Viewing patient safety in surgery through the lens of a theatrical performance: a narrative review

Abstract

Background

In the high-stakes environment of the operating room (OR), patient safety depends not only on technical expertise but also on seamless communication, clear roles, and coordinated teamwork. Traditional approaches often overlook the relational and performative dimensions of surgical care.

Methods

This narrative article proposes a metaphorical framework that compares surgical practice to live theater, where each team member plays a rehearsed role, and protocols act as scripts. The study explores key themes such as preparation (rehearsals), intraoperative coordination (live performance), and structured debriefing (curtain call). The aim is to synthesize knowledge from clinical literature and human factors theory to provide a novel interpretive framework for improving patient safety in the operating room (OR). A selective literature review was conducted focusing on peer-reviewed publications related to surgical teamwork, communication, safety checklists, and non-technical skills. Sources were identified through PubMed and Google Scholar using relevant terms such as “surgical safety,” “human factors in surgery,” and “team communication.”

Results

The metaphorical framework reveals that each member of the OR team—from the surgeon to the scrub nurse—is reimagined as a theatrical role, with their contribution being essential to the surgical outcome. Key concepts such as simulation training, checklists, psychological safety, and mutual accountability are highlighted as critical tools for enhancing performance and reducing preventable harm. The study emphasizes the importance of clear role definitions, team coordination, and continuous learning, similar to a theater production’s preparation, performance, and reflection stages.

Conclusion

Viewing the OR through the lens of theater offers a novel, human-centered model for improving surgical safety. This conceptual framework promotes structured teamwork, shared mental models, and a culture where every action is intentional and every role is respected ensuring that each surgical performance prioritizes the patient’s well-being above all.

Introduction

Imagine stepping into an operating room not as a clinician, but as an observer at the edge of a grand theater stage. The lights are bright, the air sterile, and the atmosphere charged with anticipation. Every person in the room from the surgeon to the scrub nurse to the anesthesiologist has a role, a purpose, and a script to follow. There is choreography, timing, and an unspoken rhythm that binds the team together. But unlike a theatrical performance, the stakes are life and death. There is no dress rehearsal. No encore. No second chance [1].

Surgery, in many ways, mirrors the essence of a live performance: it is high-pressure, time-sensitive, and deeply collaborative. Just as a successful stage play depends on more than just the lead actor, a safe surgical procedure requires far more than the technical skills of the surgeon. It demands coordination, communication, trust, and mutual respect among the entire operating room (OR) team. These elements, often seen as “soft skills,” are in fact foundational to patient safety and their absence can result in tragic, preventable harm [2, 3].

Globally, patient safety in surgery has emerged as a public health priority. According to the World Health Organization (WHO), unsafe surgical care contributes to a significant burden of morbidity and mortality, particularly in resource-limited settings [4]. Common contributors to surgical errors include communication breakdowns, unclear roles, and poor teamwork all human factors that mirror what might go wrong in a chaotic or poorly rehearsed play. Just as forgotten lines or missed cues can derail a theater performance, lapses in communication or teamwork in the OR can lead to retained instruments, wrong-site surgeries, or anesthesia complications [5, 6].

This narrative article proposes a metaphorical framework for viewing surgery as a form of theater. By borrowing language and structure from the performing arts, we aim to provide clinicians with a new perspective on the complexities of team-based surgical care. We argue that every aspect of a surgical procedure from preoperative briefings (rehearsals) to intraoperative coordination (live performance) to postoperative debriefs (curtain call) can benefit from the discipline, clarity, and cohesion found in successful theatrical productions.

Framing surgery as theater also helps humanize the clinical setting. It reminds us that patients are not just cases; they are the audience and the reason the performance exists at all. Moreover, it challenges clinicians to see themselves not just as technicians, but as members of an ensemble whose collective success or failure directly impacts human lives.

In the following sections, we will unpack this metaphor and explore how principles from theater can inform safer surgical practice. We begin by examining the roles of various team members as “cast,” followed by the importance of rehearsals (protocols and training), the demands of real-time performance, and finally, the reflection and feedback process that marks the end of every surgical “show.” Through this lens, we invite a deeper appreciation for the performance of surgery not as artifice, but as a structured, disciplined, and high-stakes pursuit where patient safety is always the star of the show.

