Rethinking safety culture assessment in the operating room: From crew resource management to the Safety Attitudes Questionnaire

Abstract

Background:

Patient safety in the operating room (OR) and perioperative settings relies on effective teamwork, communication, and safety culture. Over the past three decades, human factors research has contributed to the development of tools to assess safety attitudes; however, their ability to capture the unique characteristics of OR environments remains unclear.

Objective:

This scoping review aimed to examine the evolution of safety culture assessment in the OR, identify key trends, and explore limitations of existing approaches.

Methods:

A literature-informed narrative overview was conducted focusing on studies assessing safety culture in OR teams, particularly those using the Safety Attitudes Questionnaire (SAQ), its operating room version (SAQ-OR), and related instruments.

Results:

Nineteen studies were included. Most employed cross-sectional designs, while a limited number evaluated interventions such as surgical safety checklists and team training programmes. SAQ-based instruments were the most commonly used. Most studies originated from Europe and North America, with few from Asian health care settings.

Conclusions:

Safety culture research in the OR has primarily focused on measurement rather than intervention. Existing tools may not fully reflect the context-specific characteristics of OR environments. Future research should develop approaches that better reflect communication and role-related dynamics to support teamwork and safety in perioperative practice.

Keywords

Safety culture Operating room Teamwork Human factors Safety attitudes questionnaire

Introduction

The operating room (OR) functions as a complex team system in which professionals from diverse backgrounds coordinate their actions to achieve the shared goal of safe surgical care (Helmreich & Merritt 1998, Schaefer et al 1995). Surgeons, anaesthetists, and perioperative health care professionals, including nurses and Operating Department Practitioners (ODPs), must collaborate under conditions of time pressure, uncertainty, and high technical complexity, where failures in communication, coordination, or decision-making can lead to serious adverse events (Schaefer et al 1995). Early research on OR teamwork demonstrated that human error within this team system may result in catastrophic consequences and highlighted the importance of evaluating team performance, organisational commitment, and multidisciplinary training (Helmreich & Davies 1996, Helmreich & Schaefer 1994). These findings underscore that patient safety in the OR is fundamentally shaped by team dynamics and the underlying safety culture.

These insights were strongly influenced by research in high-reliability industries, particularly aviation. Crew resource management (CRM) (Helmreich 1984), originally developed to improve communication, leadership, and decision-making among flight crews, was subsequently introduced into health care to better understand team dynamics in complex clinical environments such as the OR (Helmreich & Schaefer 1994).

Building on this foundation, efforts to assess safety attitudes in health care led to the development of several measurement tools. One of the earliest instruments designed specifically for the OR context was the Operating Room Management Attitudes Questionnaire (ORMAQ) (Schaefer & Helmreich 1993, Sexton et al 2000). Subsequently, broader instruments, such as the Agency for Healthcare Research and Quality (AHRQ) Surveys on Patient Safety Culture (SOPS) (Agency for Healthcare Research and Quality (AHRQ) 2004), were developed; however, these were primarily intended for hospital-wide assessment and may not adequately capture the context-specific, team-based, and time-critical characteristics of OR environments.

The Safety Attitudes Questionnaire (SAQ), developed based on human factors and CRM research, has been widely used across health care settings, and its dimensions have been shown to align with those measured by other patient safety culture instruments (Etchegaray & Thomas 2012). However, despite the growing body of research, several important challenges remain. First, the evolution of safety culture assessment in the OR – from its origins in aviation CRM to the development of OR-specific tools – has not been comprehensively synthesised. Second, existing measurement approaches may not fully reflect the dynamic and multidisciplinary nature of OR practice. Third, much of the current research has focused on measurement rather than on developing and evaluating strategies to improve safety culture in clinical practice.

Therefore, the aim of this scoping review was to integrate and synthesise the evolution of safety culture assessment in the OR, identify key research trends, and highlight limitations in current approaches. Given its conceptual foundation and widespread use, this scoping review focuses on studies employing the Safety Attitudes Questionnaire and its operating room version (SAQ-OR) to examine safety culture in OR settings, with the aim of providing insights into communication, team dynamics, and safety culture in perioperative practice.

