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Optimizing antibiotic prescribing across the surgical pathway (before, during, and after surgery) is a key aspect of tackling important drivers of antimicrobial resistance and simultaneously decreasing the burden of infection at the global level. In the UK alone, 10 million patients undergo surgery every year, which is equivalent to 60% of the annual hospital admissions having a surgical intervention. The overwhelming majority of surgical procedures require effectively limited delivery of antibiotic prophylaxis to prevent infections. Evidence from around the world indicates that antibiotics for surgical prophylaxis are administered ineffectively, or are extended for an inappropriate duration of time postoperatively. Ineffective antibiotic prophylaxis can contribute to the development of surgical site infections (SSIs), which represent a significant global burden of disease. The World Health Organization estimates SSI rates of up to 50% in postoperative surgical patients (depending on the type of surgery), with a particular problem in low- and middle-income countries, where SSIs are the most frequently reported healthcare-associated infections. Across European hospitals, SSIs alone comprise 19.6% of all healthcare-acquired infections. Much of the scientific research in infection management in surgery is related to infection prevention and control in the operating room, surgical prophylaxis, and the management of SSIs, with many studies focusing on infection within the 30-day postoperative period. However it is important to note that SSIs represent only one of the many types of infection that can occur postoperatively. This article provides an overview of the surgical pathway and considers infection management and antibiotic prescribing at each step of the pathway. The aim was to identify the implications for research and opportunities for system improvement., (Copyright © 2017 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Objectives: To understand how frontline reports of day-to-day care failings might be better translated into improvement., Design: Qualitative evaluation of an interdisciplinary team intervention capitalising on the frontline experience of care delivery. Prospective clinical team surveillance (PCTS) involved structured interdisciplinary briefings to capture challenges in care delivery, facilitated organisational escalation of the issues they identified, and feedback. Eighteen months of ethnography and two focus groups were conducted with staff taking part in a trial of PCTS., Results: PCTS fostered psychological safety-a confidence that the team would not embarrass or punish those who speak up. This was complemented by a hard edge of accountability, whereby team members would regulate their own behaviour in anticipation of future briefings. Frontline concerns were triaged to managers, or resolved autonomously by ward teams, reversing what had been well-established normalisations of deviance. Junior clinicians found a degree of catharsis in airing their concerns, and their teams became more proactive in addressing improvement opportunities. PCTS generated tangible organisational changes, and enabled managers to make a convincing case for investment. However, briefings were constrained by the need to preserve professional credibility, and staff found some comfort in avoiding accountability . At higher organisational levels, frontline concerns were subject to competition with other priorities, and their resolution was limited by the scale of the challenges they described., Conclusions: Prospective safety strategies relying on staff-volunteered data produce acceptable, negotiated accounts, subject to the many interdisciplinary tensions that characterise ward work. Nonetheless, these strategies give managers access to the realities of frontline cares, and support frontline staff to make incremental changes in their daily work. These are goals for learning healthcare organisations., Trial Registration: ISRCTN 34806867., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Background: Adult surgical patient safety literature is plentiful; however, there is a disproportionate paucity of published safety work in the children's surgical literature. We sought to systematically evaluate the nature and quality of patient safety evidence pertaining to pediatric surgical practice., Methods: Systematic search of MEDLINE and EMBASE databases and gray literature identified 1399 articles. Data pertaining to demographics, methodology, interventions, and outcomes were extracted. Study quality was assessed utilizing formal criteria., Results: 20 studies were included. 14 (70%) comprised peer-reviewed articles. 18 (90%) were published in the last 4years. 13 (65%) described a novel intervention, and 7 (35%) described a modification of an existing intervention. Median patient sample size was 79 (29-1210). A large number (n=55) and variety (n=35) of measures were employed to evaluate the effect of interventions on patient safety. 15 (75%) studies utilized a checklist tool as a component of their intervention. 9 (45%) studies [comprising handoff tools (n=7); checklists (n=1); and multidimensional quality improvement initiatives (n=1)] reported a positive effect on patient safety. Quality assessment was undertaken on 14 studies. Quantitative studies had significantly higher quality scores than qualitative studies (61 [0-89] vs 44 [11-78], p=0.03)., Conclusions: Pediatric surgical patient safety evidence is in its early stages. Successful interventions that we identified were typically handoff tools. There now ought to be an onus on pediatric surgeons to develop and apply bespoke pediatric surgical safety interventions and generate an evidence base to parallel the adult literature., Level of Evidence: Level IV, Case series with no comparison group., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Mental skills training refers to the implementation of cognitive performance-enhancing strategies to promote optimal performance. We aimed to develop a surgery-specific mental skills curriculum (MSC) and obtain initial evidence of efficacy., Methods: The developed MSC consisted of 8 proven performance-enhancing modules. Its efficacy was assessed during laparoscopic simulator-based practice by novices using validated instruments of mental skills, workload, and stress, in addition to a skill transfer test to a porcine model. A paired t test was used to analyze the data., Results: Nine surgical novices completed the curriculum. Compared with baseline assessment, participants improved significantly their laparoscopic performance and mental skills after completion of the MSC. All participants completed the task in the porcine model without an appreciable change in their perceived stress. During the skill transfer test, 8 participants were observed using mental skills taught in the MSC., Conclusions: A surgery-specific simulator-based MSC was developed, and its efficacy in improving mental skills and surgical performance was supported during a surgical skill transfer test., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Patient safety incident reporting systems (PSRS) have been established for over a decade, but uncertainty remains regarding the role that they can and ought to play in quantifying healthcare-related harm and improving care., Objective: To establish international, expert consensus on the purpose of PSRS regarding monitoring and learning from incidents and developing recommendations for their future role., Methods: After a scoping review of the literature, semi-structured interviews with experts in PSRS were conducted. Based on these findings, a survey-based questionnaire was developed and subsequently completed by a larger expert panel. Using a Delphi approach, consensus was reached regarding the ideal role of PSRSs. Recommendations for best practice were devised., Results: Forty recommendations emerged from the Delphi procedure on the role and use of PSRS. Experts agreed reporting system should not be used as an epidemiological tool to monitor the rate of harm over time or to appraise the relative safety of hospitals. They agreed reporting is a valuable mechanism for identifying organisational safety needs. The benefit of a national system was clear with respect to medication error, device failures, hospital-acquired infections and never events as these problems often require solutions at a national level. Experts recommended training for senior healthcare professionals in incident investigation. Consensus recommendation was for hospitals to take responsibility for creating safety solutions locally that could be shared nationally., Conclusions: We obtained reasonable consensus among experts on aims and specifications of PSRS. This information can be used to reflect on existing and future PSRS, and their role within the wider patient safety landscape. The role of PSRS as instruments for learning needs to be elaborated and developed further internationally., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Background and study aims  Medical error occurs frequently with significant morbidity and mortality. This study aime to assess the frequency and type of endoscopy patient safety incidents (PSIs). Patients and methods  A prospective observational study of PSIs in routine diagnostic and therapeutic endoscopy was undertaken in a secondary and tertiary care center. Observations were undertaken within the endoscopy suite across pre-procedure, intra-procedure and post-procedure phases of care. Experienced (Consultant-level) and trainee endoscopists from medical, surgical, and nursing specialities were included. PSIs were defined as any safety issue that had the potential to or directly adversely affected patient care: PSIs included near misses, complications, adverse events and "never events". PSIs were reviewed by an expert panel and categorized for severity and nature via expert consensus. Results  One hundred and forty procedures (92 diagnostic, 48 therapeutic) over 37 lists (experienced operators n = 25, trainees n = 12) were analyzed. One hundred forty PSIs were identified (median 1 per procedure, range 0 - 7). Eighty-six PSIs (61 %) occurred in 48 therapeutic procedures. Zero PSIs were detected in 13 diagnostic procedures. 21 (15 %) PSIs were categorized as severe and 12 (9 %) had the potential to be "never events," including patient misidentification and wrong procedure. Forty PSIs (28 %) were of intermediate severity and 78 (56 %) were minor. Oxygen monitoring PSIs occurred most frequently. Conclusion  This is the first study documenting the range and frequency of PSIs in endoscopy. Although many errors are minor without immediate consequence, further work should identify whether prevention of such recurrent errors affects the incidence of severe errors, thus improving safety and quality.