Methods

This study adopts a narrative and conceptual approach to explore the relationship between surgical safety and team performance through the metaphor of live theater. Rather than presenting empirical data, the aim is to synthesize interdisciplinary knowledge from surgery, human factors, and performance studies in order to offer a novel interpretive framework for enhancing patient safety in the operating room (OR).

We conducted a selective literature review focusing on peer-reviewed publications related to surgical teamwork, communication, safety checklists, and non-technical skills. Relevant sources were identified through PubMed and Google Scholar using terms such as “surgical safety,” “human factors in surgery,” “team communication,” and “simulation in healthcare.” Foundational documents such as the WHO Surgical Safety Checklist and studies on simulation-based training were included to provide empirical grounding.

The thematic synthesis followed a conceptual analysis strategy. Key themes such as role clarity, preparation, communication, situational awareness, and debriefing were mapped onto corresponding theatrical concepts (e.g., cast, rehearsal, live performance, curtain call). This metaphorical structure was iteratively refined through feedback from clinicians, educators, and surgical staff in academic hospital settings, ensuring conceptual relevance and face validity.

This method allows for reflective insight into how surgical teams can improve safety culture by recognizing their shared performance dynamics, promoting structured preparation, and fostering psychological safety. Although narrative in nature, this article is anchored in evidence-based practices and aims to inspire practical, team-centered interventions in the OR.

Results: character roles and team interactions in the OR

The cast: roles that define outcomes

Every successful performance depends not only on a great script but also on the strength and synergy of its cast. In the operating room, each team member plays a critical role one that directly influences the safety and outcome of the procedure. Just as a theater production can collapse under the weight of poor casting or miscommunication, surgical outcomes can be jeopardized when roles are unclear or disconnected [7].

The surgeon: the lead actor

The surgeon is often seen as the star of the show the individual whose decisions and skills guide the operation. Like a lead actor, the surgeon must master the technical “lines” of the procedure and respond fluidly to unexpected complications. But even the most skilled surgeon cannot succeed in isolation. Their performance is amplified or diminished by the rhythm and readiness of the team around them [8].

The anesthesiologist: the physiological conductor

Behind every stable patient lies the vigilance of the anesthesiologist. Though often unnoticed by the “audience,” their control over the patient’s vital signs, pain, and consciousness is critical to the performance. Like a musical conductor, they maintain harmony in the patient’s physiological state, constantly adjusting to the tempo of the surgery.

The scrub nurse: the stage manager

The scrub nurse ensures that the instruments, environment, and timing are all aligned ready for each act of the operation. Like a stage manager, they anticipate the surgeon’s needs, maintain sterility, and help preserve the flow and integrity of the performance. Their behind-the-scenes coordination enables the cast to perform without interruption.

The circulating nurse: the quiet orchestrator

While less visible, the circulating nurse is vital. They manage logistics, retrieve needed equipment, and act as a liaison between the sterile field and the broader clinical environment. Like the backstage crew of a theater, they operate seamlessly in the background stepping in only when a prop is missing, a cue is lost, or an unexpected variable enters the scene.

Rehearsals and protocols: preparing for the performance

No theater performance succeeds without rehearsal. Lines are practiced, cues are memorized, and transitions are smoothed out long before the curtain rises. In surgery, this preparation is no less critical. But instead of scripts and props, surgical teams rely on protocols, checklists, simulations, and team briefings tools that help synchronize actions and reduce variability [5].

Briefings: the table read of surgery

A preoperative briefing is the OR’s version of a “table read” in theater a moment where everyone pauses to review the plan, anticipate challenges, and align on roles. This communication is essential. Studies have shown that effective team briefings reduce misunderstandings, increase efficiency, and directly correlate with improved patient outcomes. When teams don’t pause to align, small errors compound just like a stage crew missing a lighting cue can throw off the timing of an entire scene [9].

Checklists: the script of safety

Introduced by the WHO, the surgical safety checklist is one of the most powerful tools for reducing errors. It acts as a script guiding the team through critical steps before, during, and after surgery. Just as no actor skips pages of dialogue, no team should skip items on the checklist. Its consistent use is associated with lower mortality and complication rates [10].

Simulations: dress rehearsals for real lives

Simulation training allows teams to practice high-stakes scenarios in a risk-free environment. From managing a sudden hemorrhage to responding to a cardiac arrest, simulation is the rehearsal space where roles, communication, and leadership are tested. These exercises build muscle memory, enhance team trust, and provide a safe place for feedback much like theater rehearsals expose weaknesses before opening night [11].

