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Objectives: Our primary objective was to study the impact of the Norwegian National Patient Safety Campaign and Program on Surgical Safety Checklist (SSC) implementation and on safety culture. Secondary objective was associations between SSC fidelity and safety culture. We hypothesised that the programme influenced on SSC use and operating theatre personnel's safety culture perceptions., Setting: A longitudinal cross-sectional study was conducted in a large Norwegian tertiary teaching hospital., Participants: We invited 1754 operating theatre personnel to participate in the study, of which 920 responded to the surveys at three time points in 2009, 2010 and 2017., Primary and Secondary Outcome Measures: Primary outcome was the results of the patient safety culture measured by the culturally adapted Norwegian version of the Hospital Survey on Patient Safety Culture. Our previously published results from 2009/2010 were compared with new data collected in 2017. Secondary outcome was correlation between SSC fidelity and safety culture. Fidelity was electronically recorded., Results: Survey response rates were 61% (349/575), 51% (292/569) and 46% (279/610) in 2009, 2010 and 2017, respectively. Eight of the 12 safety culture dimensions significantly improved over time with the largest increase being ' Hospital managers' support to patient safety ' from a mean score of 2.82 at baseline in 2009 to 3.15 in 2017 (mean change: 0.33, 95% CI 0.21 to 0.44). Fidelity in use of the SSC averaged 88% (26 741/30 426) in 2017. Perceptions of safety culture dimensions in 2009 and in 2017 correlated significantly though weakly with fidelity (r=0.07-0.21)., Conclusion: The National Patient Safety Program, fostering engagement from trust boards, hospital managers and frontline operating theatre personnel enabled effective implementation of the SSC. As part of a wider strategic safety initiative, implementation of SSC coincided with an improved safety culture., Competing Interests: Competing interests: ASH represent the IFNA in the ESA Patient Safety and Quality Committee. NS is the Director of London Safety and Training Solutions Ltd, which provides quality and safety training and advisory services on a consultancy basis to healthcare organisation globally. The other authors report no conflicts of interest. SH had a role as lead of the Scientific Advisory Board appointed by the Norwegian Directorate of Health 2011–2013. IFNA, ESA, London Safety and Training Solutions Ltd., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Surgical safety has advanced rapidly with evidence of improved patient outcomes through structural and process interventions. However, knowledge of how to apply these interventions successfully and sustainably at scale is often lacking. The 2019 Global Ministerial Patient Safety Summit called for a focus on implementation strategies to maintain momentum in patient safety improvements, especially in low- and middle-income settings. This study uses an implementation framework, knowledge to action, to examine a model of nationwide World Health Organization (WHO) Surgical Safety Checklist implementation in Cameroon. Cameroon is a lower-middle-income country, and based on data from high- and low-income countries, we hypothesized that more than 50% of participants would be using the checklist (penetration) in the correct manner (fidelity) 4 months postintervention., Methods: A collaboration of 3 stakeholders (Ministry of Health, academic institution, and nongovernmental organization) used a prospective observational design. Based on knowledge to action, there were 3 phases to the study implementation: problem identification (lack of routine checklist use in Cameroonian hospitals), multifaceted implementation strategy (3-day multidisciplinary training course, coaching, facilitated leadership engagement, and support networks), and outcome evaluation 4 months postintervention. Validated implementation outcomes were assessed. Primary outcomes were checklist use (penetration) and fidelity; secondary outcomes were perioperative teams' reactions, learning and behavior change; and tertiary outcomes were perioperative teams' acceptability of the checklist., Results: Three hundred and fifty-one operating room staff members from 25 hospitals received training. Median time to evaluation was 4.5 months (interquartile range [IQR]: 4.5-5.5, range 3-7); checklist use (penetration) increased from 20% (95% confidence interval [CI], 16-25) to 56% (95% CI, 49-63); fidelity for adherence to 6 basic safety processes was high: verification of patient identification was 91% (95% CI, 87-95); risk assessment for difficult intubation was 79% (95% CI, 73-85): risk assessment for blood loss was 88% (95% CI, 83-93) use of pulse oximetry was 93% (95% CI, 90-97); antibiotic administration was 95% (95% CI, 91-98); surgical counting was 89% (95% CI, 84-93); and fidelity for nontechnical skills measured by the WHO Behaviorally Anchored Rating Scale was 4.5 of 7 (95% CI, 3.5-5.4). Median scores for all secondary outcomes were 10/10, and 7 acceptability measures were consistently more than 70%., Conclusions: This study shows that a multifaceted implementation strategy is associated with successful checklist implementation in a lower-middle-income country such as Cameroon, and suggests that a theoretical framework can be used to practically drive nationwide scale-up of checklist use.