Objective: This study aimed to examine the effect of perceived diagnostic delay on cancer-related distress and determine whether fear of cancer-recurrence and quality of life mediate this relationship., Methods: Cross-sectional study in which 311 colorectal cancer (CRC) survivors in Scotland completed a survey, which included questions on cancer-related distress (IES-R), perceived diagnostic delay, quality of life (trial outcome index of the FACT-C: FACT-C TOI) and fear of cancer recurrence. Fifteen patients withheld consent to data matching with medical records, leaving a sample size of 296. Participants were an average of 69 years old (range 56 to 81) and between 3.5 and 12 years post-diagnosis. Multiple regressions were used to test predictors of distress and regression and bootstrapping to test for mediation., Results: Perceived diagnostic delay was correlated with higher cancer-related distress, while objective markers of diagnostic delay (disease stage at diagnosis and treatment received) were not. Some of the relationship between perceived diagnostic delay and cancer-related distress was mediated by quality of life, but not by fear of cancer recurrence., Conclusions: Perceived diagnostic delay was associated with higher cancer-related distress among CRC survivors. While poorer quality of life partly explained such associations, fear of cancer recurrence, stage at diagnosis and treatment did not. The exact features of diagnostic delay that are associated with cancer-related distress remain unclear. Future research should examine the experiences patients go through prior to diagnosis that may increase distress, in an effort to improve our understanding of the factors affecting emotional wellbeing among CRC survivors. Copyright © 2016 John Wiley & Sons, Ltd., (Copyright © 2016 John Wiley & Sons, Ltd.)

Introduction: Debriefing is widely perceived to be the most important component of simulation-based training. This study aimed to explore the value of 360° evaluation of debriefing by examining expert debriefing evaluators, debriefers and learners' perceptions of the quality of interdisciplinary debriefings., Method: This was a cross-sectional observational study. 41 teams, consisting of 278 learners, underwent simulation-based team training. Immediately following the postsimulation debriefing session, debriefers and learners rated the quality of debriefing using the validated Objective Structured Assessment of Debriefing (OSAD) framework. All debriefing sessions were video-recorded and subsequently rated by evaluators trained to proficiency in assessing debriefing quality., Results: Expert debriefing evaluators and debriefers' perceptions of debriefing quality differed significantly; debriefers perceived the quality of debriefing they provided more favourably than expert debriefing evaluators (40.98% of OSAD ratings provided by debriefers were ≥+1 point greater than expert debriefing evaluators' ratings). Further, learner perceptions of the quality of debriefing differed from both expert evaluators and debriefers' perceptions: weak agreement between learner and expert evaluators' perceptions was found on 2 of 8 OSAD elements (learner engagement and reflection); similarly weak agreement between learner and debriefer perceptions was found on just 1 OSAD element (application)., Conclusions: Debriefers and learners' perceptions of debriefing quality differ significantly. Both groups tend to perceive the quality of debriefing far more favourably than external evaluators. An overconfident debriefer may fail to identify elements of debriefing that require improvement. Feedback provided by learners to debriefers may be of limited value in facilitating improvements. We recommend periodic external evaluation of debriefing quality., Competing Interests: Competing interests: NS is the Director of London Safety & Training Solutions, which provides team skills training and advice on a consultancy basis in hospitals and training programmes in the UK and internationally., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

OBJECTIVE Ventriculostomy is a relatively common neurosurgical procedure, often performed in the setting of acute hydrocephalus. Accurate positioning of the catheter is vital to minimize morbidity and mortality, and several anatomical landmarks are currently used. The aim of this study was to prospectively evaluate the relative performance of 3 recognized trajectories for frontal ventriculostomy using imaging-derived metrics: perpendicular to skull (PTS), contralateral medial canthus/external auditory meatus (CMC/EAM), and ipsilateral medial canthus/external auditory meatus (IMC/EAM). METHODS Participants completed 9 simulated ventriculostomy attempts (3 of each trajectory) on a model head with Medtronic StealthStation coregistered imaging. Performance measures were distance of the ventricular catheter tip to the foramen of Monro (FoM) and presence of the catheter tip in a lateral ventricle. RESULTS Thirty-one individuals of varying seniority and prior ventriculostomy experience performed a total of 279 simulated freehand frontal ventriculostomies. The PTS and CMC/EAM trajectories were found to be significantly more likely to result in both the catheter tip being closer to the FoM and in a lateral ventricle compared with the IMC/EAM trajectory. These findings were not influenced by the prior ventriculostomy experience of the participant, corroborating the significance of these results. CONCLUSIONS The PTS and CMC/EAM trajectories were superior to the IMC/EAM trajectories during freehand frontal ventriculostomy in this study, and further data from studies incorporating varying ventricular sizes and bur hole locations are required to facilitate a change in clinical practice. In addition, neuronavigation and other guidance techniques for ventriculostomy are becoming increasingly popular and may be superior to freehand techniques, necessitating further prospective data evaluating their safety, efficacy, and feasibility for routine clinical use.