Methods

Literature search

A focused literature search was conducted to identify empirical studies examining safety culture or safety climate in the OR. Three electronic databases – PubMed, Scopus, and Web of Science – were searched, as they provide comprehensive coverage of medical, multidisciplinary, and health services research literature.

Eligibility criteria

Studies were eligible for inclusion if they met the following criteria:

Addressed safety culture or safety climate in surgical settings,

Focused on the OR or perioperative environment, and

Reported empirical findings related to safety culture assessment or measurement tools.

Data extraction for this review

From the selected studies, the following information was extracted: publication year, country or region, study design, study setting, sample characteristics, instruments used for safety culture assessment, and key findings. Extracted data were analysed descriptively to identify patterns in study design, measurement tools, and geographical distribution.

Results

Included studies

A total of 19 studies (Arli 2021, Carney et al 2010, Göras et al 2013, 2017, Hill et al 2015, Khoshbin et al 2009, Lemos & Poveda 2022, Lourenção & Tronchin 2016, Magill et al 2017, Makary et al 2006, Nyberg et al 2024, Ongun & Intepeler 2017, Ongun et al 2025, Önler & Akyolcu 2019, Pevec et al 2023, Santana et al 2016, Strandbygaard et al 2022, Wolf et al 2010, Zimmermann et al 2013) were included in this review (Table 1).

Table 1

Characteristics of the studies included in the review.

