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Objectives: To identify the implementation strategies used in World Health Organization Surgical Safety Checklist (SSC) uptake in low- and middle-income countries (LMICs); examine any association of implementation strategies with implementation effectiveness; and to assess the clinical impact., Background: The SSC is associated with improved surgical outcomes but effective implementation strategies are poorly understood., Methods: We searched the Cochrane library, MEDLINE, EMBASE and PsycINFO from June 2008 to February 2019 and included primary studies on SSC use in LMICs. Coprimary objectives were identification of implementation strategies used and evaluation of associations between strategies and implementation effectiveness. To assess the clinical impact of the SSC, we estimated overall pooled relative risks for mortality and morbidity. The study was registered on PROSPERO (CRD42018100034)., Results: We screened 1562 citations and included 47 papers. Median number of discrete implementation strategies used per study was 4 (IQR: 1-14, range 0-28). No strategies were identified in 12 studies. SSC implementation occurred with high penetration (81%, SD 20%) and fidelity (85%, SD 13%), but we did not detect an association between implementation strategies and implementation outcomes. SSC use was associated with a reduction in mortality (RR 0.77; 95% CI 0.67-0.89), all complications (RR 0.56; 95% CI 0.45-0.71) and infectious complications (RR 0.44; 95% CI 0.37-0.52)., Conclusions: The SSC is used with high fidelity and penetration is associated with improved clinical outcomes in LMICs. Implementation appears well supported by a small number of tailored strategies. Further application of implementation science methodology is required among the global surgical community., Competing Interests: The authors report no conflicts of interest., (Copyright © 2020 The Author(s). Published by Wolters Kluwer Health, Inc.)

Importance: Checklists have been shown to improve patient outcomes in surgery. The intraoperatively used World Health Organization surgical safety checklist (WHO SSC) is now mandatory in many countries. The only evidenced checklist to address preoperative and postoperative care is the Surgical Patient Safety System (SURPASS), which has been found to be effective in improving patient outcomes. To date, the WHO SSC and SURPASS have not been studied jointly within the perioperative pathway., Objective: To investigate the association of combined use of the preoperative and postoperative SURPASS and the WHO SSC in perioperative care with morbidity, mortality, and length of hospital stay., Design, Setting, and Participants: In a stepped-wedge cluster nonrandomized clinical trial, the preoperative and postoperative SURPASS checklists were implemented in 3 surgical departments (neurosurgery, orthopedics, and gynecology) in a Norwegian tertiary hospital, serving as their own controls. Three surgical units offered additional parallel controls. Data were collected from November 1, 2012, to March 31, 2015, including surgical procedures without any restrictions to patient age. Data were analyzed from September 25, 2018, to March 29, 2019., Interventions: Individualized preoperative and postoperative SURPASS checklists were added to the intraoperative WHO SSC., Main Outcomes and Measures: Primary outcomes were in-hospital complications, emergency reoperations, unplanned 30-day readmissions, and 30-day mortality. The secondary outcome was length of hospital stay (LOS)., Results: In total, 9009 procedures (5601 women [62.2%]; mean [SD] patient age, 51.7 [22.2] years) were included, with 5117 intervention procedures (mean [SD] patient age, 51.8 [22.4] years; 2913 women [56.9%]) compared with 3892 controls (mean [SD] patient age, 51.5 [21.8] years; 2688 women [69.1%]). Parallel control units included 9678 procedures (mean [SD] patient age, 57.4 [22.2] years; 4124 women [42.6%]). In addition to the WHO SSC, adjusted analyses showed that adherence to the preoperative SURPASS checklists was associated with reduced complications (odds ratio [OR], 0.70; 95% CI, 0.50-0.98; P = .04) and reoperations (OR, 0.42; 95% CI, 0.23-0.76; P = .004). Adherence to the postoperative SURPASS checklists was associated with decreased readmissions (OR, 0.32; 95% CI, 0.16-0.64; P = .001). No changes were observed in mortality or LOS. In parallel control units, complications increased (OR, 1.09; 95% CI, 1.01-1.17; P = .04), whereas reoperations, readmissions, and mortality remained unchanged., Conclusions and Relevance: In this nonrandomized clinical trial, adding preoperative and postoperative SURPASS to the WHO SSC was associated with a reduction in the rate of complications, reoperations, and readmissions., Trial Registration: ClinicalTrials.gov Identifier: NCT01872195.

