits such as lack of vigilance, varying degrees of attention, poor stress management skills, inappropriate leadership, and poor team work (3–6).

Project description

Non-technical skills are especially crucial in ill-defined and rapidly evolving situations and when stakes are high. This is the case when a patient in the operating room starts desaturating, [add some examples] with no apparent reason, and when the first remediation actions show no improvement. The anesthesiologist, surgeon, and nurses must then share their perceptions of the situation, come up with interpretations, select the most plausible and take action before it is too late. In other words, the staff must address the questions “what is going on?” and “what should we do about it?”. A crisis in the operating room is essentially a matter of sense-making. Rarely was the problem seen and analyzed within the conceptual framework of sense-making7. The ultimate goal of our research program to which this study contributes is to create operational conditions appropriate for effective sense-making and train operating room staff to these processes.

This research program started in 2020 and is conducted with the anesthesiology and intensive care department of Kremlin-Bicêtre Hospital.


1. IOM. Institute of Medicine. To Err Is Human : Building a Safer Health System. In: To Err Is Human: Building a Safer Health System. ; 1999.
2. Michel P, Minodier C, Lathelize M, et al. Enquête nationale sur les événements indesirables associés aux soins observés dans les établissements de santé. Dossiers Solidar santé. 2010;17.
3. Sutcliffe KM, Lewton E, Rosenthal MM. Communication Failures : An Insidious Contributor to Medical Mishaps. Acad Med. 2004;79(2):186-194.
4. Fletcher GCL, McGeorge P, Flin RH, Glavin RJ, Maran NJ. The role of non-technical skills in anesthesia : A review of current literature. Br J Anaesth. 2002;88(3):418-429. doi:10.1093/bja/88.3.418
5. Mazzocco K, Petitti DB, Fong KT, et al. Surgical team behaviors and patient outcomes. Am J Surg. 2009;197(5):678-685. doi:10.1016/j.amjsurg.2008.03.002
6. Vogus TJ, Sutcliffe KM, Weick KE. Enabling, Enacting, and Elaborating a Culture of Safety in Health Care Executive Overview, Acad Manag Perspect. 2010:60-77.

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