Safer Surgery part 48 pps

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Chapter 27
Behaviour in the Operating Theatre: A
Clinical Perspective
Nikki Maran and Simon Paterson-Brown
As clinicians, we have spent many thousands of hours working in operating
theatres over the last 20 years. As a senior anaesthetist and surgeon, we recognize
that we have a great deal of inuence on the atmosphere created in the operating
theatre and that our behaviour inuences those around us. However, as trainees
we experienced many different ‘regimes’ in a variety of theatres in which we were
trained. There has always been a steep hierarchy within any surgical team and there
was no question but that the senior surgeon was the leader. The only time this might
ever have been in doubt was where there was an equally formidable theatre sister
or anaesthetist in post. Voices were raised, instruments thrown, brows mopped
and tears shed. These were not environments in which one questioned decision-
making or challenged leadership if one wished to set foot in the operating theatre
again! We tended to work in small clinical teams or ‘rms’ with little turnover
of staff so everyone knew each other fairly well and teams became well oiled in
‘routine practice’. Although few protocols as we recognize them today existed,
deviation from the team routine was seldom tolerated.
Patients died, usually because they had co-existing medical disease and
occasionally, due to some technical failure during surgery, at least these were
the only things we measured. Occasional emergency situations arose which
resulted in a patient’s death and these ‘unfortunate’ events were often regarded as
‘unavoidable’ complications of surgery. Occasionally a culprit was identied and
usually publically vilied in departmental mortality meetings.
As junior doctors, we provided continuity of care by working over 100 hours
per week and specialist training lasted eight to ten years. The major focus of
training was in the development of good technical skills and these were honed to
a high level through an apprenticeship style of training by ‘practising’ on patients.
Examinations measured knowledge and everyone knew the trainees who were

‘good with their hands’. The system had massive training redundancy which
gave us all plenty of time to ‘absorb’ the implicit skills which were not part of
the curriculum – those of picking up cues in the clinical environment – Situation
Awareness (SA), developing good clinical judgement – decision-making and
developing our own teamwork and leadership skills by modelling our behaviours
on those demonstrated to us by our seniors. Many of those who did not develop
good SA or decision-making would fail to reach the senior registrar grade, however,
Safer Surgery
446
leadership behaviours, styles of communication and modes of teamworking were
more subjective. The development of non-technical skills (NTS) has therefore been
an implicit, though recognized, part of the medical curriculum for generations.
Although the focus of scrutiny in health care is often on failures and adverse
events, we are well aware that, in clinical practice, many potential adverse events
are avoided when individuals within the team pick up and act on early warning
signs. This phenomenon is recorded in studies (de Leval et al. 2000, Catchpole et
al. 2007) which demonstrate that high performing teams show greater ability to
recover from minor errors.
Over the last 20 years, the health service has changed enormously. Medicine
and surgery have become more complex, we are able to keep frail patients alive
for much longer and so our patient population is becoming older and sicker. This
is well summed up by a quote from Chantler who said that where ‘Medicine used
to be simple, ineffective and relatively safe, now it is complex, effective and
potentially dangerous’ (Chantler 1999, p. 1181). We have learned from other high
reliability domains and are now aware that human factors are implicated in many
of the things which go wrong in hospitals and indeed in the operating theatre.
Indeed, the underlying causes of adverse events in healthcare are more likely to
be associated with behavioural failures than a lack of technical expertise (Bogner
1994, 2004)
Thankfully, ‘bad’ behaviour in the operating theatre has improved. Throwing

of instruments and temper tantrums are now a thing of the past. However, a recent
survey of surgical trainees in Scotland revealed that in some areas as many as 50
per cent of trainees reported experiencing bullying by senior staff which made
them feel unable to express their views (National Trainee Survey 2007), and
this is clearly liable to inuence how likely these trainees are to speak up if they
observe problems in the operating theatre. This nding is unlikely to be unique to
Scotland.
Streamlining of training has reduced the number of years for specialist training
and introduction of the European Working Time Directive (EWTD) and similar
limits to working hours in other countries has progressively reduced the number of
hours that doctors are permitted to work. While on one hand, reduction in hours of
work has been demonstrated to reduce error in clinical environments (Lockley et al.
2004), the increase in shift working increases the number of handovers of complex
patient care and highlights the need for good and effective communication. The
reduction in hours of training time means that we no longer have the luxury of
training redundancy and need to make all parts of the curriculum explicit. While
this has been done well for the knowledge and technical-skill-based competencies,
there is now an urgent need to dene the implicit skills (such as non-technical
skills) required to work in the healthcare system and to embed them into the
curriculum (Glavin and Maran 2003). The xed ‘rm’ team has been replaced by
transient teams of individuals who may come together for only short periods and
once again this highlights the need for individuals to develop portable team skills,
or non-technical skills, which will equip them to work in these situations. This
Behaviour in the Operating Theatre
447
book brings together, for the rst time, the leading researchers who are carrying
out observational research in the operating theatre. We have been lucky enough to
be directly involved in the work of some of these groups and have learned much
from the others. It is useful, perhaps to consider how this work can be of relevance
to the operating theatre clinician.