No.	Author(s)	Year	Title	Country	Region	Study type	Setting	Sample	OR only	Instrument	Main results
1	Arli	2021	Evaluation of the attitudes about patient safety in perioperative care.	Turkey	Middle East/Europe	Cross-sectional survey	Operating room	OR staff (n = 129)	Yes	SAQ-OR	Safety attitudes were generally low among perioperative staff.
2	Carney et al.	2010	Sex differences in operating room care giver perceptions of patient safety: a pilot study from the Veterans Health Administration Medical Team Training Program.	The United States	North America	Cross-sectional survey study	9 VA Medical Centres, operating room staff	n = 187 OR caregivers	Yes	SAQ (OR version)	Patient safety attitudes differed by profession and sex among OR caregivers, with surgeons reporting better working conditions and women reporting lower job satisfaction.
3	Göras et al.	2013	Swedish translation and psychometric testing of the safety attitudes questionnaire (operating room version).	Sweden	Europe	Validation study	Operating room departments	n = 237 OR staff (46% RNAs, 34% OR nurses, 17% LPNs)	Yes	SAQ-OR (Swedish version)	The Swedish version of the SAQ-OR demonstrated acceptable reliability and validity.
4	Göras et al.	2017	Interprofessional team assessments of the patient safety climate in Swedish operating rooms: a cross-sectional survey.	Sweden	Europe	Cross-sectional survey	Three operating room departments	OR staff (n ≈ 563 invited)	Yes	Safety Attitudes Questionnaire (SAQ)	Safety climate scores were generally low across OR teams, with lower ratings among nurses.
5	Hill et al.	2015	Safety culture and the 5 steps to safer surgery: an intervention study.	The United Kingdom	Europe	Intervention study	Operating theatre	OR staff (pre n = 60; post n = 53)	Yes	SAQ	Implementation of the ‘5 steps to safer surgery’ improved safety culture and teamwork.
6	Khoshbin et al.	2008	Evaluation of preoperative and perioperative operating room briefings at the Hospital for Sick Children.	The United States	North America	Intervention study	Operating room	OR staff	Yes	SAQ-OR	OR briefings improved communication and safety perceptions among staff.
7	Lemos & Poveda	2022	Effect of implementing an anesthesia nurse checklist in a safety and teamwork climate: quasi-experimental study. Rev Esc Enferm USP.	Brazil	South America	Quasi-experimental study	Operating room	Nurses and anesthesiologists (n = 63)	Yes	SAQ-OR Team Climate Inventory	Implementation of an anaesthesia nurse checklist improved safety climate and teamwork climate scores.
8	Lourenção & Tronchin	2016	Patient safety in the surgical environment: translation and cross-cultural adaptation of validated instrument.	Brazil	South America	Cross-cultural adaptation study	Surgical environment	OR professionals (pilot test n = 30)	Yes	SAQ-OR	The translated instrument demonstrated acceptable reliability and validity.
9	Magill et al.	2017	Imershein Changing Operating Room Culture: Implementation of a Postoperative Debrief and Improved Safety Culture.	The United States	North America	Intervention study	Neurosurgery OR	OR staff	Yes	Safety Attitudes Questionnaire (SAQ)	Postoperative debriefing improved perceptions of safety culture among OR staff.
10	Makary et al.	2006	Operating Room Teamwork among Physicians and Nurses: Teamwork in the Eye of the Beholder.	The United States	North America	Cross-sectional survey study	Operating room	n = 2135 (response 77%)	Yes	SAQ	The safety climate scale demonstrated good validity and internal consistency; safety climate varied significantly across hospitals but not by OR profession.
11	Nyberg et al.	2024	Longer work experience and age associated with safety attitudes in operating room nurses: an online cross-sectional study.	Sweden	Europe	Cross-sectional study	Operating room	OR nurses (n = 358)	Yes	SAQ-OR	Older and more experienced nurses reported better working conditions but lower stress recognition; communication and workload were key improvement needs.
12	Ongun et al.	2025	Artificial Intelligence Anxiety and Patient Safety Attitudes Among Operating Room Professionals: A Descriptive Cross-Sectional Study.	Turkey	Middle East/Europe	Cross-sectional study	Operating room	Operating room professionals (n = 155)	Yes	SAQ-OR + AI Anxiety Scale	AI anxiety was not significantly associated with safety attitudes; belief in AI benefits was associated with openness to change.
13	Önler & Akyolcu	2019	Evaluation of operating room staff’s attitudes related to patient safety: A questionnaire study.	Turkey	Middle East/Europe	Descriptive cross-sectional survey	Operating rooms in two university hospitals	n = 290 OR staff (190 nurses, 72 surgeons, 28 anaesthetists)	Yes	SAQ-OR (Turkish version)	SAQ-OR scores indicated a low level of positive safety culture; safety attitudes were higher among more experienced staff and in ORs with fewer daily surgeries.
14	Ongun & Intepeler	2017	Operating room professionals’ attitudes towards patient safety and the influencing factors.	Turkey	Middle East/Europe	Cross-sectional survey	Operating room	OR professionals (n = 477)	Yes	Safety Attitudes Questionnaire (SAQ)	Safety attitudes were moderate; teamwork scored highest, and training predicted safety attitudes.
15	Pevec et al.	2023	Safety culture in the operating room: translation, validation of the safety attitudes questionnaire – operating room version.	Slovenia	Europe	Translation and validation study	Operating Room	OR professionals (n = 243)	Yes	SAQ-OR	The Slovenian SAQ-OR demonstrated good reliability and acceptable construct validity.
16	Santana et al.	2016	Surgical teams’ attitudes and opinions towards the safety of surgical procedures in public hospitals in the Brazilian Federal District.	Brazil	South America	Before–after intervention study	OR (3 public hospitals)	OR professionals (n ≈ 470)	Yes	SAQ-OR-based questionnaire	WHO checklist implementation improved safety attitudes and communication.
17	Strandbygaard et al.	2022	Healthcare professionals’ perception of safety culture and the Operating Room (OR) Black Box technology before clinical implementation: a cross-sectional survey.	Denmark	Europe	Cross-sectional	Operating room	OR professionals (n ≈ 100)	Yes	Safety Attitudes Questionnaire (SAQ)	Safety climate and teamwork were the lowest-rated SAQ domains among OR staff.
18	Wolf et al.	2010	The Efficacy of Medical Team Training: Improved Team Performance and Decreased Operating Room Delays, A Detailed Analysis of 4863 Cases.	The United States	North America	Interventional before–after study	Operating room	4863 OR cases	Yes	SAQ	Medical team training improved OR teamwork and safety performance, reducing delays and improving case scores.
19	Zimmermann et al.	2013	Assessing the Safety Attitudes Questionnaire (SAQ), German Language Version in Swiss University Hospitals – A Validation Study.	Switzerland	Europe	Psychometric validation study	Hospital wards	n = 319 clinicians	No	SAQ (German version)	The German SAQ showed acceptable psychometric properties and reliability.

