2025/12/18 by George Tewfik, Uma Munnur, Lisa L. Bethea +1 · 1 voice
Chemical Engineering · Health Professions · #Chemical Safety and Risk Management #Occupational Health and Safety Research #Patient Safety and Medication Errors
paper · doi:10.1097/01.asm.0001176516.11091.22
openalex created_date 2025/12/18 · openalex publication_date 2025/12/18 · openalex updated_date 2026/07/23
Locums clinicians are temporarily employed by anesthesiology groups and departments for a variety of reasons, including vacation or leave coverage, expansion of service, or inability to recruit full-time practitioners. Although these clinicians are “transient” staff, it is essential that they participate in the culture of safety at a health care facility. Culture within a group of clinicians is often a crucial component and indicator of success or failure of a robust patient safety program; this consideration is magnified when considering the effects on patient safety of locums anesthesiologists, certified registered nurse anesthetists (CRNAs) and certified anesthesiologist assistants (CAAs). Culture in health care is broadly defined as a set of shared values, norms, and behaviors that influence clinical practice. A strong culture of safety encompasses consistent protocols, transparency, robust reporting, and feedback provided to clinicians and administrators alike. Conversely, a weak or fragmented culture is characterized by variability, underreporting, and unclear accountability. Clinician culture is often derived from three levels – the group practice or staffing agency, the health care system or facility, and the local department (Table 1). Table 1 - A summary of the levels at which anesthesia culture is created, how each level may affect locums clinicians, and best practices for patient safety. Level of Culture How Culture Affects Locums Common Risks if Culture Is Weak Best Practices to Strengthen Safety Group (Practice/Staffing Agency) Sets expectations for clinical practice and quality engagement Minimal onboarding, locums seen as “outsiders,” little peer feedback Structured onboarding, equal accountability for reporting, include locums in peer review System (Health Network/Multi-Hospital) Standardizes policies, reporting, and metrics across sites Fragmentation, inconsistent protocols, unclear adverse event attribution System-wide safety metrics, uniform reporting requirements, simulation/orientation access for locums Department (Local OR/Hospital) Shapes day-to-day teamwork, communication, and inclusion Poor teamwork, lack of local knowledge transfer, limited feedback Foster inclusive culture; ensure locums attend huddles, M&M; share “local knowledge” (equipment, protocols) Anesthesiologists, CRNAs, CAAs, and residents can become integrated into group or department culture by operating within these shared values and norms over time. However, for locums clinicians, who may work inconsistently at a facility or for short durations, there is not enough time for the culture of safety to seep in by osmosis. Concrete steps are required to ensure that patient safety and culture work hand in hand with a transient workforce (Table 2). Expectation-setting at orientation and onboarding are crucial. Peer support and mentorship are useful tools for providing reference points for locums staff. It is essential to ensure that locums clinicians are treated as equal partners, not “short term help,” and that they are not made to feel different than full-time staff. Making locums clinicians feel integrated will help get their buy-in for participation in protocols and quality improvement. Table 2 - Strategies to align patient safety and culture with a transient workforce. Domain Strategy Key Actions Impact on Safety Culture Onboarding Structured, safety-focused orientation Orientation on safety, EHR, emergencies Assign safety mentor Rapid integration and consistent safety practices Psychological Safety Foster open communication Use inclusive language (“our team today”) Encourage all voices Builds trust and empowers locums to speak up Communication and Handoffs Standardize team communication Use SBAR framework, checklists, and closed-loop communication Improves reliability and clarity in variable teams Learning and Feedback Integrate locums into safety learning Access to incident reporting Include in debriefs/M&M conferences Provide feedback Promotes learning and inclusion in safety processes Standardization Create consistent systems Uniform labels, setups, and templates Role identifiers (badges, lanyards) Reduces variability and error risk Leadership Demonstrate visible, inclusive leadership Recognize locum contributions Communicate safety priorities Reinforce shared mission Strengthens engagement and shared accountability Workforce Planning Promote continuity in staffing Limit unnecessary turnover Recurrent scheduling Structured locum handoffs Enhances familiarity and care reliability EHR = Electronic health record; SBAR = situation, background, assessment, recommendation;M&M = morbidity and mortality Health care systems