Objective: To investigate whether distractions in the operating room (OR) are associated with higher mental workload and stress, and poorer teamwork among OR personnel., Background: Engaging in multiple tasks can affect performance. There is little research on the effect of distractions on surgical team members' behavior and cognitive processes., Methods: Ninety general surgery cases were observed in real time. Cases were assessed by a surgeon and a behavioral scientist using 4 validated tools: OR Distractions Assessment Form, the Observational Teamwork Assessment for Surgery tool, NASA-Task Load Index, and short form of the State Trait Anxiety Inventory. Analysis of variance was performed to evaluate significant differences between teamwork, workload, and stress level among team members. Correlations (Pearson r) were computed to evaluate associations between variables., Results: The most prevalent distractions were those initiated by external staff, followed by case-irrelevant conversations. Case-irrelevant conversations were associated with poorer team performance. Irrelevant conversations initiated by surgeons were associated with lower teamwork in surgeons (across team skills: r = -0.44 to -0.58, P < 0.05 to 0.01) and anesthesiologists (r = -0.38 and r = -0.40, for coordination and leadership; P < 0.05). Equipment-related distractions correlated with higher stress (r = 0.48, P < 0.05) and lower teamwork (across team skills: r = -0.42 to -0.50, P < 0.05) in nurses. Acoustic distractions correlated with higher stress in surgeons (r = 0.32, P < 0.05) and higher workload in anesthesiologists (r = 0.30, P < 0.05)., Conclusions: Although some distractions may be inevitable in the OR, they can also be detrimental to the team. A deeper understanding of the effect of distractions on teams and their outcomes can lead to targeted quality improvement.

Background: Full implementation of safety checklists in surgery has been linked to improved outcomes and team effectiveness; however, reliable and standardized tools for assessing the quality of their use, which is likely to moderate their impact, are required., Study Design: This was a multicenter prospective study. A standardized observational instrument, the "Checklist Usability Tool" (CUT), was developed to record precise characteristics relating to the use of the WHO's surgical safety checklist (SSC) at "time-out" and "sign-out" in a representative sample of 5 English hospitals. The CUT was used in real-time by trained assessors across general surgery, urology, and orthopaedic cases, including elective and emergency procedures., Results: We conducted 565 and 309 observations of the time-out and sign-out, respectively. On average, two-thirds of the items were checked, team members were absent in more than 40% of cases, and they failed to pause or focus on the checks in more than 70% of cases. Information sharing could be improved across the entire operating room (OR) team. Sign-out was not completed in 39% of cases, largely due to uncertainty about when to conduct it. Large variation in checklist use existed between hospitals, but not between surgical specialties or between elective and emergency procedures. Surgical safety checklist performance was better when surgeons led and when all team members were present and paused., Conclusions: We found large variation in WHO checklist use in a representative sample of English ORs. Measures sensitive to checklist practice quality, like CUT, will help identify areas for improvement in implementation and enable provision of comprehensive feedback to OR teams., (Copyright © 2015 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Background. Poor teamwork and nontechnical skill performance are increasingly recognized as important contributing factors to errors and adverse events in the operating room. Assessment of these safety critical skills is important to facilitate improvement, however there are no tools available to assess these safety skills in Latin America. This study aimed to translate, culturally adapt and content validate the Observational Teamwork Assessment for Surgery (OTAS) tool for use in Latin America. Methods. A multi-phase, multi-method study was conducted: Phase 1: translation and back-translation; Phase 2: content validity assessed via expert consensus; Phase 3: inter-rater reliability assessed via real-time observation in 98 general surgical procedures using OTAS-S. Results. The first change in OTAS-S, was to distinguish between the surgical nurses and scrub technicians (both OR team members are captured in the nursing sub-team in the original OTAS). OTAS-S consists of 168 exemplar behaviors: 60/114 identical to the exemplars listed in the original OTAS tool, 48/114 original exemplars underwent minor modifications, 13 were duplicated (to account for the additional sub-team distinguished in OTAS-S), 6 original exemplars were removed, and 47 new exemplar behaviors were added. Inter-observer agreement was substantial (KW = 0.602; IC: 0.581-0.620). The calculated KW by phase, behaviors and teams were between 0.534 and 0.678. Conclusions. The study provides a content validated teamwork assessment tool for use within Colombian operating rooms and potentially Latin-American. OTAS-S can be used to assess the quality of teamwork in ORs, facilitate structured debriefing and thus improve patient safety and reduce team-related errors., (Copyright © 2014 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.)