Some seminal studies (Brennan et al. 1991, Vincent et al. 2001) and government
responses to these (Kohn et al. 1999, Department of Health 2000) have helped us
to understand the importance of human factors in adverse events and have driven
much of the patient safety agenda. All of the researchers who have contributed to
this volume have helped to increase our understanding of how non-technical skills
inuence the way we work more specically in the operating theatre. Increasing
our understanding of where things are going wrong will help us to develop
strategies to deal with these issues or to focus training on improving the situation.
Although we like to think that behaviour in the operating theatre has improved
over the last ten years, it is sobering to look at the ndings in observational work.
What is described is exactly what happens – it is just that it is so ‘normal’ that
we don’t notice how absurd our behaviour can sometimes be. Many problems
in the operating theatre stem from the ineffectiveness or lack of communication
(see Lingard et al., Chapter 17 in this volume). Although communication is a
major component of undergraduate and postgraduate curricula, the emphasis is
almost exclusively on doctor–patient or nurse–patient communication and very
little if any consideration given to the importance of doctor–doctor or doctor–
nurse communication. This issue is now being addressed in various safety tools
which are being introduced including the WHO patient safety brieng tool (World
Health Organization) and the use of SBAR (Situation, Background, Assessment,
Recommendation) (Leonard et al. 2004) as part of the IHI initiatives in improving
handovers.
The non-technical skills taxonomies (Fletcher et al. 2003, Yule et al. 2006)
which have been developed not only give us a vocabulary with which to express
and discuss non-technical skills ourselves but also a framework which can be
used to give feedback to help understand where we are and improve our own
non-technical skills. The denition of non-technical skills also helps to allow us
to integrate these skills into curricula (Canadian Patient Safety Institute 2005,
National Patient Safety Education Framework 2004) and we will increasingly see
non-technical skills being incorporated into workplace-based assessment. Using

these taxonomies in clinical practice (see Glavin and Patey, Chapter 11 in this
volume) will help us to recognize when trainees are failing to develop good NTS
early and introduce remediation. Further research is needed to explore whether
this can be effective and if not, this clearly has implications for selection in the
future.
Many of the research groups included in this volume are working in simulation
environments. The delity of the training mannequins which are now available
means that the simulator is the ideal place to study behaviour in emergency
situations without having to wait for these unusual events to happen in real practice
Safer Surgery
448
(Flin and Maran 2008). The same situation can be recreated on multiple occasions
to allow observation of cohorts of participants. Although human factors training
can commence in the classroom, in order to develop skills, individuals need
feedback on behaviours and an opportunity to practise these skills. The simulator
provides an optimal environment which is safe for both patient and learner to
allow observation of self and rehearsal of skills. Simulators will clearly have a
role to play in helping individuals to develop the skills required in emergency
situations and are also likely to have a role in ‘remedial’ training. The delity of
the surgical simulators currently available is still not high enough to allow good
intra-operative non-technical skills training for surgeons. However this is likely
to be overcome in the next few years as the technology develops and simulators
become more widely available. Transfer of skills from the simulator to clinical
practice is vital and NTS frameworks such as ANTS and NOTSS are designed to
give feedback in both the simulated environment and in the operating theatre.
The development of our understanding of the impact of non-technical skills
on patient outcomes should also be reected in the use of systems to analyse
behaviours when errors occur such as during incident reporting and morbidity
and mortality meetings. The Australian AIMS study (Webb et al. 1993) analyses
critical incidents from a human factors perspective, but this methodology should

