Surgical Culture

Surgical Culture


Leaving an instrument or sponge in a patient at the end of an operation seems like an unthinkable act. Yet, despite the best efforts of diligent and dedicated operating room (OR) staff, such events happen once in every 5,500 to 8,000 operations. Research shows that around 10% of hospital patients are unintentionally injured during their treatment. A lack of non-technical skills such as situation awareness, leadership and teamwork has been associated with a significant number of surgical errors, compromising patient safety and accounting for half of the adverse events in the OR, with CRICO linking a third of medical malpractice cases to communication breakdowns.


The Surgical Culture Program aims to improve patient outcomes by understanding how the non-technical skills of surgeons and surgical teams affect performance in and out of the OR. We aim to determine which behaviors associated with specific non-technical skills make a difference, and formalize training in this area to enhance performance in the most efficient manner, with maximum impact on process and outcomes.


Our group has created and led a team training program using high fidelity simulation to teach teamwork and communication to full OR teams of surgeons, anesthesiologists, and nurses. Conducted at the Neil and Elise Wallace STRATUS Center for Medical Simulation, these simulation sessions focus on the important non-technical skills with the goal to improve the safety culture in the ORs at Brigham and Women’s Hospital, while also improving patient care and surgical outcomes.

Affiliate Faculty

Erika Rangel, MD, MS



Rachel Atkinson, MD (PACTS)


Project Director – Gezzer Ortega, MD, MPH

Senior Project Manager – Emma Reidy, MPH

Research Assistant – Caroline Demko

Research Assistant – Jeenn Barreiro-Rosado

Creating a U.S. Version of Non-Technical Skills for Surgeons (NOTSS-U.S.)

The Non-Technical Skills for Surgeons (NOTSS) behavior rating tool was created to assess and improve surgeons’ nontechnical skills, such as situation awareness, decision-making, communication, teamwork and leadership. Developed at the University of Aberdeen in Scotland by Steven Yule, PhD, one of the two leaders for the Surgical Culture Program, and his colleagues, the NOTSS curriculum has been implemented throughout the UK and much of Europe. In collaboration with the Division of Education at the American College of Surgeons, we are working to develop a U.S.-based version of the curriculum and assessment tool, utilizing an expert panel through structured methods of instructional systems design and validating the resultant NOTSS-US with a multi-institutional study at a number of surgery residency programs.

Responding to Medical Emergencies in Space

Earth and space may be vastly different settings, but they share a common need: clinically trained staff who can skillfully respond to medical emergencies. With a grant from NASA’s National Space Biomedical Research Institute, A multidisciplinary team including members of the CSPH’s Surgical Culture program are venturing outside of their usual orbit to develop a tool that can help astronaut crews respond to medical emergencies in deep space. An interdisciplinary team of researchers, lead by PI, Dr. Yule, from the STRATUS Center and BWH’s Center for Surgery and Public Health, as well as experts from other institutions, are now developing and assessing a non-technical skills training program for astronauts to manage a medical event on human-exploration missions to Mars, near-Earth asteroids or the moon. The first part of the project involves identifying and assessing which skills are essential for astronaut crews for responding to in-flight medical emergencies effectively, with the goals of enhancing proficiency, reducing errors and improving patient outcomes. The second part of the project was to create a simulated spacecraft medical bay in the STRATUS Center and film a series of simulation scenarios to assess the validity and reliability of the assessment tool.

Developing Standardized Intraoperative Process Models to Enhance Surgical Safety

The goal of the project is to develop standardized surgical process models of clinician activities and medical device usage for two common procedures in cardiac surgery using a software platform, and then to evaluate these process models by applying static analyses and discrete event simulations to detect where coordination and task sequence errors might occur as well as to identify and quantify vulnerabilities that are created when humans or devices perform tasks incorrectly. Project will also perform discrete event simulations of these processes in a full-scale simulated cardiovascular operating room environment. The data will be used to iteratively improve the process models by addressing vulnerabilities and improved support for non-nominal situations. This will be aimed at enhancing the clinicians’ understanding of an on-going surgical process by providing a dashboard, or view, of the current state of that process and communicate when actual practice begins to deviate from the standardized process.


Building on work capturing and understanding surgical disparities data, CSPH received an NIH–NIMHD grant for the study, “Evaluation of Cultural Dexterity Training Program for Surgeons: The PACTS Trial.” The study focuses on improving cross-cultural care, which refers to a physician’s ability to care for patients from a culture or background different from their own, and reducing healthcare disparities. The multicenter trial to be conducted at eight academic medical centers across the U.S. will evaluate the effectiveness of a novel curriculum called the Provider Awareness and Cultural Dexterity Toolkit for Surgeons (PACTS) in improving surgical residents’ knowledge, attitudes, and skills in caring for patients of different cultural backgrounds.

NASA Program Aims to Prepare Astronauts to Become Space Doctors

A Surgical Culture project funded by NASA was covered in NBC’s Nightly News on Aug 12, 2017. NBC’s Medical Correspondent and his team visited the STRATUS Center to cover our spaceflight medical bay simulator, and the medical scenarios we filmed in the simulator.


Wall Street Journal: Future of Everything Podcast

“What happens when an injury occurs on a commercial space flight or manned mission to Mars? Meet the scientists and astronauts studying how to keep us safe where routine care is impossible–and the closest hospital is a million miles away.” The Wall Street Journal: the Future of Everything Podcast visits the NASA-BWH Collaboration at STRATUS.