Introduction: Evidence suggests that health outcomes for hospitalised children in the UK are worse than other countries in Europe, with an estimated 1500 preventable deaths in hospital each year. It is presumed that some of these deaths are due to unanticipated deterioration, which could have been prevented by earlier intervention, for example, sepsis. The Situation Awareness For Everyone (SAFE) intervention aims to redirect the 'clinical gaze' to encompass a range of prospective indicators of risk or deterioration, including clinical indicators and staff concerns, so that professionals can review relevant information for any given situation. Implementing the routine use of huddles is central to increasing situation awareness in SAFE., Methods and Analysis: In this article, we describe the realistic evaluation framework within which we are evaluating the SAFE programme. Multiple methods and data sources are used to help provide a comprehensive understanding of what mechanisms for change are triggered by an intervention and how they have an impact on the existing social processes sustaining the behaviour or circumstances that are being targeted for change., Ethics and Dissemination: Ethics approval was obtained from London-Dulwich Research Ethics Committee (14/LO/0875). It is anticipated that the findings will enable us to understand what the important elements of SAFE and the huddle are, the processes by which they might be effective and-given the short timeframes of the project-initial effects of the intervention on outcomes. The present research will add to the extant literature by providing the first evidence of implementation of SAFE and huddles in paediatric wards in the UK., Competing Interests: Conflicts of Interest: None declared., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Background: In many healthcare systems, treatment recommendations for cancer patients are formulated by multidisciplinary tumor boards (MTBs). Evidence suggests that interdisciplinary contributions to case reviews in the meetings are unequal and information-sharing suboptimal, with biomedical information dominating over information on patient comorbidities and psychosocial factors. This study aimed to evaluate how different elements of the decision process affect the teams' ability to reach a decision on first case review., Methods: This was an observational quantitative assessment of 1045 case reviews from 2010 to 2014 in cancer MTBs using a validated tool, the Metric for the Observation of Decision-making. This tool allows evaluation of the quality of information presentation (case history, radiological, pathological, and psychosocial information, comorbidities, and patient views), and contribution to discussion by individual core specialties (surgeons, oncologists, radiologists, pathologists, and specialist cancer nurses). The teams' ability to reach a decision was a dichotomous outcome variable (yes/no)., Results: Using multiple logistic regression analysis, the significant positive predictors of the teams' ability to reach a decision were patient psychosocial information (odds ratio [OR] 1.35) and the inputs of surgeons (OR 1.62), radiologists (OR 1.48), pathologists (OR 1.23), and oncologists (OR 1.13). The significant negative predictors were patient comorbidity information (OR 0.83) and nursing inputs (OR 0.87)., Conclusions: Multidisciplinary inputs into case reviews and patient psychosocial information stimulate decision making, thereby reinforcing the role of MTBs in cancer care in processing such information. Information on patients' comorbidities, as well as nursing inputs, make decision making harder, possibly indicating that a case is complex and requires more detailed review. Research should further define case complexity and determine ways to better integrate patient psychosocial information into decision making.

Objectives: The aims of the study were to determine whether differences in leadership self-perception/behaviour in healthcare researchers may influence research performance and to evaluate whether certain leadership characteristics are associated with enhanced leadership efficiency in terms of motivation, effectiveness and satisfaction., Design and Participants: All Faculty of Medicine Professors at Imperial College London (n=215) were sent the Multifactor Leadership Questionnaire (MLQ) Self form as a means of evaluating self-perception of leadership behaviours., Main Outcome Measures: For each professor, we extracted objective research performance measures (total number of publications, total number of citations and h index) from 1 January 2007 to 31 December 2009. The MLQ measured three leadership outcomes, which included motivation, effectiveness and satisfaction. Regression analysis was used to determine associations., Results: A total number of 90 responses were received, which equated to a 42% response rate. There were no significant correlations between transformational, transactional or passive/avoidant leadership behaviours and any of the research performance measures. The five transformational leadership behaviours (ie, idealised attributes (IA), idealised behaviours (IB), inspirational motivation (IM), intellectual stimulation (IS), individual consideration (IC)) were highly significant predictors of leadership outcomes, extra effort (all B>0.404, SE=0.093-0.146, p<0.001), effectiveness (IA, IM, IS, IC B>0.359, SE=0.093-0.146, p<0.001; IB B=0.233, SE=0.103, p=0.026) and satisfaction (IA, IM, IS, IC B>0.483, SE=0.086-0.139, p<0.001; IB B=0.296, SE=0.101, p=0.004). Similarly, contingent reward was a significant predictor of extra effort (B=0.400, SE=0.123, p=0.002), effectiveness (B=0.353, SE=0.113, p=0.002) and satisfaction (B=0.326, SE=0.114, p=0.005)., Conclusions: This study demonstrates that transformational leadership and contingent reward positively influence leadership efficiency in healthcare researchers. Although we did not show an association between leadership behaviours and research performance metrics, further studies using contextual performance measures at team and organisational levels are required., Competing Interests: Competing interests: None declared., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Teamwork is essential for addressing many of the challenges that arise in the coordination and delivery of cancer care, especially for the problems that are presented by patients who cross geographic boundaries and enter and exit multiple health care systems at various times during their cancer care journeys. The problem of coordinating the care of patients with cancer is further complicated by the growing number of treatment options and modalities, incompatibilities among the vast variety of technology platforms that have recently been adopted by the health care industry, and competing and misaligned incentives for providers and systems. Here we examine the issue of regional care coordination in cancer through the prism of a real patient journey. This article will synthesize and elaborate on existing knowledge about coordination approaches for complex systems, in particular, in general and cancer care multidisciplinary teams; define elements of coordination derived from organizational psychology and human factors research that are applicable to team-based cancer care delivery; and suggest approaches for improving multidisciplinary team coordination in regional cancer care delivery and avenues for future research. The phenomenon of the mobile, multisystem patient represents a growing challenge in cancer care. Paradoxically, development of high-quality, high-volume centers of excellence and the ease of virtual communication and data sharing by using electronic medical records have introduced significant barriers to effective team-based cancer care. These challenges urgently require solutions.