be more widely used.
Challenges for the future include training trainers to become familiar with
assessing and providing feedback on non-technical skill as (see Graham et al.,
Chapter 12 in this volume) have clearly demonstrated that inter-rater reliability of
such systems is not high unless assessors are both experienced in the observation
of skills and have been well calibrated. The aviation model of trainer accreditation
for both teaching and assessing non-technical skills (Civil Aviation Authority
2003) is one that we can only aspire to in healthcare.
We have come a long way in healthcare over the last ten years and many of
those who have contributed to this book have helped to drive this change. In the
next ten years, non-technical skills will become an implicit part of the curriculum
for doctors, nurses and all other health professionals involved in the delivery of
healthcare. As a result, the assessment of non-technical skills will become the norm,
and understanding the importance of non-technical skills in certain specialties will
drive the need to identify individuals with good NTS early in training for selection
to certain specialities. Future generations will nd the operating theatre a very
different place to work in and, as a result, ultimately a safer place for patients.
References
Bogner M. (ed.) (1994) Human Error in Medicine. Hillsdale, NJ: LEA.
Bogner M. (ed.) (2004) Misadventures in Health Care. Mahwah, NJ: LEA.
Brennan, T., Leape, L., Laird, N.M., Herbert, L., Localio, A.R., Lawthers, A.G.,
Newhouse, J.P., Weiler, P.C. and Hiatt, H.H. (1991) Incidence of adverse
Behaviour in the Operating Theatre
449
events and negligence in hospitalised patients: Results of the Harvard Medical
Practice Study I. New England Journal of Medicine 324, 370–6.
Canadian Patient Safety Institute. (2007) Safety Competencies Framework
– Groundbreaking Project on Interprofessional Education. Available from:
<
[last accessed March 2009].

Catchpole, K.R., Giddings, A.E., Wilkinson, M., Hirst, G., Dale T. and de Leval,
M.R. (2007) Improving patient safety by identifying latent failures in successful
operations. Surgery 142(1), 102–10.
Chantler, C. (1999) The role and education of doctors in the delivery of healthcare.
Lancet 353, 1178–81.
Civil Aviation Authority (2003) Crew Resource Management (CRM) Training.
Guidance for Flight Crew, CRM Instructors (CRMIS) and CRM Instructor-
examiners (CRMIES). CAP 737. London: Civil Aviation Authority.
de Leval, M.R., Carthey, J., Wright D.J. and Reason, J.T. (2000) Human factors
and cardiac surgery: A multicenter study. Journal of Thoracic Cardiovascular
Surgery, 119, 661–72.
Department of Health (2000) An Organisation with a Memory: Learning from
Adverse Events in the NHS. London: The Stationery Ofce.
Fletcher, G., Flin, R., McGeorge, P., Glavin, R., Maran, N. and Patey, R. (2003)
Anaesthetists’ Non-Technical Skills (ANTS): Evaluation of a behavioural
marker system. British Journal of Anaesthesia 90(5), 580–8.
Flin, R. and Maran, N. (2008) Non-technical skills. In R. Riley (ed.) Simulation in
Medicine. Oxford: Oxford University Press.
Glavin, R.J. and Maran, N.J. (2003) Integrating human factors into the medical
curriculum. Medical Education 37(Suppl.1), 59–64.
Kohn, L, Corrigan, J and Donaldson, M. (eds) (1999) To Err is Human. Building
a Safer Healthcare System. Washington, DC: Institute of Medicine National
Academy Press.
Leonard, M., Graham, S. and Bonacum, D. (2004) The human factor: The critical
importance of effective teamwork and communication in providing safe care.
Quality and Safety in Health Care 13(Suppl 1), i85–i90.
Lockley, S., Cronin, J., Evans, E., Cade, B., Lee, C., Landrigan, C., Rothschild,
J., Katz, J., Lilly, C., Stone, P., Aeschbach, D., Czeisler, C. and Harvard Work
Hours, Health and Safety Group (2004) Effect of reducing interns’ weekly
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Medicine 351(18), 1829–37.
National Patient Safety Education Framework (2004) An Initiative of the Australian
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patientsafety.org.au/framework/index.html> [last accessed 11 March 2009].
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Safer Surgery
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Safe Surgery Saves Lives (2008) World Health Organization. Available from:
<www.who.int/patientsafety/safesurgery/> [last accessed March 2009].
Vincent, C., Neale, G. and Woloshynowych, M. (2001) Adverse events in British
Hospitals: Preliminary retrospective record review. British Medical Journa,
322, 517–19.
Webb, R.K. Currie, M., Morgan, C.A., Williamson, J.A., Mackay, P., Russell,
W.J. and Runciman, W.B. (1993) The Australian Incident Monitoring Study:
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Yule, S., Flin, R., Paterson-Brown, S., Maran, N. and Rowley, D. (2006)
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Index
A-TEAM 129
behaviour categories 132
development of 136–7
feedback 138
in the operating theatre 141–4
rationale 130–36
summative assessment 138, 141
training 137–8