Background: Evidence suggests that full implementation of the WHO surgical safety checklist across NHS operating theatres is still proving a challenge for many surgical teams. The aim of the current study was to assess patients' views of the checklist, which have yet to be considered and could inform its appropriate use, and influence clinical buy-in., Method: Postoperative patients were sampled from surgical wards at two large London teaching hospitals. Patients were shown two professionally produced videos, one demonstrating use of the WHO surgical safety checklist, and one demonstrating the equivalent periods of their operation before its introduction. Patients' views of the checklist, its use in practice, and their involvement in safety improvement more generally were captured using a bespoke 19-item questionnaire., Results: 141 patients participated. Patients were positive towards the checklist, strongly agreeing that it would impact positively on their safety and on surgical team performance. Those worried about coming to harm in hospital were particularly supportive. Views were divided regarding hearing discussions around blood loss/airway before their procedure, supporting appropriate modifications to the tool. Patients did not feel they had a strong role to play in safety improvement more broadly., Conclusions: It is feasible and instructive to capture patients' views of the delivery of safety improvements like the checklist. We have demonstrated strong support for the checklist in a sample of surgical patients, presenting a challenge to those resistant to its use., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Background: There is emerging evidence indicating that distractions in the operating room (OR) are prevalent. Studies have shown a negative impact of distractions, but they have been conducted mostly with residents in simulated environments. We tested the hypothesis that intraoperative distractions are associated with deterioration in patient safety checks in the OR., Methods: We assessed 24 elective urologic procedures. Blinded trained assessors (two surgeons, one psychologist) used validated instruments to prospectively assess in vivo frequency and severity of distractions (related to communication, phones/pagers, equipment/provisions, OR environment, other hospital departments, or a member of the OR team) and completion of safety-related tasks (related to the patient, equipment, and communication). Descriptive and correlational analyses were conducted., Results: Mean case duration was 70 min (mean intraoperative time 31 min). A mean of 4.0 communication distractions (range 0-9) and 2.48 other distractions (range 0-5) were recorded per case (distraction rate of one per 10 min). Distractions from external visitors (addressed to the entire team or the surgeon) and distractions due to lack of coordination between hospital departments were most disruptive. Regarding safety checks, patient tasks were completed most often (85-100 %) followed by equipment tasks (75-100 %) and communication tasks (55-90 %). Correlational analyses showed that more frequent/severe communication distractions were linked to lower completion of patient checks intraoperatively (median rho -0.56, p < 0.05)., Conclusions: Distractions are prevalent in ORs and in this study were linked to deterioration in intraoperative patient safety checks. Surgeons should be mindful of their tolerance to distractions. Surgical leadership can help control distractions and reduce their potential impact on patient safety and performance.

Background: The nontechnical and team skills of surgical teams are critical for safety and efficiency in the operating room. Assessment of nontechnical and team skills can facilitate improvement by encouraging both self-reflection and team reflection, identifying training needs, and informing operating room (OR) team training approaches. The observational teamwork assessment for surgery (OTAS) tool is a well-validated and robust tool for capturing teamwork in the operating room. The aims of the present study were to systematically adapt and refine the OTAS for German-speaking OR staff and to test the adapted assessment tool (OTAS-D) for psychometric properties and metric equivalence., Methods: The study was carried out in three stages: at stage 1, OTAS was translated into German. At stage 2, experienced German OR experts (surgeons, OR nurses, anesthetists) were interviewed. At stage 3, two blinded assessors observed 11 general surgical operations (general surgical and vascular procedures) and interrater reliability was tested for refined OTAS-D behavioral exemplars and scorings., Results: The German OR experts confirmed the applicability and content validity of the vast majority of translated behavioral exemplars. After their evaluation, 32 items were changed slightly, six were changed substantially, and one item was added. During observations, perfect and substantial interobserver agreement was found for 77 behavioral exemplars (67.1 % of the items, kappa coefficient >0.60). Rating at all OTAS behaviors showed acceptable levels of reliability (intraclass correlation coefficients >0.72)., Conclusions: The OTAS-D is a tool for valid and reliable assessment of nontechnical skills that contribute to safe and effective surgical performance in ORs staffed by German-speaking professionals. Furthermore, our study serves as an example for systematically adapting and customizing well-established observational tools across different healthcare environments.

