Patient safety culture, teamwork, and observed perioperative safety compliance in a high-volume surgical unit
In a high-volume Indonesian surgical unit, a prospective observational study found that while patient safety culture directly improved perioperative safety compliance and fostered better teamwork, the latter did not significantly mediate the relationship between culture and observed checklist adherence.
Original paper licensed under CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). This is an AI-generated explanation of a preprint that has not been peer-reviewed. It is not medical advice. Do not make health decisions based on this content. Read full disclaimer
In the high-stakes environment of a hospital operating room, the difference between a successful surgery and a preventable error often comes down to a simple list. Surgical safety checklists are designed to be a final safeguard, a moment where the entire team pauses to confirm the patient's identity, the correct procedure, and the necessary equipment. However, having a list on a clipboard does not guarantee that the team actually reads it, discusses it, or follows every item on it. The real question for safety experts is not whether the list exists, but whether the culture of the hospital and the way the team works together actually encourages people to use it correctly. When a hospital has a strong "safety culture," it means the staff feel safe speaking up about mistakes without fear of punishment, and they trust that leadership will listen. When "teamwork" is strong, it means everyone is watching out for one another and communicating clearly. Researchers have long wondered if a positive culture and good teamwork are the invisible engines that drive teams to actually complete these safety checks, or if other factors are at play.
To find the answer, a team of researchers in Indonesia set out to watch what really happens in the operating room, rather than just asking staff how they think they behave. They conducted a study in a large public teaching hospital in Surakarta, a facility that handles dozens of surgeries every day. Between April and May 2026, they recruited eighty healthcare professionals, including surgeons, anesthesiologists, and nurses, to participate. These volunteers first filled out surveys about their perceptions of the hospital's safety culture and how well their teams worked together. Then, the researchers did something more rigorous: they stood in the operating rooms and watched the surgeries unfold. They observed fifty unique operations, recording 240 separate instances where a specific safety action was supposed to happen. They used a detailed checklist based on international standards to score whether the team completed each step, such as the initial check-in before the surgery, the "time-out" pause before the incision, and the final sign-out after the procedure.
The results painted a clear picture of the relationship between how people feel and what they actually do. The study found that when staff perceived a strong safety culture—where errors were treated as learning opportunities rather than reasons for blame—they were significantly more likely to work well as a team. Furthermore, this strong safety culture was directly linked to higher rates of actually completing the safety checks. In fact, the overall compliance rate for these safety steps across all observed surgeries was about 75 percent. However, the researchers discovered that the link between teamwork and actually following the checklist was not as straightforward as expected. While teams that felt they worked well together did tend to have slightly better compliance, the statistical evidence was not strong enough to say that teamwork alone was the main reason the checks were completed. In other words, a good team dynamic helped, but it did not fully explain why some teams followed the rules better than others. The data suggested that the broader organizational environment, specifically the culture of safety, was the more powerful driver.
The study also highlighted specific areas where the system struggled. While the team did well during the pre-surgery check-in and the time-out pause, the final sign-out phase had the lowest compliance rate, with only about 71 percent of the required steps being completed. This suggests that as a surgery ends and the focus shifts to recovery and cleaning the room, the team's attention to the final safety checklist slips. The researchers identified two specific behaviors that stood out as critical targets for improvement. First, the culture of how the hospital responds to errors was the strongest factor linked to a positive safety environment; when staff felt safe reporting mistakes, the whole system worked better. Second, "situation monitoring"—the practice of team members actively watching the procedure and speaking up if something changes—was the most important teamwork skill linked to better performance.
Ultimately, this research supports the idea that patient safety is a system-wide issue, not just a matter of individual discipline or team training. The findings suggest that simply teaching a team how to work together is not enough to guarantee that safety checklists are followed perfectly. Instead, hospitals need to focus on building a culture where learning from errors is encouraged and where staff are actively monitoring the situation throughout the entire procedure. The data indicates that to improve safety, leaders should pay particular attention to the end of the surgery, redesigning how the final sign-out is handled to ensure it receives the same attention as the beginning. By strengthening the organizational culture and refining specific monitoring habits, hospitals can move beyond just having a checklist on the wall to ensuring that every critical safety step is actually taken.
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