OR = operating room; SAQ = Safety Attitudes Questionnaire; SAQ-OR = Safety Attitudes Questionnaire – Operating Room version.

Study design

Most studies employed cross-sectional designs to assess safety culture in OR teams. However, five studies (Hill et al 2015, Khoshbin et al 2009, Magill et al 2017, Santana et al 2016, Wolf et al 2010) used interventional designs, examining the effects of safety initiatives such as surgical safety checklists or team training programmes. These findings indicate that interventional research in OR safety culture remains limited compared with cross-sectional investigations.

Assessment tools

Among the included studies, 11 (Arli 2021, Carney et al 2010, Göras et al 2013, Khoshbin et al 2009, Lemos & Poveda 2022, Lourenção & Tronchin 2016, Nyberg et al 2024, Ongun et al 2025, Önler & Akyolcu 2019, Pevec et al 2023, Santana et al 2016) used the SAQ-OR, while 8 (Göras et al 2017, Hill et al 2015, Magill et al 2017, Makary et al 2006, Ongun & Intepeler 2017, Strandbygaard et al 2022, Wolf et al 2010, Zimmermann et al 2013) used the original SAQ.

This distribution suggests that SAQ-based instruments are the most commonly applied tools for assessing safety culture in OR settings, reflecting their strong conceptual foundation in human factors and CRM research.

Geographical distribution

The included studies were conducted primarily in Europe (n = 7) (Göras et al 2013, 2017, Hill et al 2015, Nyberg et al 2024, Pevec et al 2023, Strandbygaard et al 2022, Zimmermann et al 2013) and North America (n = 5) (Carney et al 2010, Khoshbin et al 2009, Magill et al 2017, Makary et al 2006, Wolf et al 2010), followed by South America (n = 3) (Lemos & Poveda 2022, Lourenção & Tronchin 2016, Santana et al 2016) and Middle Eastern and European collaborative settings (n = 4) (Arli 2021, Ongun & Intepeler 2017, Ongun et al 2025, Önler & Akyolcu 2019). Notably, no eligible studies from Asian countries were identified. This geographical imbalance highlights a lack of evidence from Asian health care systems, indicating a critical gap in the global understanding of safety culture in OR settings.

Discussion

This review examined the evolution of safety culture assessment in the OR and identified several key trends and gaps in the existing literature. The findings highlight important considerations for understanding and improving safety culture in perioperative practice.

Focus on safety culture research in the ORs

Most studies focused on measuring safety culture using standardised survey instruments, particularly the SAQ-OR. Cross-sectional survey designs predominated, reflecting the growing interest in assessing perceptions of teamwork and safety climate among perioperative staff. These findings suggest that much of the existing literature has concentrated on evaluating safety culture rather than examining strategies to actively improve it.

Intervention strategies to improve teamwork and safety

A number of intervention studies have begun to explore strategies aimed at improving teamwork and safety in surgical environments. Several studies examined the implementation of safety initiatives such as surgical safety checklists and team training programmes. For example, the introduction of the World Health Organization (WHO) Surgical Safety Checklist (World Health Organization 2009) has been associated with improvements in safety attitude scores and reductions in postoperative complications, suggesting that enhancing team communication and safety climate may contribute to improved patient outcomes.

Geographical gaps in the literature

Another important finding of this review was the uneven geographical distribution of studies. Most research originated from Europe and North America, while no eligible studies from Asian countries were identified in this review. Although patient safety culture research using the SAQ has been conducted in several Asian health care settings, OR-specific investigations remain limited in this region. This observation suggests a potential gap in the literature and highlights the need for further research examining safety culture within diverse health care systems and cultural contexts.