Objectives: The aim of this systematic review was to assess the impact of surgical safety checklists on the quality of teamwork and communication in the operating room (OR)., Background: Safety checklists have been shown to impact positively on patient morbidity and mortality following surgery, but it is unclear whether this clinical improvement is related to an improvement in OR teamwork and communication., Methods: A systematic search strategy of MEDLINE, EMBASE, PsycINFO, Google Scholar, and the Cochrane Database for Systematic Reviews was undertaken to obtain relevant articles. After de-duplication and the addition of limits, 315 articles were screened for inclusion by 2 researchers and all articles meeting a set of prespecified inclusion criteria were retained. Information regarding the type of checklist, study design, assessment tools used, outcomes, and study limitations was extracted., Results: Twenty articles formed the basis of this systematic review. All articles described an empirical study relating to a case-specific safety checklist for surgery as the primary intervention, with some measure of change/improvement in teamwork and/or communication relating to its use. The methods for assessing teamwork and communication varied greatly, including surveys, observations, interviews, and 360° assessments. The evidence suggests that safety checklists improve the perceived quality of OR teamwork and communication and reduce observable errors relating to poor team skills. This is likely to function through establishing an open platform for communication at the start of a procedure: encouraging the sharing of critical case-related information, promoting team coordination and decision making, flagging knowledge gaps, and enhancing team cohesion. However, the evidence would also suggest that when used suboptimally or when individuals have not bought in to the process, checklists may conversely have a negative impact on the function of the team., Conclusions: Safety checklists are beneficial for OR teamwork and communication and this may be one mechanism through which patient outcomes are improved. Future research should aim to further elucidate the relationship between how safety checklists are used and team skills in the OR using more consistent methodological approaches and utilizing validated measures of teamwork such that best practice guidelines can be established.

Objectives: To explore the current status of performance feedback (debriefing) in the operating room and to develop and evaluate an evidence-based, user-informed intervention termed "SHARP" to improve debriefing in surgery., Background: Effective debriefing is a key educational technique for optimizing learning in surgical settings. However, there is a lack of a debriefing culture within surgery. Few studies have prospectively evaluated educational interventions to improve the quality and quantity of performance feedback in surgery., Methods: This was a prospective pre- and post-study of 100 cases involving 22 trainers (attendings) and 30 surgical residents (postgraduate years 3-8). A trained researcher assessed the quality of debriefings provided to the trainee using the validated Objective Structured Assessment of Debriefing (OSAD) tool alongside ethnographic observation. Following the first 50 cases, an educational intervention termed "SHARP" was introduced and measures repeated for a further 50 cases. User satisfaction with SHARP was assessed via questionnaire. Twenty percent of the cases were observed independently by a second researcher to test interrater reliability., Results: Interrater reliability for OSAD was excellent (ICC = 0.994). Objective scores of debriefing (OSAD) improved significantly after the SHARP intervention: median pre = 19 (range, 8-31); median post = 33 (range, 26-40), P < 0.001. Strong correlations between observer (OSAD) and trainee rating of debriefing were obtained (median ρ = 0.566, P < 0.01). Ethnographic observations also supported a significant improvement in both quality and style of debriefings. Users reported high levels of satisfaction in terms of usefulness, feasibility, and comprehensiveness of the SHARP tool., Conclusions: SHARP is an effective and efficient means of improving performance feedback in the operating room. Its routine use should be promoted to optimize workplace-based learning and foster a positive culture of debriefing and performance improvement within surgery.

Background: Positive changes in safety culture have been hypothesized to be one of the mechanisms behind the reduction in mortality and morbidity after the introduction of the World Health Organization's Surgical Safety Checklist (SSC). We aimed to study the checklist effects on safety culture perceptions in operating theatre personnel using a prospective controlled intervention design at a single Norwegian university hospital., Methods: We conducted a study with pre- and post-intervention surveys using the intervention and control groups. The primary outcome was the effects of the Norwegian version of the SSC on safety culture perceptions. Safety culture was measured using the validated Norwegian version of the Hospital Survey on Patient Safety Culture. Descriptive characteristics of operating theatre personnel and checklist compliance data were also recorded. A mixed linear regression model was used to assess changes in safety culture., Results: The response rate was 61% (349/575) at baseline and 51% (292/569) post-intervention. Checklist compliance ranged from 77% to 85%. We found significant positive changes in the checklist intervention group for the culture factors 'frequency of events reported' and 'adequate staffing' with regression coefficients at -0.25 [95% confidence interval (CI), -0.47 to -0.07] and 0.21 (95% CI, 0.07-0.35), respectively. Overall, the intervention group reported significantly more positive culture scores-including at baseline., Conclusions: Implementation of the SSC had rather limited impact on the safety culture within this hospital.