Background: Patients' involvement in patient safety has increased in healthcare. Use of checklists may improve patient outcome in surgery, though few have attempted to engage patients' use of surgical checklist. To identify risk elements of complications based on patients' and healthcare workers' experiences is warranted. This study aims to identify what the patients and healthcare workers find to be the risk elements that should be included in a patient-driven surgical patient safety checklist., Method: A qualitative study design where post-operative patients, surgeons, ward physicians, ward nurses, and secretaries from five surgical specialties took part in focus group interviews. Eleven focus groups were conducted including 25 post-operative patients and 27 healthcare workers at one tertiary teaching hospital and one community hospital in Norway. Based on their experiences, participants were asked to identify perceived risks before and after surgery. The interviews were analysed using content analysis., Results: Safety risk factors were categorised as pre-operative information: pre-operative preparations, post-operative information, post-operative plans and follow-up. The subcategories under pre-operative information and preparations were: contact information, medication safety, health status, optimising health, dental status, read information, preparation two weeks before surgery, inform your surgical ward, planning your own discharge, preparation on admission and just before surgery. The subcategories under post-operative information, further plans and follow-up were: prevention and complications, restriction and activity, medication safety, pain relief, stomach functions, further care and appointments. Both healthcare workers and patients express the need for a surgical patient safety checklist., Conclusion: A broad spectre of risk elements for a patient safety checklist were identified. Developing a surgical safety checklist based on these risk elements might reduce complications and unwanted errors., Trail Registration: The study is registered as part of a clinical trial in ClinicalTrials.gov: NCT03105713.

The incidence of surgical complications has remained largely unchanged over the past two decades. Inherent complexity in surgery, new technology possibilities, increasing age and comorbidity in patients may contribute to this. Surgical safety checklists may be used as some of the tools to prevent such complications. Use of checklists may reduce critical workload by eliminating issues that are already controlled for. The global introduction of the World Health Organization Surgical Safety Checklist aimed to improve safety in both anesthesia and surgery and to reduce complications and mortality by better teamwork, communication, and consistency of care. This review describes a literature synthesis on advantages and disadvantages in use of surgical safety checklists emphasizing checklist development, implementation, and possible clinical effects and using a theoretical framework for quality of provided healthcare (structure-process-outcome) to understand the checklists' possible impact on patient safety.

Objective: We hypothesize that high-quality implementation of the World Health Organization's Surgical Safety Checklist (SSC) will lead to improved care processes and subsequently reduction of peri- and postoperative complications., Background: Implementation of the SSC was associated with robust reduction in morbidity and length of in-hospital stay in a stepped wedge cluster randomized controlled trial conducted in 2 Norwegian hospitals. Further investigation of precisely how the SSC improves care processes and subsequently patient outcomes is needed to understand the causal mechanisms of improvement., Methods: Care process metrics are reported from one of our earlier trial hospitals. Primary outcomes were in-hospital complications and care process metrics, e.g., patient warming and antibiotics. Secondary outcome was quality of SSC implementation. Analyses include Pearson's exact χ test and binary logistic regression., Results: A total of 3702 procedures (1398 control vs. 2304 intervention procedures) were analyzed. High-quality SSC implementation (all 3 checklist parts) improved processes and outcomes of care. Use of forced air warming blankets increased from 35.3% to 42.4% (P < 0.001). Antibiotic administration postincision decreased from 12.5% to 9.8%, antibiotic administration preincision increased from 54.5% to 63.1%, and nonadministration of antibiotics decreased from 33.0% to 27.1%. Surgical infections decreased from 7.4% (104/1398) to 3.6% (P < 0.001). Adjusted SSC effect on surgical infections resulted in an odds ratio (OR) of 0.52 (95% confidence interval (CI): 0.38-0.72) for intervention procedures, 0.54 (95% CI: 0.37-0.79) for antibiotics provided before incision, and 0.24 (95% CI: 0.11-0.52) when using forced air warming blankets. Blood transfusion costs were reduced by 40% with the use of the SSC., Conclusions: When implemented well, the SSC improved operating room care processes; subsequently, high-quality SSC implementation and improved care processes led to better patient outcomes.

This study examined a thematic network aimed at identifying experiences that influence patients' outcomes (e.g., patients' satisfaction, anxiety, and discharge readiness) in an effort to improve care transitions and reduce patient burden. We drew upon the Sociology and Complexity Science Toolkit to analyze themes derived from 61 semistructured, longitudinal interviews with 20 patients undergoing either a benign or malignant colorectal resection (three interviews per patient over a 30-day after hospital discharge). Thematic interdependencies illustrate how most outcomes of care are significantly influenced by two cascades identified as patients' medical histories and home circumstances. Patients who reported previous medical or surgical histories also experienced less distress during the discharge process, whereas patients with no prior experiences reported more concerns and greater anxiety. Patient dissatisfactions and challenges were due in large part to the contrasts between hospital and home experiences. Our hybrid approach may inform patient-centered guidelines aimed at improving transitions of care among patients undergoing major surgery.

