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February 2018 SEA-Q


In the patient safety literature, team performance is recognized as being crucial to reducing preventable errors. Which of the following statements IS true?

  • Lack of clinical skills is the most significant contributing factor to the incidence of adverse events.
  • Lack of knowledge or training is the most significant contributing factor to increased preventable errors.
  • A hierarchical culture reduces preventable errors as long as the leader is competent.
  • Disruptive behavior can undermine a culture of patient safety and has been associated with poor patient outcomes.


Disruptive behavior can undermine a culture of patient safety and has been associated with poor patient outcomes.


Historically, the culture of health care has tolerated disruptive behavior exhibited by certain members in exchange for their high level of skills and expertise. However, many studies have shown that high quality and safe patient care depend on teamwork, communication and a collaborative work environment and culture. In 2009, the Joint Commission implemented a leadership standard that included a disruptive behavior policy. They defined disruptive behavior (or behaviors that undermine a culture of safety) as including "overt actions as verbal outbursts, and physical threats, as well as passive activities such as refusing to perform assigned tasks or quietly exhibiting uncooperative attitudes during routine activities", and that disruptive behavior as well as failure in communication and teamwork are related to increased incidence of adverse event reports. 
A hierarchical culture can be useful in certain situations but these characteristics lead to significant difference in status and can lead to disruptive behavior. Also, in a centralized approach to management, team members are reluctant to challenge authority or speak up when errors are recognized. Hospital and surgical teams with rigid hierarchical culture have been shown to have inferior performance and safety climate measures.


  1. Patient Safety in the Cardiac Operating Room: Human Factors and Teamwork Circulation 2013; 128:1139-1169
  2. Rosenstein AH. The Joint Commission disruptive behavior standard: intent and impact. J ASPR 2009; 16:6-7
  3. Manser T. Teamwork and patient safety in dynamic domains of healthcare: a review of the literature. Acta Anesth Scand 2009; 53:143-151

Author Information:

Annette Mizuguchi, MD, PhD
Assistant Professor
Brigham and Women's Hospital, Department of Anesthesiology

The SEA is proud to be a member-driven organization, dedicated to the teaching and development of future anesthesiologists, and to the advancement of those who educate them.

Contact Info:

Society for Education in Anesthesia
6737 W. Washington St, Suite 4210 • Milwaukee, WI 53214 • (414) 389-8614