Background: Although a number of validated tools are available for assessing nontechnical skills and teamwork in the operating room (OR), there are no tools for measuring completion of key OR tasks, which is fundamental to effective teamwork, patient safety, and OR efficiency. This study describes the development and content validation of a new tool (ie, the Metric for Evaluating Task Execution in the Operating Room) for measuring basic task completion during surgical procedures., Study Design: The content validity of 106 OR tasks was assessed using 50 real-time observations of general surgical procedures, followed by a process of expert consensus. A panel of 15 OR experts (ie, surgeons, anesthesiologists, and OR nurses) were asked to rate all tasks observed in <70% of procedures for relevance to patient safety and OR efficiency (using scientifically accepted definitions). Tasks rated highly were retained. Those perceived less relevant were removed. A second panel of patient-safety experts refined the tool to remove duplication, ensure usability, and include novel tasks., Results: Twenty-four of the original 106 tasks were observed in <70% of cases. Seven of these were rated highly by the OR experts for relevance to patient safety and efficiency and were retained in the Metric for Evaluating Task Execution in the Operating Room. Of the remaining 17, four were retained and 13 were removed by the patient-safety experts. In the final revision phase, an additional 23 tasks were removed and 10 new tasks added. The final tool consists of 80 OR tasks relating to well-established processes of care., Conclusions: The Metric for Evaluating Task Execution in the Operating Room is easy to use and can identify specific gaps in safety and/or efficiency in OR processes. Next, we should examine its links with additional measures of OR performance, for example, patient outcomes, list cancellations/delays, and nontechnical skills., (Copyright © 2013 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

The publication of To Err Is Human in the USA and An Organisation with a Memory in the UK more than a decade ago put patient safety firmly on the clinical and policy agenda. To date, however, progress in improving safety and outcomes of hospitalized patients has been slower than the authors of these reports had envisaged. Here, we first review and analyse some of the reasons for the lack of evident progress in improving patient safety across healthcare specialities. We then focus on what we believe is a critical part of the healthcare system that can contribute to safety but also to error-healthcare teams. Finally, we review team training interventions and tools available for the assessment and improvement of team performance and we offer recommendations based on the existing evidence-base that have potential to improve patient safety and outcomes in the coming decade.

Objectives/hypothesis: To assess the face and construct validity of two assessment tools for a microlaryngoscopy simulator-a Checklist Assessment for Microlaryngeal Surgery and Global Rating Assessment for Microlaryngeal Surgery., Study Design: Blinded experimental simulator-based study., Methods: There were 15 candidates divided into a novice (≤50 procedures performed) or experienced (>50 procedures) group depending on their previous microlaryngoscopy experience. Each candidate undertook a 10-minute simulation of a microlaryngoscopy and excision biopsy, and two blinded experts rated their performance live on each of the two assessment tools. To assess face validity, each candidate subsequently completed a questionnaire about the simulator., Results: The model demonstrated good face validity across all levels of experience. The global rating assessment demonstrated excellent interrater reliability (0.9) compared to the checklist assessment (0.7). The checklist assessment was able to differentiate experienced and novice candidates and therefore demonstrated construct validity. The global rating tool, however, was unable to differentiate candidates. There was a significant correlation between the two assessment tools (correlation coefficient = 0.624)., Conclusions: This study is the first reported study of a high-fidelity microlaryngoscopy simulator with task-specific rating tools. Use of these tools is recommended within otolaryngology training programs, with the global rating assessment for use as a frequently used feedback tool, and the checklist assessment as a confirmatory evaluation of competency at transitions of professional training., (Copyright © 2012 The American Laryngological, Rhinological, and Otological Society, Inc.)