adverse events 12–13, 151, 445, 446–7
all team members’ behaviour scale see
A
-TEA
M
alpha-amylase analysis 377–8
American Society of Anesthesiologists
(ASA) scores
264
anaesthesia
adaptive coordination 204–15, 225–33
observation systems 228–33
task-analytic approach 234
behavioural markers 308–9
clinical guidelines 371–80
coding reliability 230–31
collaborative management of
unexpected events 225–8
communication 241–55, 311–15, 316,
399
coordination behaviour 203
data recording 230
emergence 246–9
experts’ judgement 309
handover from 249–55
human factors 305
induction 244–6
nonroutine events (NRE) 205
observation evaluation tools 308–10
observational studies 231–3

participants in study 306
problem solving 303–5
shared mental models 315
simulators 304
study results 311–12
teamwork 203–4
training scenarios 306–8
transitions 244
Anaesthetists’ Non-Technical Skills
System (ANTS)
development 176–7
information gathering 181–2
intraclass correlation (ICC) 195
lessons learnt 199–200
methodology 190
misclassication 198
promotion of 177–9
qualitative data 196–9
questionnaires 196–7
rater training 193–5
safety standards 198–9
study design 190
taxonomy 209, 214–15
teaching 180–83
trainee assessment 185–6
video 190–93
workplace-based assessment 179–80,
189–200
AN
ZCA (

Australian and New Zealand
College of Anaesthetists) 189
ASA ( A
merican Society of
Anesthesiologists) 264
audio-video recording 388–90
Australian and N
ew Zealand College of
Anaesthetists (ANZCA) 189
behaviour scales and teamwork 130,
132–4
Behavioural Marker Risk Index (BMRI)
266–7, 271–2
behavioural markers 263, 273, 423–35
anaesthesia 308–9
Non-Technical Skills for Surgeons
(NOTSS) 14
rating of 194–5
Safer Surgery
452
scores 270–71
systems 85, 263
BMRI (Behavioural Marker Risk Index)
266–7, 271–2
C
anME
DS 353
Case Based Discussion (CBD) 180
CIT (critical incident technique) 13
clinical competence, assessment of 28

clinical environment, interruptions 406
clinical guidelines 371–2
observations 374–5
simulator-based evaluation 372–4
Cognitive Task Analysis 14
commodity approach to healthcare 442
communication
anaesthesia 241–55, 311–15, 316, 399
operating theatre (OT) 118, 286–8
problem solving 301–16
surgery 273–4
surgical performance 283–97
teamwork 143–4, 156–7, 283–97
coordination behaviour 203
cortisol analysis 377
costs of incidents 169
crew resource management (CRM) 67,
153–5, 302, 423–5
in aviation 425–6
healthcare 433–5
in medicine 426–33
critical incident technique (CIT) 13
CR
M see Crew
Resource Management
decision-making see surgical decision-
making
Directly Observed Procedural Skills
(DOPS) 180
Disruptions in Surgery Index (DiSI) 408–9

DOPS (Directly Observed Procedural
Skills) 180
double-loop learning 155
emergency department, interruptions
406–7
environmental psychology 406
ergospirometry 375–7
European Working Time Directive 8, 29,
274
failure source model 322, 329–31
followership 134–6
heedful interrelating 207–8
ICC (intraclass correlation) 195
I
ndependent Sector T
reatment Centres
(ISTC) 29
infant simulators 372–4
innovation 438
instrument nurses see scrub nurses
IN
TERAC
T 209
intraclass correlation (ICC) 195
I
STC
(Independent Sector Treatment
Centres) 29
JA (Judgement Analysis) 364–6
J

ARTEL (Joint Aviation
Requirements:
Translation and Elaboration of
Legislation) project 14
Judgement Analysis (JA) 364–6
Kaiser Permanente, surgical safety
programme 274–8
latent failures 151
leadership 134–6, 154, 445
learning, double-loop 155
Line Operations Safety Audit (LOSA) 85,
424, 433
logistic regression model 267
Mini
Clinical
Evaluation Exercise
(MiniCEX) 180, 183
music in operating theatres 410–11
noise in operating theatres 410–11
non-technical skills (NTS) see also
Non-Technical Skills for Surgeons
(NOTSS); Oxford NOTECHS
system; Surgical NOTECHS
anaesthesia 175–6, 186
crew resource management 67–8
nurses 68
orthopaedic surgery 335
patient safety 301
surgery 103
surgical training 7–9, 21–2