Purpose: To determine the association between professors' self-perception of mentoring skills and their academic performance., Design: Two hundred and fifteen professors from Imperial College London, the first Academic Health Science Centre (AHSC) in the UK, were surveyed. The instrument adopted was the Mentorship Skills Self-Assessment Survey. Statement scores were aggregated to provide a score for each shared core, mentor-specific and mentee-specific skill. Univariate and multivariate regression analyses were used to evaluate their relationship with quantitative measures of academic performance (publications, citations and h-index)., Results: There were 104 professors that responded (response rate 48%). There were no statistically significant negative correlations between any mentoring statement and any performance measure. In contrast, several mentoring survey items were positively correlated with academic performance. The total survey score for frequency of application of mentoring skills had a statistically significant positive association with number of publications (B=0.012, SE=0.004, p=0.006), as did the frequency of acquiring mentors with number of citations (B=1.572, SE=0.702, p=0.030). Building trust and managing risks had a statistically significant positive association with h-index (B=0.941, SE=0.460, p=0.047 and B=0.613, SE=0.287, p=0.038, respectively)., Conclusions: This study supports the view that mentoring is associated with high academic performance. Importantly, it suggests that frequent use of mentoring skills and quality of mentoring have positive effects on academic performance. Formal mentoring programmes should be considered a fundamental part of all AHSCs' configuration., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Objectives: The 'gender gap' in academic medicine remains significant and predominantly favours males. This study investigates gender disparities in research performance in an Academic Health Science Centre, while considering factors such as mentoring and scientific collaboration., Materials and Methods: Professorial registry-based electronic survey (n=215) using bibliometric data, a mentoring perception survey and social network analysis. Survey outcomes were aggregated with measures of research performance (publications, citations and h-index) and measures of scientific collaboration (authorship position, centrality and social capital). Univariate and multivariate regression models were constructed to evaluate inter-relationships and identify gender differences., Results: One hundred and four professors responded (48% response rate). Males had a significantly higher number of previous publications than females (mean 131.07 (111.13) vs 79.60 (66.52), p=0.049). The distribution of mentoring survey scores between males and females was similar for the quality and frequency of shared core, mentor-specific and mentee-specific skills. In multivariate analysis including gender as a variable, the quality of managing the relationship, frequency of providing corrective feedback and frequency of building trust had a statistically significant positive influence on number of publications (all p<0.05)., Conclusions: This is the first study in healthcare research to investigate the relationship between mentoring perception, scientific collaboration and research performance in the context of gender. It presents a series of initiatives that proved effective in marginalising the gender gap. These include the Athena Scientific Women's Academic Network charter, new recruitment and advertisement strategies, setting up a 'Research and Family Life' forum, establishing mentoring circles for women and projecting female role models., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Despite taking advantage of established learning from other industries, quality improvement initiatives in healthcare may struggle to outperform secular trends. The reasons for this are rarely explored in detail, and are often attributed merely to difficulties in engaging clinicians in quality improvement work. In a narrative review of the literature, we argue that this focus on clinicians, at the relative expense of managerial staff, has proven counterproductive. Clinical engagement is not a universal challenge; moreover, there is evidence that managers-particularly middle managers-also have a role to play in quality improvement. Yet managerial participation in quality improvement interventions is often assumed, rather than proven. We identify specific factors that influence the coordination of front-line staff and managers in quality improvement, and integrate these factors into a novel model: the model of alignment. We use this model to explore the implementation of an interdisciplinary intervention in a recent trial, describing different participation incentives and barriers for different staff groups. The extent to which clinical and managerial interests align may be an important determinant of the ultimate success of quality improvement interventions., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Background: Work disruption in operating rooms hinders flow of patients and increases chances of error. Previous studies have largely considered the types of disruption occurring in operating rooms, but have not analysed systematically the objective impact of disruption., Objective: The objective was to evaluate the impact of disruption on time efficiency in preoperative anaesthetic work in the operating room and to link disruption to failures in co-ordination of care., Design: Prospective, cross-sectional and observational study., Setting: Disruptions were evaluated in operating rooms of five hospitals across three countries: Australia (one community hospital, one teaching hospital); Thailand (two community hospitals); China (one teaching hospital)., Participants: The preoperative phase of anaesthesia induction/patient positioning of 64 surgical patients across specialities was prospectively evaluated (Australia = 33; Thailand = 12; China = 10). Further, interviews were carried out with 16 consultant anaesthetists and surgeons and 13 senior operating room nurses involved in the care of these patients., Main Outcome Measures: Disruptions were identified by trained observers in real time during the preoperative phase; four types of care co-ordination problems were identified from the interviews with senior anaesthetists, surgeons and nurses, and linked to the disruptions. Descriptive analyses of time efficiency were performed., Results: Complete data were available from 55 cases. Good inter-observer agreement was obtained across measurements (range 74 to 92%). An average of three disruptions per case during the preoperative phase, were observed (range 2 to 9). 'Disruption types': disruptive staff activities were associated with most timewasting (median = 1 min per case, range 0 min 0 s to 4 min 45 s per case). 'Care co-ordination problems': co-ordination lapses within the operating room team, and between them and the preoperative team were associated with most timewasting (median = 1 min per case, range 0 min 0 s to 5 min 0 s per case)., Conclusion: The study quantifies time inefficiencies affecting anaesthetic work during the preoperative phase. Work disruption wastes time and is preventable.

Competing Interests: Competing interests: NS is the Director of London Safety & Training Solutions Ltd, which provides team skills training and advice on a consultancy basis in hospitals and training programmes in the UK and internationally.

Objective/background: To modify, content validate, and evaluate a teamwork assessment tool for use in endovascular surgery., Methods: A multistage, multimethod study was conducted. Stage 1 included expert review and modification of the existing Observational Teamwork Assessment for Surgery (OTAS) tool. Stage 2 included identification of additional exemplar behaviours contributing to effective teamwork and enhanced patient safety in endovascular surgery (using real-time observation, focus groups, and semistructured interviews of multidisciplinary teams). Stage 3 included content validation of exemplar behaviours using expert consensus according to established psychometric recommendations and evaluation of structure, content, feasibility, and usability of the Endovascular Observational Teamwork Assessment Tool (Endo-OTAS) by an expert multidisciplinary panel. Stage 4 included final team expert review of exemplars., Results: OTAS core team behaviours were maintained (communication, coordination, cooperation, leadership team monitoring). Of the 114 OTAS behavioural exemplars, 19 were modified, four removed, and 39 additional endovascular-specific behaviours identified. Content validation of these 153 exemplar behaviours showed that 113/153 (73.9%) reached the predetermined Item-Content Validity Index rating for teamwork and/or patient safety. After expert team review, 140/153 (91.5%) exemplars were deemed to warrant inclusion in the tool. More than 90% of the expert panel agreed that Endo-OTAS is an appropriate teamwork assessment tool with observable behaviours. Some concerns were noted about the time required to conduct observations and provide performance feedback., Conclusion: Endo-OTAS is a novel teamwork assessment tool, with evidence for content validity and relevance to endovascular teams. Endo-OTAS enables systematic objective assessment of the quality of team performance during endovascular procedures., (Copyright © 2016. Published by Elsevier Ltd.)

