Abstract
<title>Abstract</title> <p> <bold>Background</bold> Spine surgery is among the most cognitively demanding surgical subspecialties, requiring sustained multidisciplinary coordination under conditions of high technical complexity. Despite technological advances, clinically relevant perioperative complications persist, including incidental durotomy, new neurological deficit, and surgical site infection. A growing body of evidence also indicates that human factors and Non-Technical Skills (NTS)—including communication, leadership, situational awareness, and teamwork—are important determinants of safe surgical performance. However, structured observational analyses in the specific context of spine surgery remain limited. [1–7] <bold>Objective</bold> To characterize NTS profiles and identify human factors-related system vulnerabilities in a specialist spine surgery team, using an observational methodology as the initial phase of the SPINESAFE project. <bold>Methods</bold> A qualitative observational pilot study was conducted over two months at a tertiary referral spine surgery center (IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy). Direct in-situ observation sessions covered 40 surgical procedures—including degenerative, deformity, and oncological spine pathologies—performed by a multidisciplinary team comprising senior and junior surgeons, an anesthesiologist, scrub and circulating nurses, a neurophysiology technician; an external surgical consultant was present in selected cases. Observations were conducted by a single trained non-participant observer (a systemic-relational psychotherapist with expertise in human factors) across the full surgical pathway. Behavioral and organizational dynamics were assessed using TeamSTEPPS, Oxford NOTECHS II, and the Human Factors Analysis and Classification System (HFACS). <bold>Results</bold> Observational data identified several modifiable contributors to perioperative risk: variability in team communication and briefing practices, fragmented communication during care transitions, environmental stressors such as frequent noise and interruptions and fluctuating levels of situational awareness under cognitive load. TeamSTEPPS analysis showed moderate-to-high overall performance (mean domain scores 3.10-3.50/5), with situation monitoring/situational awareness highest (3.50 ± 0.75) and leadership lowest (3.10 ± 0.78). Oxford NOTECHS II provided a complementary profile, with situational awareness scoring lowest across its domains (2.92 ± 0.66/4), suggesting that individual monitoring behaviors may be stronger than shared team-level situational awareness. HFACS analysis identified unsafe acts (Level 1: mean 0.65 ± 0.48) and preconditions for unsafe acts (Level 2: 0.55 ± 0.50) as the most frequently observed vulnerability categories. Key modifiable contributors included communication fragmentation, inconsistent WHO Surgical Safety Checklist adherence, hierarchical inhibition of speaking-up behaviors, environmental noise and workflow interruptions. <bold>Conclusions</bold> This observational pilot study suggests that modifiable human factors and system conditions may contribute to perioperative vulnerability in spine surgery. Psychological safety, structured communication, shared situational awareness, and environmental management emerged as priority intervention targets. These findings provide a preliminary empirical foundation for subsequent SPINESAFE phases, which will evaluate NTS-based interventions and their relationship with team performance and patient safety outcomes. </p>