Protocols: direction and discipline

Protocols offer more than routine they provide structure and predictability in a space where chaos is always one mistake away. Like a director guiding a performance, protocols ensure that the rhythm of care doesn’t falter. But protocols must be dynamic. Just as directors revise scenes when something isn’t working, surgical teams must regularly update their protocols based on new evidence, feedback, and performance audits [12].

Live surgery: performing under pressure

When the lights go up in a theater, there’s no room for hesitation every movement, every word, every pause matters. In the operating room, the stakes are even higher: a real human life is on the line. Unlike theater, there are no encore performances or second takes. The surgical team must deliver precision and coordination in real time, often under immense pressure.

Real-time decision making: improv with consequences

While preparation is essential, surgery like live performance often requires improvisation. Unexpected bleeding, an anatomical variation, or a sudden change in vital signs can demand immediate decisions. The quality of these responses depends not just on the surgeon’s expertise, but on how well the team communicates under pressure.

Breakdowns in communication during critical moments are a major cause of adverse events. A mistimed medication, a misheard instruction, or an unvoiced concern can lead to patient harm. In this high-stakes environment, clarity, brevity, and assertiveness are key to survival much like actors on stage must stay in character, no matter the disruption [13].

Closed-loop communication: echoing for safety

Closed-loop communication is a cornerstone of safe surgical practice. When a surgeon requests a clamp, the nurse repeats the instruction (“Clamp coming”), confirms the action, and the surgeon acknowledges (“Thank you”). This system minimizes errors caused by background noise, fatigue, or stress. It’s the OR’s version of actors repeating lines to ensure they’re on the same page.

Situational awareness: staying in the scene

Every team member must maintain what is known as situational awareness an ongoing perception of the patient’s condition, the progression of the procedure, and the actions of teammates. Losing this awareness, even briefly, can lead to dangerous consequences. It’s like an actor forgetting they’re on stage and missing their cue only here, the price may be irreversible [14].

The role of emotion: performing under emotional load

Surgery is emotionally charged. Tension, fatigue, hierarchy, and fear of failure all weigh heavily. In the theater of surgery, emotional control is critical. Leaders who foster psychological safety where team members feel empowered to speak up are more likely to run successful operations. The best performances happen when the cast trusts one another [15].

Curtain call: debriefing and learning after the performance

When the final stitch is placed and the patient is transferred, the surgical performance comes to an end but the learning does not. Just as actors gather backstage to discuss their show, surgical teams must engage in structured reflection to improve future performance.

Debriefing: reflecting with purpose

A structured debrief allows the surgical team to reflect on what went well, what didn’t, and what could be improved next time. It’s not about blame it’s about learning. This reflection builds a culture of transparency and continuous improvement. Teams that debrief regularly show lower rates of complications and higher levels of team satisfaction [16].

Questions like:

• Did we communicate effectively?

• Were all safety protocols followed?

• Were there any near-misses?

can reveal hidden system flaws or gaps in training. Like reviewing the recording of a stage performance, debriefing turns lived experience into lessons.

Psychological safety: the foundation of honest dialogue

Effective debriefs require psychological safety. If team members fear judgment or retaliation, they will remain silent. But when leaders create an open, non-punitive environment, even the quietest voices can contribute valuable insights. This sense of safety strengthens teamwork and prevents repeat errors [17].

From reflection to action: closing the loop

It’s not enough to identify problems we must act on them. The most successful teams turn debrief findings into concrete changes: revising checklists, adjusting protocols, or organizing training sessions. Just as theater directors revise the script based on feedback, surgical teams must evolve their practice based on real experiences.

Conclusion: from performance to patient safety

Surgery is more than a procedure it is a coordinated performance where communication, preparation, and teamwork determine the outcome. By viewing the operating room as a stage, we recognize the importance of clarity, rehearsal, role definition, and post-performance reflection. Patient safety, like a great performance, depends not on individual brilliance, but on collective harmony.

If we can learn to rehearse better, communicate clearer, support one another emotionally, and reflect honestly we can save more lives.

Author contributions

S.A.R contributed to the conception and design of the study, literature review, drafting of the manuscript, and final approval of the version to be published.

Funding

This research received no external funding.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.