In the UK, treatment recommendations for patients with cancer are routinely made by multidisciplinary teams in weekly meetings. However, their performance is variable.The aim of this study was to explore the underlying structure of multidisciplinary decision-making process, and examine how it relates to team ability to reach a decision.This is a cross-sectional observational study consisting of 1045 patient reviews across 4 multidisciplinary cancer teams from teaching and community hospitals in London, UK, from 2010 to 2014. Meetings were chaired by surgeons.We used a validated observational instrument (Metric for the Observation of Decision-making in Cancer Multidisciplinary Meetings) consisting of 13 items to assess the decision-making process of each patient discussion. Rated on a 5-point scale, the items measured quality of presented patient information, and contributions to review by individual disciplines. A dichotomous outcome (yes/no) measured team ability to reach a decision. Ratings were submitted to Exploratory Factor Analysis and regression analysis.The exploratory factor analysis produced 4 factors, labeled "Holistic and Clinical inputs" (patient views, psychosocial aspects, patient history, comorbidities, oncologists', nurses', and surgeons' inputs), "Radiology" (radiology results, radiologists' inputs), "Pathology" (pathology results, pathologists' inputs), and "Meeting Management" (meeting chairs' and coordinators' inputs). A negative cross-loading was observed from surgeons' input on the fourth factor with a follow-up analysis showing negative correlation (r = -0.19, P < 0.001). In logistic regression, all 4 factors predicted team ability to reach a decision (P < 0.001).Hawthorne effect is the main limitation of the study.The decision-making process in cancer meetings is driven by 4 underlying factors representing the complete patient profile and contributions to case review by all core disciplines. Evidence of dual-task interference was observed in relation to the meeting chairs' input and their corresponding surgical input into case reviews., Competing Interests: The authors report no conflicts of interest.

Application of statistical process charts has led to consistent quality production improvement in the industrial sector. Aim of this simulation study is to assess if the use of exponentially weighted moving average chart with control limits (CL) could help to identify mortality trends in a cardiac surgery scenario. Mortality rate of 9 cardiac centers has been continuously monitored by a central clinical governance unit since 2010; prospectively collected monthly mortality rate of calendar year 2013-2014 from each center was used to retrospectively build an exponentially weighted moving average chart; mortality level was set at 4% as per threshold defined by the Italian Ministry of Health recommendation; upper CLs were set as 1.5 standard deviation from the specified level; lowest mortality rate (2.6%) was observed during calendar year 2012-2013, hence that was considered the center of the chart. All centers were considered as 1 entity and consecutively plotted in the chart following a geographic distribution, from North to South. A total number of 4049 operations were performed; 108 patients died while in hospital (2.6%). Different mortality trends that consisted of minor and major out-of-control process defined as a point of the chart outside the upper CLs were demonstrated. In conclusion, mortality trends could have been potentially identified at earlier time points before reaching the 4% limits of mortality; exponentially weighted and controlled chart may facilitate clinical governance units to their monitoring role., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: The surgical care pathway is characterized by multiple transitions, from preoperative assessment to inpatient stay, discharge from hospital, and follow-up care. Breakdowns in one phase can affect subsequent phases, which in turn can cause delays, cancellations, and complications. Efforts to improve care transitions focused primarily on post-discharge care coordination and inpatient education for medically complex patients have not demonstrated consistent effects. This study aimed to understand the expectations and perceptions of postoperative inpatients regarding transition from hospital to home in an effort to reduce patient burden., Materials and Methods: Patients who underwent a colorectal resection at a large academic medical center and were discharged home were eligible to participate in the study. Patients were recruited during their postoperative hospital stays and interviewed over the phone within a week after discharge about their perceptions of care, values, and attitudes. Overall, we recruited 16 patients with benign (n = 8) and malignant (n = 8) indications. Recruitment continued until theme saturation., Results: Factors that shaped patients' understanding of postsurgical recovery and that motivated them to seek provider attention post-discharge fell into three major groups: patient expectations versus reality, availability and role of informal caregivers in the postoperative recovery process, and communication as a key to patient confidence and trust., Conclusions: For patients and caregivers, postoperative planning starts long before surgery and hospital admission. Providers should consider these dynamics in designing interventions to improve care transitions, patient satisfaction, and long-term outcomes. This study was limited to colorectal surgical patients treated in a single institution and may be not generalizable to other surgical procedures, non-academic settings or different regions., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: To develop a tool for independent observational assessment of cancer multidisciplinary team meetings (MDMs), and test criterion validity, inter-rater reliability/agreement and describe performance., Design: Clinicians and experts in teamwork used a mixed-methods approach to develop and refine the tool. Study 1 observers rated pre-determined optimal/sub-optimal MDM film excerpts and Study 2 observers independently rated video-recordings of 10 MDMs., Setting: Study 2 included 10 cancer MDMs in England., Participants: Testing was undertaken by 13 health service staff and a clinical and non-clinical observer., Intervention: None., Main Outcome Measures: Tool development, validity, reliability/agreement and variability in MDT performance., Results: Study 1: Observers were able to discriminate between optimal and sub-optimal MDM performance (P ≤ 0.05). Study 2: Inter-rater reliability was good for 3/10 domains. Percentage of absolute agreement was high (≥80%) for 4/10 domains and percentage agreement within 1 point was high for 9/10 domains. Four MDTs performed well (scored 3+ in at least 8/10 domains), 5 MDTs performed well in 6-7 domains and 1 MDT performed well in only 4 domains. Leadership and chairing of the meeting, the organization and administration of the meeting, and clinical decision-making processes all varied significantly between MDMs (P ≤ 0.01)., Conclusions: MDT-MOT demonstrated good criterion validity. Agreement between clinical and non-clinical observers (within one point on the scale) was high but this was inconsistent with reliability coefficients and warrants further investigation. If further validated MDT-MOT might provide a useful mechanism for the routine assessment of MDMs by the local workforce to drive improvements in MDT performance., (© The Author 2016. Published by Oxford University Press in association with the International Society for Quality in Health Care; all rights reserved.)