Background: although effective teamwork is fundamental to patient safety in the operating room (OR), acute stress increasingly is recognized as detrimental for teamwork. This study concurrently assessed teamwork and stress levels experienced by OR team members., Methods: data were collected in real time in 20 elective surgical cases. The validated Observational Teamwork Assessment for Surgery was used to assess teamwork, whereas stress was assessed using the validated State-Trait Anxiety Inventory., Results: teamwork was overall above the scale midpoint, with higher scores preoperatively than in subsequent phases of the procedure, and also higher ratings for anesthetic subteams compared with surgical and nursing subteams (all P < .01). Overall stress levels were low. Qualitative analyses revealed differences across team members: circulating staff preoperatively and assistant surgeons intraoperatively and postoperatively were most likely to be stressed., Conclusions: the study offers a feasible method for concurrently assessing stress and teamwork in the OR and reveals differences across team members' stress levels as surgery unfolds. This methodology can be used to increase understanding of the impact of stress on team performance in the OR., (2011 Elsevier Inc. All rights reserved.)

Background: Stress can impair surgical performance and may compromise patient safety. This prospective, cross-sectional study describes the feasibility, reliability, and validity of the Imperial Stress Assessment Tool (ISAT) as an approach to measuring stress during surgery., Methods: A total of 54 procedures were observed with 11 surgeons (4 attendings, 4 senior residents and 3 junior residents) in a large university teaching hospital in London, UK. Data collection involved physiological measures of operating surgeons [heart rate (HR) and salivary cortisol] and self-report questionnaires (State Trait Anxiety Inventory, or STAI)., Results: In all, 23 of 54 procedures were stressful, as identified by self-reporting. For stressful procedures compared to nonstressful ones, STAI was higher (mean +/- SD) 9.81 +/- 2.20 vs. 12.87 +/- 4.27, t (30.64) = 3.15 as was the HR (mean +/- SD) 79.94 +/- 8.55 vs. 93.17 +/- 14.94, t(32.57) = 3.81) (p < 0.05). Significant positive correlations were obtained between the measures indicating concurrent validity: Pearson's r = 0.47 (HR vs. STAI), 0.34 (cortisol vs. STAI), and 0.57 (HR vs. cortisol) (p < 0.05). Perfect correlation of subjective and objective measures was found for 70% of the procedures. HR and cortisol had specificities of 78% and 91% and sensitivities of 91% and 70% respectively for detecting stress during surgery., Conclusion: ISAT is a nonintrusive, feasible approach that combines subjective and objective methods for measuring stress in the operating room. The ISAT may increase understanding of the effects of stress on clinical performance and outcomes, leading to improved patient care.

Objectives: We conducted a systematic review of published literature to gain a better understanding of interprofessional information transfer and communication (ITC) in hospital setting in the field of surgical and anesthetic care., Background: Communication breakdowns are a common cause of surgical errors and adverse events., Data Sources: Medline, Embase, PsycINFO, Cochrane Database of Systematic Reviews, and hand search of articles bibliography., Study Selection: Of the 4027 citations identified through the initial electronic search and screened for possible inclusion, 110 articles were retained following title and abstract reviews. Of these, 38 were accepted for this review., Data Extraction: Data were extracted from the studies about objectives, clinical domain, methodology including study design, sample population, tools for assessing communication, results, and limitations., Results: Information transfer failures are common in surgical care and are distributed across the continuum of care. They not only lead to errors in care provision but also lead to patient harm. Most of the articles have focused on ITC process in different phases especially in operating room. None of the studies have looked at whole of the surgical care process. No standard tool has been developed to capture the ITC process in different teams and to evaluate the effect of various communication interventions. Uses of standardized communication through checklist, proformas, and technology innovations have improved the ITC process, with an effect on clinical and patient outcomes., Conclusions: ITC deficits adversely affect patient care. There is a need for standard measures to evaluate this process. Effective and standardized communication among healthcare professionals during the perioperative process facilitates surgical safety.

Background: Stressful events occur in the operating room (OR) with potentially severe consequences for patient safety. We recorded the incidence of these events in the OR, assessed the levels of stress that they caused, and investigated their detectability., Methods: Stressful incidents in the OR were recorded and rated in real time by an observer in 55 general and orthopedic procedures. Operating surgeons also rated incident stressfulness and their stress (validated State Trait Anxiety Inventory)., Results: The total count of stressors/case ranged from 1 to 23.5 (mean, 5.87). Technical, patient, and equipment problems occurred frequently and were most stressful. Frequent but least severe stressors were distractions/interruptions, whereas least frequent/most severe stressors were teamwork problems. These events were associated with an increase in surgeons' self-reported stress. The observer was able to capture surgeons' stress accurately., Conclusions: Systematically occurring stressors in the OR affect surgeons and can be assessed accurately. Further research should investigate the impact of stress on surgical performance.