Objective: To evaluate impact of WHO checklist compliance on risk-adjusted clinical outcomes, including the influence of checklist components (Sign-in, Time-out, Sign-out) on outcomes., Background: There remain unanswered questions surrounding surgical checklists as a quality and safety tool, such as the impact in cases of differing complexity and the extent of checklist implementation., Methods: Data were collected from surgical admissions (6714 patients) from March 2010 to June 2011 at 5 academic and community hospitals. The primary endpoint was any complication, including mortality, occurring before hospital discharge. Checklist usage was recorded as checklist completed in full/partly. Multilevel modeling was performed to investigate the association between complications/mortality and checklist completion., Results: Significant variability in checklist usage was found: although at least 1 of the 3 components was completed in 96.7% of cases, the entire checklist was only completed in 62.1% of cases. Checklist completion did not affect mortality reduction, but significantly lowered risk of postoperative complication (16.9% vs. 11.2%), and was largely noticed when all 3 components of the checklist had been completed (odds ratio = 0.57, 95% confidence interval: 0.37-0.87, P < 0.01). Calculated population-attributable fractions showed that 14% (95% confidence interval: 7%-21%) of the complications could be prevented if full completion of the checklist was implemented., Conclusions: Checklist implementation was associated with reduced case-mix-adjusted complications after surgery and was most significant when all 3 components of the checklist were completed. Full, as opposed to partial, checklist completion provides a health policy opportunity to improve checklist impact on surgical safety and quality of care.

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.)

Objectives: To evaluate how the World Health Organization (WHO) surgical safety checklist was implemented across hospitals in England; to identify barriers and facilitators toward implementation; and to draw out lessons for implementing improvement initiatives in surgery/health care more generally., Background: The WHO checklist has been linked to improved surgical outcomes and teamwork, yet we know little about the factors affecting its successful uptake., Methods: A longitudinal interview study with operating room personnel was conducted across a representative sample of 10 hospitals in England between March 2010 and March 2011. Interviews were audio recorded over the phone. Interviewees were asked about their experience of how the checklist was introduced and the factors that hindered or aided this process. Transcripts were submitted to thematic analysis., Results: A total of 119 interviews were completed. Checklist implementation varied greatly between and within hospitals, ranging from preplanned/phased approaches to the checklist simply "appearing" in operating rooms, or staff feeling it had been imposed. Most barriers to implementation were specific to the checklist itself (eg, perceived design issues) but also included problematic integration into preexisting processes. The most common barrier was resistance from senior clinicians. The facilitators revealed some positive steps that can been taken to prevent/address these barriers, for example, modifying the checklist, providing education/training, feeding-back local data, fostering strong leadership (particularly at attending level), and instilling accountability., Conclusions: We identified common themes that have aided or hindered the introduction of the WHO checklist in England and have translated these into recommendations to guide the implementation of improvement initiatives in surgery and wider health care systems.

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: 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.

Purpose: Surgical morbidity and mortality conferences (M&MCs) provide surgeons with an opportunity to confront medical errors, discuss adverse events, and learn from their mistakes. Yet, no standardized format for these conferences exists. The authors hypothesized that introducing a standardized presentation format using a validated framework would improve presentation quality and educational outcomes for all attendees., Method: Following a review of the literature and the solicitation of experts' opinions, the authors adapted a validated communication tool-the SBAR (Situation, Background, Assessment, Recommendations) framework. In 2010, they then introduced this novel standardized presentation format into the surgical M&MCs at the Oregon Health & Science University. The authors assessed three outcome measures--user satisfaction, presentation quality, and education outcomes--before and after implementation of their standardized presentation format., Results: Over the six-month study period, residents delivered 66 presentations to 197 faculty, resident, and medical student attendees. Attendees' performance on the multiple-choice questionnaires improved after the intervention, indicating an improvement in their knowledge. Presentation quality also improved significantly after the intervention, according to evaluations by trained faculty assessors. They noted specific improvements in the quality of the Background, Assessment, and Recommendation sections., Conclusions: The M&MC plays a pivotal role in educating residents and improving patient safety. Standardizing the M&MC presentation format using an adapted SBAR framework improved the quality of residents' presentations and attendees' educational outcomes. The authors recommend using such a standardized presentation format to enhance the educational value of M&MCs, with the goal of improving surgeons' knowledge, skills, and patient care practices.

