**4. Culture of safety**

*Latest Developments in Medical Robotics Systems*

they too are an integral part of the robotic program.

Adoption of properly designed curriculum-based training is extremely important. This training should be subjected to all team members, including console surgeon, anesthesiologist, bedside assistance, assistance holding the uterine manipulator, and circulator. Initial training should include set up, docking, undocking, emergency shut down, and both mechanical and electrical troubleshooting [22]. Further training should be procedure-specific, and surgeons need to be involved in training the staff [23]. Some challenges come into play when trying to effectively build a team capable of performing these robotic procedures correctly and efficiently. For one, the surgeon must play the role of both the leader of the surgical procedure along with the leader who can effectively troubleshoot any problems which may arise through the process and can optimize operating with advanced technology. Moreover, the surgical team, including the surgeon and team members, must be willing to embrace this new technology and new approach to surgery after many years of training and practicing in ways that are totally different. A study published in Harvard Business Review by Edmonson compared 16 institutions that employed a minimally invasive approach to cardiac surgery. This study showed that some of these institutions were better able to use their experience for their advantage than others. The study demonstrated that motivation to learn was the most consistent characteristic with the ability to build a successful team, not the conventional predictors like case volume or experience level [24]. Personality traits of members of a successful team are not limited to openness to change, willingness to seek and elicit feedback, and readiness to recognize when they make a mistake. On the contrary, less successful programs employed leaders who were not as open to change and were not as effective at creating an environment conducive to learning. While this study primarily focused on cardiac surgery, the same parameters should

room along with the order of events preoperatively, intraoperatively, and postoperatively. In robotic surgery, the surgeon sits on a robotic console almost 5–10 feet away from the patient. The absence of the surgeon at the patient's bedside adds additional complexity and anxiety in the operating room among the team members. These new arrangements, including surgeon console, robotic arms, and robotic tower, require an operating room with a surgical team that is well-trained and understands the intricacies that go along with robotic surgeries, as well as the ability to share the burden of problem-solving and troubleshooting any issues that may arise throughout the process. The robotic platform brings unique challenges for the team. For instance, in nonrobotic surgery, surgeons often communicate with their team by signaling or often using not more than a single word [21]. Many a time, assistants understand the need before the surgeon even utters a word. However, in a robotic procedure, communication involves more detailed and clear instructions like pilots communicating with each other or with a control room, and everything needs to be loud and clear. The team needs to be trained to have effective bilateral communication and acknowledgment of all the instructions given by the surgeon or other way around. While traditional surgery has somewhat painted operating rooms as very strict and technical with the surgeon as the chief of events, the robotics platform enforces more of a team approach with a unique chronology of events. Thus, building an efficient team is very crucial for the success of a robotic program. This aspect can often be overlooked by either the hospital administration, the surgeon, or the operating room team. This may be overlooked because the territory of minimally invasive surgery seems familiar, but there remains the aspect of the robotic platform, which is not so familiar including the change in dynamics of the operating room with the integration of robotics. Therefore, the ability to have a successful robotic program depends not only on a surgeon who is well-versed in these technologies and surgical processes, but also a team made of members who feel like

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The Institute of Medicine identifies patient safety as one of the key issues that are critical for health care delivery [26]. Changes to practice patterns that are well-established and proven to be effective always raise concerns about how they affect the safety of the patient. The same is true, to maybe an even higher degree, in the process of implementing complex and advanced technologies like roboticassisted surgical procedures. These concerns come from healthcare personnel in every aspect of the patients' care, including operating room staff, perioperative nursing staff, anesthesia team members, and many others. While these concerns may be unfounded and unproven, they could affect morale and consequently patient outcomes [27]. Often, many hospitals implement Enhanced Recovery After Surgery (ERAS) program with robotic procedures. Many surgeons discharge robotic hysterectomy in a few hours after surgery. Nursing staff who are traditionally trained to keep minimal invasive surgery patients at least one-night inpatient may feel a little less safe to operate Enhanced Recovery After Surgery (ERAS) program and help to discharge patients home in few hours after major surgery. Studies have found that teamwork and collaboration, meetings to provide opportunities for clarification [28, 29], and staff education [30, 31] are key elements for the success of ERAS, which again supports our argument to develop an adequate culture of safety by proper communications with all stakeholders involved in postoperative care, including patients. Similarly, this has been shown in several studies that have shown that scoring higher on questions about teamwork and better communication/co-ordination is correlated with shorter length of stay and associated postoperative morbidities and mortalities. A study by Hughes et al. highlighted that 40% of US hospital nursing staff think that making changes to make improvements is difficult most of the time or all the time, which is very relevant to the implementation of advanced technologies in medical practice [32]. Recognizing that errors are sometimes inevitable, incorporating nonpunitive error reporting and analysis systems, a platform for open discussion, a willingness to learn from errors, and identifying latent threats are all characteristics of strong cultures of safety.

Three vital organizational factors are responsible for a strong environment of culture of safety: (1) environmental structures and processes within the organization, (2) the attitudes and perceptions of workers, and (3) the safety-related behaviors of individuals [33]. Institute of Medicine (US) Committee on the Work Environment for Nurses and Patient Safety narrated the following essential elements of an effective safety culture. These include a commitment of leadership to safety, empowerment and engagement of all employees in ongoing vigilance, communication, non-hierarchical decision making, constrained improvisation, training, confidential error reporting, fair and just responses to reported errors, reporting near misses as well as errors, etc. [34]. Two major barriers have been identified in adopting culture of safety. First is 'A nursing culture that fosters unrealistic expectations of clinical perfection.' Nurses are trained to believe that there is no alternative to clinical perfection, and error is the result of their carelessness that makes them less than good nurses. Higher standards and error-free care are always appreciated, but when that belief becomes counterproductive, it affects the overall care and goals of any program. Therefore, it is imperative to communicate with

nurses that error is a systemic problem and not an individual one. Their minds need to be trained not to think any less of their colleagues when they make errors. Second is 'litigation and regulatory barriers.' Unfortunately, regulatory boards and the court of law or peer review processes at hospitals again reinforce the idea of clinical perfection. Therefore, it is very difficult for nursing staff to deviate from the routine practice and adopt changes that come with new technology. The culture of safety will play a large role in the outcomes of robotic-assisted surgeries, and therefore, it is both necessary and vital to address the changes that come with the implementation of novel technology. To develop a successful robotic program, it is important to implement frequent reviews of outcomes, multidisciplinary discussions, development of parameter-based new postoperative care protocols, and consideration of recommendations and management strategies from all the team members. This is a crucial part of the process of building a gynecologic surgical robotic program, and it requires commitment from members at all levels in the health care delivery system with a strong sense of culture of safety.