Background: The recent emergence of the Systems Approach to the safety and quality of surgical care has triggered individual and team skills training modules for surgeons and anaesthetists and relevant observational assessment tools have been developed., Objective: To develop an observational tool that captures operating room (OR) nurses' technical skill and can be used for assessment and training., Methods: The Imperial College Assessment of Technical Skills for Nurses (ICATS-N) assesses (i) gowning and gloving, (ii) setting up instrumentation, (iii) draping, and (iv) maintaining sterility. Three to five observable behaviours have been identified for each skill and are rated on 1-6 scales. Feasibility and aspects of reliability and validity were assessed in 20 simulation-based crisis management training modules for trainee nurses and doctors, carried out in a Simulated Operating Room., Results: The tool was feasible to use in the context of simulation-based training. Satisfactory reliability (Cronbach alpha) was obtained across trainers' and trainees' scores (analysed jointly and separately). Moreover, trainer nurse's ratings of the four skills correlated positively, thus indicating adequate content validity. Trainer's and trainees' ratings did not correlate., Conclusions: Assessment of OR nurses' technical skill is becoming a training priority. The present evidence suggests that the ICATS-N could be considered for use as an assessment/training tool for junior OR nurses.

Background: Current surgical training provides little opportunity for surgeons to recognize and manage intraoperative stress before it affects performance and compromises patient safety. We explored the perceived need for structured stress training and propose an intervention design that may be acceptable and appropriate., Methods: Fifteen semistructured interviews identified stressors in the operating room, characterized coping strategies, and explored surgeons' views about a training intervention. Interviews were analyzed using standard qualitative methods., Results: Stressors and coping strategies confirmed those identified in previous work. Key components of an intervention should include recognizing stress in oneself and in others; experiencing the impact of stress on performance; providing effective coping strategies; offering feedback; and providing opportunities to practice what has been taught in a safe, simulation-based environment., Conclusions: There is a need for structured training in management of intraoperative stress. Surgeons would welcome a simulation-based intervention to enhance performance and patient safety.

Background: Recent studies have investigated disruptions to surgical process via observation. We developed the Disruptions in Surgery Index (DiSI) to assess operating room professionals' self-perceptions of disruptions that affect surgical processes., Materials: The DiSI assesses individual issues, operating room environment, communication, coordination/situational awareness, patient-related disruptions, team cohesion, and organizational issues. Sixteen surgeons, 26 nurses, and 20 anesthetists/operating departmental practitioners participated. Participants judged for themselves and for their colleagues how often each disruption occurs, its contribution to error, and obstruction of surgical goals., Results: We combined the team cohesion and organizational disruptions to improve reliability. All participants judged that individual issues, operating room environment, and communication issues affect others more often and more severely than one's self. Surgeons reported significantly fewer disruptions than nurses or anesthetists., Conclusion: Although operating room professionals acknowledged disruptions and their impact, they attributed disruptions related to individual performance and attitudes more to their colleagues than to themselves. The cross-professional discrepancy in perceived disruptions (surgeons perceiving fewer than the other two groups) suggests that attempts to improve the surgical environment should always start with thorough assessment of the views of all its users. DiSI is useful in that it differentiates between the frequency and the severity of disruptions. Further research should explore correlations of DiSI-assessed perceptions and other observable measures.

Background: High-reliability organizations have stressed the importance of non-technical skills for safety and of regularly providing such training to their teams. Recently safety skills training has been applied in the practice of medicine. In this study, we developed and piloted a module using multidisciplinary crisis scenarios in a simulated operating theatre to train entire surgical teams., Methods: Twenty teams participated (n = 80); each consisted of a trainee surgeon, anesthetist, operating department practitioner (ODP), and scrub nurse. Crisis scenarios such as difficult intubation, hemorrhage, or cardiac arrest were simulated. Technical and non-technical skills (leadership, communication, team skills, decision making, and vigilance), were assessed by clinical experts and by two psychologists using relevant technical and human factors rating scales. Participants received technical and non-technical feedback, and the whole team received feedback on teamwork., Results: Trainees assessed the training favorably. For technical skills there were no differences between surgical trainees' assessment scores and the assessment scores of the trainers. However, nurses overrated their technical skill. Regarding non-technical skills, leadership and decision making were scored lower than the other three non-technical skills (communication, team skills, and vigilance). Surgeons scored lower than nurses on communication and teamwork skills. Surgeons and anesthetists scored lower than nurses on leadership., Conclusions: Multidisciplinary simulation-based team training is feasible and well received by surgical teams. Non-technical skills can be assessed alongside technical skills, and differences in performance indicate where there is a need for further training. Future work should focus on developing team performance measures for training and on the development and evaluation of systematic training for technical and non-technical skills to enhance team performance and safety in surgery.