Background: Performance feedback or debriefing in surgery is increasingly recognized as an essential means to optimize learning in the operating room (OR). However, there is a lack of evidence regarding the current practice and barriers to debriefing in the OR., Methods: Phase 1 consisted of semistructured interviews with surgical trainers and trainees to identify features of an effective debriefing and perceived barriers to debriefing. Phase 2 consisted of ethnographic observations of surgical cases to identify current practice and observed barriers to debriefing., Results: Surgical trainers and trainees identified key features of effective debriefing with regard to the approach and content; however, these were not commonly identified in practice. Culture was recognized as a significant barrier to debriefing across both phases of the study., Conclusions: There is a disparity between what the surgical community views as effective debriefing and actual debriefing practices in the OR. Improvements to the current debriefing culture and practice within the field of surgery should be considered to facilitate learning from clinical practice., (Copyright © 2013. Published by Elsevier Inc.)

Background: Failures in nontechnical and teamwork skills frequently lie at the heart of harm and near-misses in the operating room (OR). The purpose of this systematic review was to assess the impact of nontechnical skills on technical performance in surgery., Study Design: MEDLINE, EMBASE, PsycINFO databases were searched, and 2,041 articles were identified. After limits were applied, 341 articles were retrieved for evaluation. Of these, 28 articles were accepted for this review. Data were extracted from the articles regarding sample population, study design and setting, measures of nontechnical skills and technical performance, study findings, and limitations., Results: Of the 28 articles that met inclusion criteria, 21 articles assessed the impact of surgeons' nontechnical skills on their technical performance. The evidence suggests that receiving feedback and effectively coping with stressful events in the OR has a beneficial impact on certain aspects of technical performance. Conversely, increased levels of fatigue are associated with detriments to surgical skill. One article assessed the impact of anesthesiologists' nontechnical skills on anesthetic technical performance, finding a strong positive correlation between the 2 skill sets. Finally, 6 articles assessed the impact of multiple nontechnical skills of the entire OR team on surgical performance. A strong relationship between teamwork failure and technical error was empirically demonstrated in these studies., Conclusions: Evidence suggests that certain nontechnical aspects of performance can enhance or, if lacking, contribute to deterioration of surgeons' technical performance. The precise extent of this effect remains to be elucidated., (Copyright © 2012 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The Surgical Morbidity and Mortality (M&M) conference is considered the golden hour of surgical education. However, evaluation methods for ensuring that quality M&M presentations efficiently contribute to resident education have not been clearly defined. To provide surgical trainees with the skills required to present a quality M&M presentation it is essential to have a robust tool to measure presentation skill and guide formative feedback., Methods: A prospective observational study was conducted to develop an assessment tool for M&M conference. Literature review and expert consensus provided content for tool development. The tool, created using the situation, background, assessment, and recommendation format, was refined successively based on assessor feedback and assessed for reliability (internal consistency, interassessor reliability) and construct validity., Results: Three successive iterations of the tool were developed. Internal consistency and interassessor reliability improved from the first to third versions. A trend also was shown for increasing construct validity with the third iteration of the tool., Conclusions: A psychometrically robust assessment tool based on the situation, background, assessment, and recommendation format was developed and validated to identify and improve the overall quality and educational value of the surgical M&M conference., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Objective: To assess the feasibility, validity, and reliability of a postoperative Handover Assessment Tool (PoHAT) and to evaluate the current practices of the postoperative handover at 2 large European hospitals., Background: Postoperative handover is one of the most critical phases in the care of a patient undergoing surgery. However, handovers are largely informal and variable. A thorough understanding of the problem is necessary before safety solutions can be considered., Methods: Postoperative Handover Assessment Tool (PoHAT) was developed through task analysis, semistructured interviews, literature review, and learned society guidelines. Subsequent validation was done by the Delphi technique. Feasibility and reliability were then evaluated by direct observation of handovers at 2 large European hospitals. Outcomes measures included information omissions, task errors, teamwork evaluation, duration of handover, and number of distractions., Results: The tool was feasible to use and inter-rater reliability was excellent (r = 0.96, P < 0.001). Evaluation of handover at the 2 study sites revealed a median of 8 information omissions per handover at both the centers (IQR 7-10). There were a median of 3 task errors per handover (IQR 2-4). Thirty-five percent of handovers had distractions, which included competing demands for nurse attention, bleeps, and case-irrelevant communication., Conclusion: This study has established the feasibility, validity, and reliability of a tool for evaluating postoperative handover. In addition to serving as an objective measure of postoperative handover, the tool can also be used to evaluate the efficacy of any intervention developed to improve this process. The study has also shown that postoperative handover is characterized by incomplete transfer of information and failures in the performance of key tasks.