Index
453
Non-Technical Skills for Surgeons
(NOTSS) 8–21, 49, 113
adverse event and mortality reviews
12–13
attitude survey 11
behavioural markers 14
critical incident reviews 13–14
development of 14–15
future research 22–3
literature review 10–11
observations 12
Procedure Based Assessments (PBAs)
44
project design 9–20
rating scale 15
system evaluation 15–17
system usability 17–20
task analysis 9–14
user handbook 17
nonroutine events (NRE) 205
N
OTECH
S 105 see also Non-T
echnical
Skills for Surgeons (NOTSS);
Oxford NOTECHS system;
Sur
gical N

OTECHS
NOTSS
see Non-Technical Skills for
Surgeons
NRE (nonroutine events) 205
NTS see non-technical skills
Nurses’
NOTECHS 67–8
communication 69–70, 74
consultant surgeon interviews 77–8
decision making 72–3, 76
expert panels 78
leadership 72–3, 76
literature review 68–73
scrub nurse interviews 73
situation awareness 71–2, 76
teamwork 70–71, 74–6
Objective Structured A
ssessment of
Technical Skill (OSA
TS) 48–9
observational methods 130–31, 263–4
Observational Teamwork Assessment for
Surgery
©
(OTAS
©
)
assessment process 90–95
behaviour ratings 88, 89

development 87–8
holistic assessment 97
non-teamwork surgical processes 96
observation 113
observer’s expertise 96
Oxford
NOT
ECHS system 111
phases 88–9
retrospective rating 96
simulation-based team training 96
task checklist 88, 89
team feedback 89–90
team orientation 89
teamwork 84–7, 95
O
CAP
see Orthopaedic Competence
A
ssessment Project
operating room see operating theatre
Operating Room Management A
ttitudes
Questionnaire (ORMAQ) 11
operating theatre (OT)
bad behaviour 446
communication 286–8
crew resource management (CRM)
155
distractions 405–15

environment 406
interruptions 405–15
music 410–11
noise 410–11
observation 387–8
prospective memory 340–41
silence 288–96
teamwork 153
telephones 334
O
R
see operating theatre
ORM
AQ (Operating Room Management
Attitudes Questionnaire) 11
Orthopaedic Competence A
ssessment
Project (OCAP) 40, 42, 43–4
orthopaedic surgery 321–36
cases 322–3
distracters 334
dual observers 331–3
equipment 335
expert observers 335
failures 323–9, 333
index procedures 34
non-technical skills (NTS) 335
patient safety 333–5
Sur
gical N

OTECHS 107
teams 322–3
Safer Surgery
454
telephones 334
OSATS (Objective Structured Assessment
of Technical Skill) 48–9
OT see operating theatre
OTAS
©
see Observational Teamwork
Assessment for Surgery
©
Oxford NOTECHS system 108–11
assessment of team performance
113
minor failures 112, 113
Observational Teamwork Assessment
for Surgery
©
(OTAS
©
) 111
technical errors 112
paediatric cardiac surgery 105–6
patient safety
clinical performance 223
human factors 447
non-technical skills (NTS) 301
orthopaedic surgery 333–5

surgery 151
systemic threats 321–2
teamwork 224, 399–400
time pressure 398
PB
As
see Procedure Based Assessments
PM see
prospective memory
PMETB (Postgraduate Medical
Education
and Training Board) 28
post-stress questionnaire 380
Postgraduate Medical Education and
T
raining Board (PMETB) 28
problem solving
anaesthesia 303–5
communication 301–16
Procedure Based Assessments (PBAs)
acceptance survey 42–3
assessment 33
baseline survey 42
curriculum 36–8
design and development 34–9
development of 27
domains 30
elements of 30–31
index procedures 34, 40
initiation 33

international compatibility 44
later years of training 43
meaning of 29–30
NOTSS (Non-Technical Skills for
Surgeons) system 44
O
CAP
online 43–4
orthopaedic community 36
patients 36
PowerPoint guides 44
rating scale 38–9
R
egional I
n-service Training
Assessment (RI TA) 43
reliability 40–41
summary sheet 33
surgical environment 35
surgical skill assessment 48–9
surgical task 35
trainer/trainee characteristics
35–6
validity 40
prospective memory (PM)
clinical practice 349–50
denition 343
dynamic change of plans 340, 345
interruptions 341–2
phases 343–4

