At 3:15 AM on an otherwise unremarkable Thursday morning, a routine appendectomy was about to begin. Well, at least everyone thought it would be routine. Nothing about the 22-year-old woman’s history was remarkable and her story as well as examination findings, laboratory results, and imaging studies all pointed directly at a diagnosis of acute appendicitis. Half-heartedly and half-asleep, the various team members mechanically acknowledged their respective pieces of the preoperative checklist as the circulating nurse methodically moved through the numerous items. Eventually, an incision was made and, shortly thereafter, insufflation of the abdomen was initiated. Within 30 seconds, the otherwise healthy patient had experienced a bradycardic arrest and was undergoing chest compressions as the team frantically tried to respond. The situation could only be described as chaos.

“Why did no one tell me the patient was unstable while we were insufflating?!” the surgeon shouted between compressions. “Is this a drug reaction? What antibiotics were given? Was the patient bradycardic and atropine wasn’t given?!”

“Where is the code cart?” came an exasperated response from the nurse anesthetist at the head of the bed.

“Where is the attending anesthesiologist? Is she still placing that epidural in the labor and delivery unit?” cried the circulating nurse while scrambling to the find the defibrillator.

Situations like this one highlight the crucial need for teamwork in the operating room (OR). Although common in other industries, the concepts of team training and non-technical skill (NTS) development are relatively new to the perioperative environment. Where such techniques have been applied, results have often been striking. Perhaps they would have been in this case as well. Perhaps in an OR characterized by greater psychological safety, the overnight medical student would have felt comfortable speaking up when he noticed that the patient’s heart rate had suddenly dropped from 70 to 35 beats per minute. Perhaps greater attentiveness during the pre-briefing would have created clarity about the antibiotics given prior to incision. Perhaps learning names and role would have allowed someone to take a leadership role amidst the chaos.

Even beyond these crises, however, the need for team training and NTS development has a tangible impact on the quality of health care delivery in surgical contexts. In this monograph, we trace the historical underpinnings of team training and NTS to the OR and provide a review of the evidence regarding their effectiveness. We also provide interested readers with resources for the development of individual and team NTS.