Rationale and Aims: Research suggests that there are problems of communication effectiveness in surgery. Here we describe the content, initiators and recipients of communications that intrude or interfere with individual surgical cases. We also consider the level at which the surgical team and its team members are distracted by these case-irrelevant communications (CICs)., Methods: Two psychologist observers sampled 48 general surgery procedures and they recorded the initiator and the recipient of CIC events, their content and the level of observable distraction that they caused., Results: Irrelevant comments and queries (i.e. 'small-talk') accounted for half of the observed CICs. From the remaining CICs that we observed, most were related to the organization and administration of the case-list, to operating theatre provisions and to teaching junior staff. Surgeons initiated a third of the observed CICs, while receiving two thirds of them. External staff visiting the operating theatre initiated the most distracting communications. The CICs addressed to surgeons introduced significantly less distraction to the operating theatre than those addressed to anaesthetists and nurses., Conclusions: Some of the observed CICs contributed to the administration of the operating theatre case-list. Nonetheless, this communication can interfere with highly sensitive work. More effectively co-ordinated communication could reduce this interference. More research should assess the communication effectiveness and the impact of CICs on task performance in the operating theatre.

Surgery depends on interprofessional teamwork, which is becoming increasingly specialized. If surgery is to become a highly reliable system, it must adapt and professionals must learn from, and share, tested models of interprofessional teamwork. Trainers also need valid measures of teamwork to assess individual and team performance. However, measurement and assessment of interprofessional teamwork is lacking and interprofessional team training is scarce in the surgical domain. This paper addresses the complexity of measuring interprofessional teamwork in the operating theatre. It focuses mainly on the design and properties of observational assessment tools. The report and analysis serves to inform the researcher or clinician of the issues to consider when designing or choosing from alternative measures of team performance for training or assessment.

An observational tool was developed to record distraction and interruption in the operating theatre during surgery. Observed events were assigned to pre-defined categories and rated in relation to the level of team involvement - the sum of which was treated as a measure of intra-operative interference. Many events (0.29 +/- 0.02 per min) were observed and rated in 50 general operations sampled from a single operating theatre. The rating of individual events (r(s) = 0.65) and of cases (r(s) = 0.89) correlated between independent observers. Interference levels (1.04 +/- 0.07/min) also correlated with door opening frequency (0.68 +/- 0.03/min) (r = 0.47, p < 0.001). Some sources of interference were intrinsic to the work of the surgical team, including equipment, procedure and environment, while others were extraneous, including bleepers, phone calls and external staff. The findings highlight the need to further develop measures of interference, to assess its variation, intensity and its effect on surgical team performance.

Rationale: The aim of the research that we report here was to empirically assess the cohesiveness of the multidisciplinary operating theatre (OT) team., Method: We used concepts from the team performance and team mental models literature to assess OT professionals' perceptions of their teamwork, the structure of their teams and their respective roles within them and their teams' performance., Results: Team structure: OT professionals would welcome a change from the current structure of the team, although there was no agreement on what that structure is. Nurses perceived the team as unitary, surgeons and anaesthetists perceived it as comprising multiple subteams. Team roles: OT professionals tended to overrate their own understanding of their colleagues' role in the OT relative to the role understanding that the colleagues attributed to them. This tendency was especially marked for the surgeons. Team communication and team performance: OT professionals agreed on the relative importance of the various communicating pairs in the OT. Moreover, they were satisfied with the quality of communication among them, except for the communication between the surgeon and the anaesthetist, which received lower ratings. Finally, the quality of the teamwork in the OT was deemed acceptable, although there is room for improvement., Conclusions: The OT environment need not be as cohesive as previously assumed--a finding that carries implications for the effectiveness of team training interventions. Further research is needed in order to fully comprehend the dynamics of the OT as a working environment and, most importantly, their relation to patient safety.