pilot study results 346–8
questionnaire study 346–8
recurrent measurements 339–40, 345
research 348–9
simulator study 346
treatment in time 339, 344
RAT
E
see Remote A
nalysis of Team
Environments
Regional In-service Training Assessment
(RITA) 43
Remote Analysis of
Team Environments
(RATE) 117
coding schemes 126
data collection 120–22
event-marking software 124–6
playback software 123–4
setup procedure 122–3
teamwork evaluation 119–20
RI
TA see Regional
In-service Training
Assessment (RITA)
safety science 437–8
saliva sampling 379–80
scrub nurses 67, 73
Index

455
shared mental models 301, 302, 304,
312–13, 315–16
Shefeld Surgical Skills Study 47
acceptability of tools 54
assessment 51
assessor training 56–8
clinicians 55–6
collaboration 60–61
design and methodology 49–51
dichotomy 61
feasibility of tools 53–4
implementation 51, 62–3
index procedures 50
observation 50–51
participants 50
patient participants 58–9
progress to date 51
purpose of 49
reliability of tools 53
research aims 51–4
research team 54–5
sample size 50
surgical specialties 63–4
surgical trainee participants 59–60
timescale 49
validity of tools 52–3
video recording 64
Shipman
Inquiry

28–9
short-term memory 131–2
silence 288–96
SimBaby
™
372–4
situation awareness 71–2, 76, 445–6
SME (subject matter experts) 390
stress 371–2
measurement 375–80
subject matter experts (SME) 390
surgeons, technical competence 273
surgery
adverse events 151, 445
communication 273–4
complexity 446
complications 266
decision-making 353–66
effectiveness 446
error causation 103–8
leadership 445
non-technical skills 103
patient safety 151
public attitude to 28–9
safety 446
systems view 405
training 21–2, 27–9
working hours 446
surgical decision-making
decision modelling 357

experimental approach 360–62,
364
Judgement A
nalysis 364–6
knowledge elicitation 358–60, 364
modelling approach 360–62, 364
multimodal approach
358–64
observational approaches 357–8
process approaches 357–8
self-reporting 356–7
simulation 362–4, 365
structured 132–3, 357
study methods 356–8
Sur
gical N
OTECHS 105
orthopaedic surgery 107
Oxford
NOT
ECHS system
108–14
paediatric cardiac surgery 105–6
scoring system 105–6
surgical pause 429
surgical performance
communication 283–97
distractions 405–14
interruptions 405–14
observation of 48–9

systems approach 353–4
teamwork 83–97
video recordings 64
surgical safety
programme 274–8
systems approach 353–5
Surgical Safety Checklist 164–5
surgical skills assessment 47–9
Surgical Skills Study see Shefeld
Surgical Skills Study
surgical teams
disciplines 88, 431–2
teamwork 272, 274
surgical time out 429
surgical trainees
training time 29, 446
workplace-based assessment 8
Safer Surgery
456
TARGETS (Tar
geted Acceptable
Responses to Generated Events or
Tasks) 84–5
team output 398–9
teamwork
adaptive coordination 224–5
anaesthesia 203–4
barriers to 154
behaviour scales 130, 132–4
communication 143–4, 156–7, 283–97

dysfunctional 432
evaluation of 118–20
implementation 440–41
leadership 154
measurement 84–7, 439–40
nurses 70–71, 74–6
operating theatre (OT) 153
patient outcomes 261–2
patient safety 224, 399–400
surgery 95–7
surgical performance 83–97
surgical teams 153, 272, 274
sustaining 441–2
time pressure 385–400
time pressure
audio-video recording 388–90
context of care 397–8
data collection 388–90, 397
patient safety 398
study methodology 387–8
subject matter experts (SME) 390
task shedding 395–6
team coordination 396–7
video analysis 390–95, 397
TKR (total knee replacement surgery) 322,
334
TOPplus
aims 153
debrieng 155–6, 160, 165–6, 168–9
implementation 159–60, 168

pilot study 158
results 161–4
poster 156, 159–60, 166
principles 153–4
questionnaire 156–7
time out procedure 155–6, 160, 165,
166, 168–9
total knee replacement (TKR) surgery
322, 334
video recording 388–90
WHO (World Health Organization),
Surgical Safety Checklist 164–5
working memory 131–2
workplace-based assessment 179–80,
189–200
World Health Organization (WHO),
Surgical Safety Checklist
164–5