Background: Effective teamwork is crucial for safe surgery. Failures in nontechnical and teamwork skills are frequently implicated in adverse events. The Observational Teamwork Assessment for Surgery (OTAS) tool assesses teamwork of the entire team in the operating room. Empirical testing of OTAS has yet to explore the content validity of the tool., Study Design: This was a cross-sectional observational study. Data were collected in 30 procedures by 2 trained researchers. Five teamwork behaviors were scored (ie, communication, leadership, cooperation, coordination, and monitoring) and behavior exemplar completion was recorded (phase 1). Expert operating room personnel (5 surgeons, 5 anesthesiologists, and 5 scrub nurses) assessed the content validity of the OTAS exemplar behaviors. Finally, a panel of operating room patient-safety experts refined the exemplars (phase 2)., Results: In total, the observability (presence/absence) of 130 exemplars was assessed by 2 blinded observers in 30 general surgical cases. Observer agreement was high (Cohen's κ ≥ 0.41) for 83.85% (109 of 130) of exemplar behaviors; 60.77% (79 of 130) of exemplar behaviors were observed frequently with high observer agreement. The majority of the exemplars were rated by expert operating room practitioners and an expert panel as substantial contributors to teamwork and patient safety. Based on expert consensus, 21 behavior exemplars were removed from OTAS and an additional 23 were modified., Conclusions: The exemplars of OTAS demonstrated very good content validity. Taken together with recent evidence on the construct validity of the tool, these findings demonstrate that OTAS is psychometrically robust for capturing teamwork in the operating room., (Copyright © 2010 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The ability to decide when to operate and when not to operate is a key surgical skill. The aim of this study was to investigate factors affecting that decision., Methods: In phase 1, semistructured interviews were used to investigate how expert surgeons decide when to operate. In phase 2, clinical case vignettes were constructed, and 22 general surgeons at various stages of their training indicated whether they would operate and their confidence in patient outcomes., Results: Interviews answers centered on the theme of "patient outcome," which was defined similarly by all surgeons. In phase 2, surgeons chose to operate when they perceived the outcome with an operation to be better than the outcome without. Surgeons with <5 years of experience were less certain about what outcomes might be. These surgeons opted to perform significantly more operations (40 +/- 4%) than surgeons with > or =5 years of experience (18 +/- 2%)., Conclusions: A subjective, balanced assessment of the likelihood of patient outcome is crucial in deciding whether to operate. Novices face higher degrees of uncertainty, explaining differences in decisions taken., (2010 Elsevier Inc. All rights reserved.)

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.

Hypothesis: Health care failure mode and effect analysis identifies critical processes prone to information transfer and communication failures and suggests interventions to improve these failures., Design: Failure mode and effect analysis., Setting: Academic research., Participants: A multidisciplinary team consisting of surgeons, anesthetists, nurses, and a psychologist involved in various phases of surgical care was assembled., Main Outcome Measures: A flowchart of the whole process was developed. Potential failure modes were identified and evaluated using a hazard matrix score. Recommendations were determined for certain critical failure modes using a decision tree., Results: The process of surgical care was divided into the following 4 main phases: preoperative assessment and optimization, preprocedural teamwork, postoperative handover, and daily ward care. Most failure modes were identified in the preoperative assessment and optimization phase. Forty-one of 132 failures were classified as critical, 26 of which were sufficiently covered by current protocols. Recommendations were made for the remaining 15 failure modes., Conclusions: Modified health care failure mode and effect analysis proved to be a practical approach and has been well received by clinicians. Systematic analysis by a multidisciplinary team is a useful method for detecting failure modes.

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: Decision-making is an essential skill for surgeons, but systematic objective feedback is lacking. Cognitive feedback provides information about how risk factors relate to outcomes, and how individual surgeons mentally synthesize these relationships., Methods: Pre-feedback, we assessed accuracy and reliability of 105 trainee surgeons'/medical students' estimates of operative mortality for major surgery for 28 patient vignettes with varying risk factors, using a published risk model as a gold standard. Post-feedback, participants were retested on a second case set., Results: Post-feedback, both groups' estimates became more reliable. Pre-feedback, medical students were less accurate than trainee surgeons; post-feedback, their accuracy improved to match that of trainee surgeons, who did not improve further., Conclusions: Cognitive feedback improved risk estimate reliability in both groups and accuracy in the medical students group. Lack of improvement in the surgical group implies a ceiling effect. These findings have implications for training and assessment of surgical decision-making.

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.