and facilities also share an important role in ensuring that patient safety culture is ingrained within a locums clinician workforce. This can be successfully accomplished by ensuring standardized quality metrics across clinical sites, and by mandatory participation in reporting systems such as the Anesthesia Quality Institute's National Anesthesia Clinical Outcomes Registry or incident reports unique to a facility or system. Locums clinicians should also be included in training to improve patient safety in modalities such as crisis management protocols, mock codes, and multidisciplinary simulation exercises. Facilities and systems must bear the burden of ensuring consistency in reporting, protocols, and emergency systems, striving to avoid the pitfalls of fragmentation, which can cause confusion among clinicians. A significant roadblock to ensuring patient safety culture for locums clinicians may exist at the department level. Full-time staff should be encouraged to treat locums clinicians with respect and as equal, capable practitioners. Efforts should be made to incorporate their practice within the department, including willingness to share unwritten “local knowledge” such as surgeon preference, quirks within electronic health records or reporting systems, and the locations of equipment or available resources. Perhaps most important is to include locums clinicians in communication avenues that involve patient safety. This can include grand rounds, educational events, email communication, the morbidity and mortality conference, quality improvement initiatives, and care coordination huddles. Creating an inclusive culture within a department ensures consistency with the development and implementation of safety processes, from administration to the frontlines of patient care. Leadership reluctance to utilize paid locums hours to participate in patient safety activities is a significant barrier. Investments in patient safety should extend to both full-time and locums clinicians in the forms of time, money, and available resources on an equitable basis. This investment in all staff will yield dividends via avoidance of adverse events and improved patient outcomes for the entire practice or department. The consequences of failing to ensure an adequate and robust culture of patient safety with locums clinicians cannot be overstated. When locums clinicians are excluded from reporting systems, either by design or by inadvertent omission, adverse events will be missed. The result is hinderance of thoughtful analysis that may reveal systemic or localized opportunities for improvement in care. A lack of feedback that results from a poor adverse event analysis process may lead to repeated errors or unsafe practices. When there is a poor orientation process, personnel may not be able to easily access crucial items or support in a critical situation. Finally, a cultural divide between full-time staff and “outsiders” will generally lead to poor teamwork and ineffective communication among all clinicians and support personnel. Solutions to address patient safety with locums clinicians, including anesthesiologists, CRNAs and CAAs, should address potential limitations at the group/practice, systems, and department levels (Table 1). At the group or practice level, structured onboarding and an effective peer-review process are essential first steps. At the systems level, quality metrics should be standardized, and reporting expectations should be set and communicated across all facilities. Finally, departments should strive to foster inclusivity and include locums staff in regular communications and debriefing, while ensuring access to proper safety resources. Across all interactions, locums should be treated as “temporary in presence, permanent in responsibility.” The use of locums clinicians in practices across the United States continues to be an important trend. Leaders and administrators should seek to create and foster a culture that ensures patient safety. A strong culture at the group/practice, systems, and department level can increase the likelihood that locums clinicians integrate seamlessly; conversely, a weak culture may magnify patient safety gaps. As anesthesiologists, building a culture that values inclusivity and transparency will help us to maintain the highest levels of patient safety.George Tewfik, MD, MBA, FASA, ASA Committee on Patient Safety and Education, ASA Committee on Practice Management, Associate Professor, and Director of Quality Assurance, Department of Anesthesiology, Rutgers-New Jersey Medical School, Newark, New Jersey.Uma Munnur, MD, MS, ASA Committee on Patient Safety and Education, and Professor, Baylor College of Medicine, Houston, Texas.Lisa L. Bethea, MD, CPPS, ASA Committee on Patient Safety and Education, and Assistant Member, Department of Anesthesiology, Moffitt Cancer Center, Tampa, Florida.Jennifer Feldman-Brillembourg, MD, FASA, ASA Committee on Membership, ASA Committee on Patient Safety and Education, and Attending Anesthesiologist, Washington, D.C.