Introduction: Debriefing is essential to maximise the simulation-based learning experience, but until recently, there was little guidance on an effective paediatric debriefing. A debriefing assessment tool, Objective Structured Assessment of Debriefing (OSAD), has been developed to measure the quality of feedback in paediatric simulation debriefings. This study gathers and evaluates the validity evidence of OSAD with reference to the contemporary hypothesis-driven approach to validity., Methods: Expert input on the paediatric OSAD tool from 10 paediatric simulation facilitators provided validity evidence based on content and feasibility (phase 1). Evidence for internal structure validity was sought by examining reliability of scores from video ratings of 35 postsimulation debriefings; and evidence for validity based on relationship to other variables was sought by comparing results with trainee ratings of the same debriefings (phase 2)., Results: Simulation experts' scores were significantly positive regarding the content of OSAD and its instructions. OSAD's feasibility was demonstrated with positive comments regarding clarity and application. Inter-rater reliability was demonstrated with intraclass correlations above 0.45 for 6 of the 7 dimensions of OSAD. The internal consistency of OSAD (Cronbach α) was 0.78. Pearson correlation of trainee total score with OSAD total score was 0.82 (p<0.001) demonstrating validity evidence based on relationships to other variables., Conclusion: The paediatric OSAD tool provides a structured approach to debriefing, which is evidence-based, has multiple sources of validity evidence and is relevant to end-users. OSAD may be used to improve the quality of debriefing after paediatric simulations., Competing Interests: Competing interests: NS delivers regular teamwork and safety training on a consultancy basis in the UK and internationally., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Objectives: With the aim to facilitate a more comprehensive review process in public health including patient safety, we established a tool that we have termed ICROMS (Integrated quality Criteria for the Review Of Multiple Study designs), which unifies, integrates and refines current quality criteria for a large range of study designs including qualitative research., Study Design: Review, pilot testing and expert consensus., Methods: The tool is the result of an iterative four phase process over two years: 1) gathering of established criteria for assessing controlled, non-controlled and qualitative study designs; 2) pilot testing of a first version in two systematic reviews on behavioural change in infection prevention and control and in antibiotic prescribing; 3) further refinement and adding of additional study designs in the context of the European Centre for Disease Prevention and Control funded project 'Systematic review and evidence-based guidance on organisation of hospital infection control programmes' (SIGHT); 4) scrutiny by the pan-European expert panel of the SIGHT project, which had the objective of ensuring robustness of the systematic review., Results: ICROMS includes established quality criteria for randomised studies, controlled before-and-after studies and interrupted time series, and incorporates criteria for non-controlled before-and-after studies, cohort studies and qualitative studies. The tool consists of two parts: 1) a list of quality criteria specific for each study design, as well as criteria applicable across all study designs by using a scoring system; 2) a 'decision matrix', which specifies the robustness of the study by identifying minimum requirements according to the study type and the relevance of the study to the review question. The decision matrix directly determines inclusion or exclusion of a study in the review. ICROMS was applied to a series of systematic reviews to test its feasibility and usefulness in the appraisal of multiple study designs. The tool was applicable across a wide range of study designs and outcome measures., Conclusion: ICROMS is a comprehensive yet feasible appraisal of a large range of study designs to be included in systematic reviews addressing behaviour change studies in patient safety and public health. The tool is sufficiently flexible to be applied to a variety of other domains in health-related research. Beyond its application to systematic reviews, we envisage that ICROMS can have a positive effect on researchers to be more rigorous in their study design and more diligent in their reporting., (Copyright © 2015 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.)

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.

Safety in aviation has often been compared with safety in healthcare. Following a recent article in this journal, the UK government set up an Independent Patient Safety Investigation Service, to emulate a similar well-established body in aviation. On the basis of a detailed review of relevant publications that examine patient safety in the context of aviation practice, we have drawn up a table of comparative features and a conceptual framework for patient safety. Convergence and divergence of safety-related behaviours across aviation and healthcare were derived and documented. Key safety-related domains that emerged included Checklists, Training, Crew Resource Management, Sterile Cockpit, Investigation and Reporting of Incidents and Organisational Culture. We conclude that whilst healthcare has much to learn from aviation in certain key domains, the transfer of lessons from aviation to healthcare needs to be nuanced, with the specific characteristics and needs of healthcare borne in mind. On the basis of this review, it is recommended that healthcare should emulate aviation in its resourcing of staff who specialise in human factors and related psychological aspects of patient safety and staff wellbeing. Professional and post-qualification staff training could specifically include Cognitive Bias Avoidance Training, as this appears to play a key part in many errors relating to patient safety and staff wellbeing.

Background: To date, there is a paucity of theory-driven research on the likely determinants of patient involvement in safety-relevant behaviors. In particular, very little work has focused on predictors of patient behaviors that do not involve direct interactions with health-care staff., Objective: To examine predictors of patients' intentions to engage in 2 safety behaviors: (1) reporting an error to a national reporting system and (2) bringing medicines into hospital., Design: Cross-sectional survey study., Participants: Eighty medical and surgical hospital inpatients aged 18 to 80 years (mean, 48 years) from one inner city London teaching hospital., Method: Survey that measured the utility of constructs of the health belief model and theory of planned behavior in predicting patients' intentions to report an error to a national reporting system or to bring their medications into hospital. Data were analyzed using multiple regression analysis., Results: Control beliefs were the strongest predictors of patients' intentions. Normative beliefs were also a strong predictor of intentions to report an error to a national reporting system. The regression model accounted for smaller percentage of the variance in patients' intentions to bring medications into hospital than to report an error to a national reporting system (37% and 48%, respectively)., Conclusions: Interventions aimed at encouraging the participation of patients in promoting their own safety should consider the extent to which patients feel in control and capable of performing the behavior in question; this will help support patients to work with health-care professionals in ensuring safe care.

Background: Effective teamwork is critical to safety in the operating room; however, implementation of phase III of the American College of Surgeons (ACS) and Association of Program Directors in Surgery (APDS) Curriculum that focuses on team-based skills remains worryingly low. Training and assessing the complexities of teamwork is challenging. The objective of this study was to establish guidelines and recommendations for training faculty in assessing/debriefing team skills., Methods: A multistage survey-based consensus study was completed by 108 experts responsible for training and assessing surgical residents from the ACS Accredited Educational Institutes., Results: Experts agreed that a program to teach faculty to assess team-based skills should include training in the recognition of teamwork skills, practice rating these skills, and training in the provision of feedback/debriefing. Agreement was reached that faculty responsible for conducting team-based skills assessment should be revalidated every 2 years and stringent proficiency criteria should be met., Conclusions: Faculty development is critical to ensure high-quality, standardized training and assessment. Training faculty to assess team-based skills has the potential to facilitate the effective implementation of phase III of the ACS and APDS Curriculum., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Non-technical skills are of increasing importance in surgery and surgical training. A traditional focus on technical skills acquisition and competence is no longer enough for the delivery of a modern, safe surgical practice. This review discusses the importance of non-technical skills and the values that underpin successful modern surgical practice. This narrative review used a number of sources including written and online, there was no specific search strategy of defined databases. Modern surgical practice requires; technical and non-technical skills, evidence-based practice, an emphasis on lifelong learning, monitoring of outcomes and a supportive institutional and health service framework. Finally these requirements need to be combined with a number of personal and professional values including integrity, professionalism and compassionate, patient-centred care.

Objective: To elicit expert views to define the aims, optimal design, format and function of an inflammatory bowel disease (IBD) multidisciplinary team (MDT) with the overall purpose of enhancing the quality of MDT-driven care within an IBD service provision., Design: This study was a multicentre, prospective, qualitative study using a standard semistructured interview methodology., Participants: A multidisciplinary sample of 28 semistructured interviews of which there are six consultant colorectal surgeons, six IBD nurse specialists, seven consultant gastroenterologists, five consultant radiologists and four consultant histopathologists., Setting: Participants were recruited from 10 hospitals, which were a mixture of community hospitals and specialist IBD centres between June and October 2013., Results: Experts argued that the main goal of MDT-driven IBD care is to improve patient outcomes via sharing collective expertise in a formalised manner. Themes regarding the necessary requirements for an IBD MDT to occur included good attendance, proactive contribution, a need to define core members and appropriate and functional computer facilities. Emergent themes regarding the logistics of an effective IBD MDT included an eligibility criterion for case selection and discussion and appropriate scheduling. Themes regarding the overall design of the IBD MDT included a 'hub-and-spoke' model versus a 'single-centre' model., Conclusions: Defining key elements for an optimal design format for the IBD MDT is necessary to ensure quality of care and reduce variation in care standards. This study has produced a set of expert-based standards that can be used to structure the IBD MDT. These standards now require larger scale validation and consensus prior to becoming a practical guideline for the management of IBD care.

