Table 2 Quotations subthemes (n = numbers of participants providing data for the subtheme)

Theme 1: Individual accountability as a safety net

Subtheme 1a:

Role understanding and interprofessional accountability

(n = 17)

Operating room nurse (ID02): “I evaluate the situation. Sometimes, they are very focused; other times, we may talk about completely different things as well. So, I have to assess if it is time for me to give that message or wait.”

Nurse anesthetists (ID05): “Bringing out the best in each other, being generous with one another…you're probably better at this when you can broaden your perspective, gain some experience, and see others, not just focusing on your tasks.”

Anesthesiologist (ID10): “I think it’s important that we help each other and understand each other’s roles so that we can catch if something goes wrong or something isn’t done…that we have an overview of everything, not just ourselves.”

Subtheme 1b:

Competence and commitment to healthcare delivery

(n = 17)

Operating room nurse (ID01): “It happens that I read even more carefully and study the pictures more closely to ensure that the surgeon has ordered the right equipment. Is it supposed to be done like this? Occasionally, I make a call, and both orders and everything else turn out differently, and the whole operation also becomes completely different.”

Anesthesiologist (ID07): “It’s probably a system designed so that we all act as safety nets, each individual being a safety net. Maybe things go relatively well because everyone is quite thorough, so the safety nets overlap.”

Anesthesiologist (ID14): “If you read the newspaper, you can easily think that doctors, especially those who are accused of being arrogant, are, well, I believe that is somewhat misunderstood. I think that one of the things we fear most is not doing well. Yes, we strongly desire to succeed, probably because we are so ambitious, but we also want it to be good for the patients. And how catastrophically it feels personally when you harm a patient.”

Subtheme 1c:

Balancing work demand and patient safety on a knife edge

(n = 17)

Operating room nurse (ID01): “Sometimes, the management doesn’t fully understand what we’re dealing with. This is because they have a money bag, and they are terrified of it running dry, while we have a patient, and we are terrified that the patient might die.”

Surgeon (ID03): “We are supposed to be trained, which takes more time. You may not be able to do that because you must get through what you need to.”

Nurse anesthetists (ID04): “It becomes a situation where you try to be as quick as possible. You often prepare for the next patient while still taking care of the previous one, drawing up medications, and in many situations, that's perfectly fine. If you have a stable patient, you can easily draw up medications in a corner of the room. However, it can become challenging for safety when there is too much pressure to get through things and too much rush.”

Theme 2. Psychological safety as a facilitator for well-being and safe performance in the operating room

Subtheme 2a:

Leadership and empowering communication

(n = 17)

Operating room nurse (ID02): “It's much easier to speak up with the younger ones in the operation room. Many, not all, of course, but some have a slightly different attitude towards us as professionals and, generally, teamwork.”

Surgeon (ID08): “There are many ways to perform leadership. It is possible to lead with dignity…the leader must make every team member proud of their role in the machinery. Because without this role, it wouldn’t work. Everyone must understand that they are seen and have their position.”

Anesthesiologist (ID10): “Lately, I have experienced training from certain personality types, and I can notice that I become insecure, perform worse, lose self-confidence, and fight for my abilities. I believe that how team members talk to each other in stressful and dramatic situations is crucial because I have experienced how it affects me when experiencing scolding and obvious criticism of oneself.”

Subtheme 2b:

A supportive parachute and a culture of openness

(n = 17)

Anesthesiologist (ID06): “We must acknowledge that we make mistakes, that it can happen, and that it’s part of the profession. Statistically, things will sometimes go wrong, and we must be able to work with that. We should also ensure that we provide strong support for each other and that everyone is open about the fact that it could be any of us. So, it’s important that everyone feels that we’re all in the same boat.”

Surgeon (ID16): “If there had been a culture of fear or ridicule, it would probably have made you feel more nervous. If it sharpens one’s focus, nervousness is good, but being too nervous can be destructive. I feel there’s a low threshold for asking for help and admitting that I’m uncertain: ‘Can you help me?’ Those are issues that probably contribute to providing that freedom to reduce the percentage.”

Nurse anesthetists (ID11): “One talks about positive events or like 'oh, what did I just do’, ‘have you heard?' sort of like 'this wasn't good' or supports each other if there are things to share. So, we have a very informal, but it's a good culture for discussing professional issues and talking about such things, and it indirectly impacts patient safety.”

Subtheme 2c:

Continuity and cohesion in the team

(n = 17)

Operating room nurse (ID09): “You know the people you work with, and you're aware of the qualities each one possesses, and communication flows very smoothly. It's not necessarily everything that's said, but there's just this understanding that you know, it's a bit like ((gestures with hands and eyes)) now I'm showing that we see each other and um (.) that we know what the other can do and what they're doing. The patient also notices, without them saying it, you can feel that the patient senses it when the team is coordinated, and things are going as they should.”

Surgeon (ID13): “And it’s always nice if you are well familiar with a system and accustomed to working in a place where you know the people you work with, and you work in a team that you trust and have knowledge of their expertise.”

Surgeon (ID17): “I know many personnel who work here regularly. But there are turnovers, so there may be personnel I don’t know. However, it’s very nice to know each other’s strengths and communicate or get along. Here, I know that the screw is quality assured in a way, or it’s that type of screw. In another place, when you don’t know them [colleagues], you might think you must double-check to ensure it is correct.”

Theme 3. Proactive structures and participation in organizational learning

Subtheme 3a:

Forum for discussing risk, safety, and events among allied healthcare professionals

(n = 17)

Operating room nurse (ID12): “At one place, events were discussed at staff meetings approximately once a month. Then, they addressed the recurring incidents because they often have common themes. They discussed what we could improve to prevent it from happening again, and everyone participated and listened. They inquired if any actions had been initiated or if there were any suggestions on what actions to take to improve the performance. That's what I think the purpose of such a system is.”

Surgeon (ID13): “The fact that the patient receives the best treatment with a predictable outcome is for the benefit of everyone involved: As an employee, colleague, and team member. It provides economically favorable results. So, it’s essential, and I wish that patient safety and quality work had a higher standing than randomized controlled studies at the receptor level.”

Anesthesiologist (ID14): “The curse of working in a healthcare system is that when criticism arises, we often tend to close ranks within our profession. It means that when criticism arises, anesthesia professionals, for example, defend themselves against external attacks. Operating room nurses do the same if they receive criticism from anesthesia professionals. Surgeons do it if they receive criticism. I perceive this as almost uniformly negative, the fact that as we retreat into our professional, we miss the opportunities for improvement.”

Subtheme 3b:

An efficient and formal system for reporting and learning from adverse events

(n = 16)

Nurse anesthetists (ID04): “I often sense that physicians have an attitude that the most constructive approach is to talk about the event, thinking ‘we can just inform them’, with reporting seen as a means of holding someone accountable. Some of them seem to find it tidier to make a phone call. However, that`s not the essence of it. Reporting is not primarily about personal issues. It`s more often a systemic problem, a system issue.”

Anesthesiologist (ID10): “I think the most important thing is communicating with the employees and ensuring functional reporting systems. I think that's the most crucial thing. If you don’t know, nothing will happen. But when you have the report, you must talk to the frontline workers to gather input and insight into the daily work. And what interventions are effective.”

Surgeon (ID13): “It’s something I’ve requested and wanted more focus on. Because it’s obvious that events occur, and it’s something we can learn from. An event isn’t necessarily about the person who caused it. It’s more about the system, and we all need to learn from it, so we don’t only learn when we experience such an event ourselves.”