Implications for teamwork and future OR environments

The OR represents a complex environment in which multiple professional subgroups must cooperate to achieve a common goal. In line with this, recent studies have emphasised the importance of leadership and human factors, as well as aspects of team performance, in promoting surgical safety (Brennan et al 2021, Catchpole et al 2024, Gogalniceanu et al 2022, 2024).

As Helmreich and Merritt noted, it provides a setting where diverse teams work together to complete procedures with the best possible outcome for the patient while minimising the likelihood of human error and mitigating the consequences of errors that do occur (Helmreich & Merritt 1998).

Advances in digital health technologies and artificial intelligence are likely to further transform OR environments in the foreseeable future. Emerging tools such as digital surgical checklists, real-time data monitoring systems, and artificial intelligence (AI)-assisted decision support have the potential to enhance perioperative safety and improve situational awareness within surgical teams (Ongun et al 2025). However, technological innovation in health care alone cannot ensure safe surgical care. As emphasised in early human factors research in the operating theatre, improving team performance and communication remains fundamental to achieving safer surgical care (Schaefer et al 1994). Ultimately, the goal is not merely to measure safety culture but to foster surgical teams capable of consistently delivering the safest possible care for patients.

Taken together, these findings suggest that while substantial progress has been made in measuring safety culture in OR settings, current approaches may not fully capture the complexity and context-specific nature of OR environments. In particular, the reliance on standardised survey instruments alone may be insufficient to address the dynamic, multidisciplinary, and time-critical characteristics of surgical teams. Therefore, there is a need to move beyond measurement towards the development of context-sensitive approaches that integrate human factors, team dynamics, and organisational processes. Such an approach may provide a more comprehensive understanding of safety culture and support meaningful improvements in perioperative practice.

Conclusion

This review traced the evolution of safety culture assessment in the OR, from early human factors research and the development of OR management attitudes measures to contemporary studies using the SAQ and its OR version. The findings indicate that research in this field has predominantly focused on measurement, while intervention studies aimed at improving teamwork and communication remain limited. In addition, the geographical distribution of studies highlights a lack of OR-specific safety culture research in several regions, particularly in Asian health care settings.

As surgical environments continue to evolve with advances in digital technologies, including minimally invasive and robotic systems, the complexity of OR practice is expected to increase further. However, despite these technological developments, surgical care remains fundamentally dependent on human teams working in complex and high-risk environments. Therefore, consistent with early human factors research, effective communication and team performance remain essential for achieving safe surgical care.

Ultimately, the goal is not merely to measure safety culture but to foster surgical teams capable of consistently delivering the safest possible care for patients. This principle is explicitly reflected in the SAQ-OR, where effective teamwork is characterised by the resolution of disagreements based not on ‘who is right’, but on what is best for the patient. This item captures a core aspect of CRM, emphasising the mitigation of hierarchical barriers and the promotion of patient-centred decision-making within surgical teams. In this context, the fundamental principle is not ‘who is right’, but ‘what is best for the patient’ (Helmreich & Foushee 2010, Sexton et al 2006). This perspective, rooted in human factors and CRM, underscores the importance of shared responsibility, open communication, and collective decision-making within surgical teams.

Footnotes

Declaration of conflicting interests

The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author received no financial support for the research, authorship, and/or publication of this article.

Ethical approval

This study was approved by the institutional review board of the author’s institution.

ORCID iD

Aki Enomoto

Data availability

The data that support the findings of this study are available from the corresponding author upon reasonable request.

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Rethinking safety culture assessment in the operating room: From crew resource management to the Safety Attitudes Questionnaire – Operating Room Version (SAQ-OR)

Abstract

Background:

Objective:

Methods:

Results:

Conclusions:

Keywords

Introduction

Methods

Literature search

Eligibility criteria

Data extraction for this review

Results

Included studies

Study design

Assessment tools

Geographical distribution

Discussion

Focus on safety culture research in the ORs

Intervention strategies to improve teamwork and safety

Geographical gaps in the literature

Implications for teamwork and future OR environments

Conclusion

Footnotes

Declaration of conflicting interests

Funding

Ethical approval

ORCID iD

Data availability

References