This study postulates that traditional human error identification techniques fail to consider motion economy principles and, accordingly, their applicability in operating theatres may be limited. This study addresses this gap in the literature with a dual aim. First, it identifies the principles of motion economy that suit the operative environment and second, it develops a new error mode taxonomy for human error identification techniques which recognises motion economy deficiencies affecting the performance of surgeons and predisposing them to errors. A total of 30 principles of motion economy were developed and categorised into five areas. A hierarchical task analysis was used to break down main tasks of a urological laparoscopic surgery (hand-assisted laparoscopic nephrectomy) to their elements and the new taxonomy was used to identify errors and their root causes resulting from violation of motion economy principles. The approach was prospectively tested in 12 observed laparoscopic surgeries performed by 5 experienced surgeons. A total of 86 errors were identified and linked to the motion economy deficiencies. Results indicate the developed methodology is promising. Our methodology allows error prevention in surgery and the developed set of motion economy principles could be useful for training surgeons on motion economy principles., (Copyright © 2015 Elsevier Ltd and The Ergonomics Society. All rights reserved.)

Importance: Improving the quality of health care for general medical patients is a priority, but the organization of general medical ward care receives less scrutiny than the management of specific diseases. Optimizing teams' performance improves patient outcomes in other settings, and interdisciplinary practice is a major target for improvement efforts. However, the effect of interdisciplinary team interventions on general medical ward care has not been systematically reviewed., Objectives: To describe the range of objective patient outcomes used in studies of general medical ward interdisciplinary team care, and to evaluate the performance of interdisciplinary interventions against them., Evidence Review: We searched EMBASE, MEDLINE, and PsycINFO from January 1, 1998, through December 31, 2013, for interdisciplinary team care interventions in adult general medical wards using an objective patient outcome measure. Reference lists of included articles were also searched. The last search was conducted on January 29, 2014, and the narrative and statistical analysis was conducted through December 1, 2014. Study quality was assessed using the Cochrane Effective Practice and Organization of Care group's tool., Findings: Thirty of 6934 articles met the selection criteria. The studies included 66,548 patients, with a mean age of 63 years. Nineteen of 30 (63%) studies reported length of stay, readmission, or mortality rate as their primary outcome, or did not specify the primacy of their outcomes. The most commonly reported objective patient outcomes were length of stay (23 of 30 [77%]), complications of care (10 of 30 [33%]), in-hospital mortality rate (8 of 30 [27%]), and 30-day readmission rate (8 of 30 [27%]). Of 23 interventions, 16 (70%) had no effect on length of stay, 12 of 15 (80%) did not reduce readmissions, and 14 of 15 (93%) did not affect mortality. Five of 10 (50%) interventions reduced complications of care. In an exploratory quantitative analysis, the interventions did not consistently reduce the relative risk of early readmission or early mortality, or the weighted mean difference in length of stay. All studies had a medium or high risk of bias., Conclusions and Relevance: Current evidence suggests that interdisciplinary team care interventions on general medical wards have little effect on traditional measures of health care quality. Complications of care or preventable adverse events may merit inclusion as quality indicators for general medical wards. Future study should clarify how best to implement interdisciplinary team care interventions and establish quality metrics that are credible to both health care professionals and patients in this setting.

The importance of surgeons' nontechnical skills is gaining widespread recognition as a critical element of high-quality and safe surgical care. This article reviews the knowledge base on training and assessing surgeons, and operating room (OR) teams, in nontechnical aspects of their performance. Nontechnical skills are defined in the context of the OR and key assessment instruments that have been developed to capture these skills are reviewed. Key developments that have taken place in the past decade on formal skills training are discussed, and recommendations to further advance nontechnical skills and team-based training and assessment in surgery are presented., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Objectives: Simulation is gaining increasing interest as a method of delivering high-quality, time-effective, and safe training to neurosurgical residents. However, most current simulators are purpose-built for simulation, being relatively expensive and inaccessible to many residents. The purpose of this study was to provide the first comprehensive validity assessment of ventriculostomy performance metrics from the Medtronic StealthStation S7 Surgical Navigation System, a neuronavigational tool widely used in the clinical setting, as a training tool for simulated ventriculostomy while concomitantly reporting on stress measures., Design: A prospective study where participants performed 6 simulated ventriculostomy attempts on a model head with StealthStation-coregistered imaging. The performance measures included distance of the ventricular catheter tip to the foramen of Monro and presence of the catheter tip in the ventricle. Data on objective and self-reported stress and workload measures were also collected., Setting: The operating rooms of the National Hospital for Neurology and Neurosurgery, Queen Square, London., Participants: A total of 31 individuals with varying levels of prior ventriculostomy experience, varying in seniority from medical student to senior resident., Results: Performance at simulated ventriculostomy improved significantly over subsequent attempts, irrespective of previous ventriculostomy experience. Performance improved whether or not the StealthStation display monitor was used for real-time visual feedback, but performance was optimal when it was. Further, performance was inversely correlated with both objective and self-reported measures of stress (traditionally referred to as concurrent validity). Stress and workload measures were well-correlated with each other, and they also correlated with technical performance., Conclusions: These initial data support the use of the StealthStation as a training tool for simulated ventriculostomy, providing a safe environment for repeated practice with immediate feedback. Although the potential implications are profound for neurosurgical education and training, further research following this proof-of-concept study is required on a larger scale for full validation and proof that training translates into improved long-term simulated and patient outcomes., (Copyright © 2015 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Screening using fecal occult blood testing (FOBt) reduces colorectal cancer mortality, but the test has low sensitivity. A "missed" cancer may cause psychologic harms in the screened population that partially counteract the benefits of early detection., Methods: Three hundred and eleven people diagnosed with colorectal cancer (i) after a negative FOBt result (interval cancer), (ii) a positive result (screen-detected cancer), or (iii) in regions where screening was not offered, completed questions on quality of life (FACT-C), depression (CES-D), perceived diagnostic delay, and trust in the results of FOBt screening. Fifteen withheld consent to data matching with medical records, leaving a sample size of 296., Results: Controlling for demographic and clinical variables, patients with an interval cancer reported poorer quality of life (difference in means = 6.16, P = 0.03) and more diagnostic delay (OR, 0.37; P = 0.02) than patients with screen-detected disease, with no differences in depression. No differences were observed between the interval cancer group and the group not offered screening on these measures. Patients with an interval cancer reported the lowest levels of trust in FOBt., Conclusions: An interval cancer has adverse effects on trust in FOBt, but does not result in worse psychologic outcomes compared with people diagnosed in areas with no screening program. People with an interval cancer report poorer quality of life than people with screen-detected disease., Impact: Improvements in test sensitivity could improve quality of life among people who complete an FOB test over and above any benefits already conferred by earlier detection., (©2015 American Association for Cancer Research.)

Background: Patient accessible electronic health records (PAEHRs) enable patients to access and manage personal clinical information that is made available to them by their health care providers (HCPs). It is thought that the shared management nature of medical record access improves patient outcomes and improves patient satisfaction. However, recent reviews have found that this is not the case. Furthermore, little research has focused on PAEHRs from the HCP viewpoint. HCPs include physicians, nurses, and service providers., Objective: We provide a systematic review of reviews of the impact of giving patients record access from both a patient and HCP point of view. The review covers a broad range of outcome measures, including patient safety, patient satisfaction, privacy and security, self-efficacy, and health outcome., Methods: A systematic search was conducted using Web of Science to identify review articles on the impact of PAEHRs. Our search was limited to English-language reviews published between January 2002 and November 2014. A total of 73 citations were retrieved from a series of Boolean search terms including "review*" with "patient access to records". These reviews went through a novel scoring system analysis whereby we calculated how many positive outcomes were reported per every outcome measure investigated. This provided a way to quantify the impact of PAEHRs., Results: Ten reviews covering chronic patients (eg, diabetes and hypertension) and primary care patients, as well as HCPs were found but eight were included for the analysis of outcome measures. We found mixed outcomes across both patient and HCP groups, with approximately half of the reviews showing positive changes with record access. Patients believe that record access increases their perception of control; however, outcome measures thought to create psychological concerns (such as patient anxiety as a result of seeing their medical record) are still unanswered. Nurses are more likely than physicians to gain time efficiencies by using a PAEHR system with the main concern from physicians being the security of the PAEHRs., Conclusions: This review implements a novel scoring system, which shows there is a lack of rigorous empirical testing that separates the effect of record access from other existing disease management programs. Current research is too targeted within certain clinical groups' needs, and although there are positive signs for the adoption of PAEHRs, there is currently insufficient evidence about the effect of PAEHRs on health outcomes for patients or HCPs.

Introduction: The majority of preventable deaths in healthcare are due to errors on general wards. Staff perceptions of safety correlate with patient survival, but effectively translating ward teams' concerns into tangibly improved care remains problematic. The Hospital Event Analysis Describing Significant Unanticipated Problems (HEADS-UP) trial evaluates a structured, multidisciplinary team briefing, capturing safety threats and adverse events, with rapid feedback to clinicians and service managers. This is the first study to rigorously assess a simpler intervention for general medical units, alongside an implementation model applicable to routine clinical practice., Methods/analysis: 7 wards from 2 hospitals will progressively incorporate the intervention into daily practice over 14 months. Wards will adopt HEADS-UP in a pragmatic sequence, guided by local clinical enthusiasm. Initial implementation will be facilitated by a research lead, but rapidly delegated to clinical teams. The primary outcome is excess length of stay (a surplus stay of 24 h or more, compared to peer institutions' Healthcare Resource Groups-predicted length of stay). Secondary outcomes are 30-day readmission or excess length of stay; in-hospital death or death/readmission within 30 days; healthcare-acquired infections; processes of escalation of care; use of traditional incident-reporting systems; and patient safety and teamwork climates. HEADS-UP will be analysed as a stepped wedge cluster controlled trial. With 7840 patients, using best and worst case predictions, the study would achieve between 75% and 100% power to detect a 2-14% absolute risk reduction in excess length of stay (two-sided p<0.05). Regression analysis will use generalised linear mixed models or generalised estimating equations, and a time-to-event regression model. A qualitative analysis will evaluate facilitators and barriers to HEADS-UP implementation and impact., Ethics and Dissemination: Participating institutions' Research and Governance departments approved the study. Results will be published in peer-reviewed journals and at conference presentations., Trial Registration Number: ISRCTN34806867., (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.)

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.

Objective: To systematically review the latest evidence for patient safety education for physicians in training and medical students, updating, extending and improving on a previous systematic review on this topic., Design: A systematic review., Data Sources: Embase, Ovid Medline and PsycINFO databases., Study Selection: Studies including an evaluation of patient safety training interventions delivered to trainees/residents and medical students published between January 2009 and May 2014., Data Extraction: The review was performed using a structured data capture tool. Thematic analysis also identified factors influencing successful implementation of interventions., Results: We identified 26 studies reporting patient safety interventions: 11 involving students and 15 involving trainees/residents. Common educational content included a general overview of patient safety, root cause/systems-based analysis, communication and teamwork skills, and quality improvement principles and methodologies. The majority of courses were well received by learners, and improved patient safety knowledge, skills and attitudes. Moreover, some interventions were shown to result in positive behaviours, notably subsequent engagement in quality improvement projects. No studies demonstrated patient benefit. Availability of expert faculty, competing curricular/service demands and institutional culture were important factors affecting implementation., Conclusions: There is an increasing trend for developing educational interventions in patient safety delivered to trainees/residents and medical students. However, significant methodological shortcomings remain and additional evidence of impact on patient outcomes is needed. While there is some evidence of enhanced efforts to promote sustainability of such interventions, further work is needed to encourage their wider adoption and spread., (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.)

Objectives: We hypothesized reduction of 30 days' in-hospital morbidity, mortality, and length of stay postimplementation of the World Health Organization's Surgical Safety Checklist (SSC)., Background: Reductions of morbidity and mortality have been reported after SSC implementation in pre-/postdesigned studies without controls. Here, we report a randomized controlled trial of the SSC., Methods: A stepped wedge cluster randomized controlled trial was conducted in 2 hospitals. We examined effects on in-hospital complications registered by International Classification of Diseases, Tenth Revision codes, length of stay, and mortality. The SSC intervention was sequentially rolled out in a random order until all 5 clusters-cardiothoracic, neurosurgery, orthopedic, general, and urologic surgery had received the Checklist. Data were prospectively recorded in control and intervention stages during a 10-month period in 2009-2010., Results: A total of 2212 control procedures were compared with 2263 SCC procedures. The complication rates decreased from 19.9% to 11.5% (P < 0.001), with absolute risk reduction 8.4 (95% confidence interval, 6.3-10.5) from the control to the SSC stages. Adjusted for possible confounding factors, the SSC effect on complications remained significant with odds ratio 1.95 (95% confidence interval, 1.59-2.40). Mean length of stay decreased by 0.8 days with SCC utilization (95% confidence interval, 0.11-1.43). In-hospital mortality decreased significantly from 1.9% to 0.2% in 1 of the 2 hospitals post-SSC implementation, but the overall reduction (1.6%-1.0%) across hospitals was not significant., Conclusions: Implementation of the WHO SSC was associated with robust reduction in morbidity and length of in-hospital stay and some reduction in mortality.