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Purpose There is increasing interest in the use of heart rate variability (HRV) as an objective measurement of mental stress in the surgical setting. To identify areas of improvement, the aim of our study was to review current use of HRV measurements in the surgical setting, evaluate the different methods used for the analysis of HRV, and to assess whether HRV is being measured correctly. Methods A systematic review was performed according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA). 17 studies regarding HRV as a measurement of mental stress in the surgical setting were included and analysed. Results 24% of the studies performed long-term measurements (24 h and longer) to assess the long-term effects of and recovery from mental stress. In 24% of the studies, artefact correction took place. Conclusions HRV showed to be a good objective assessment method of stress induced in the workplace environment: it was able to pinpoint stressors during operations, determine which operating techniques induced most stress for surgeons, and indicate differences in stress levels between performing and assisting surgery. For future research, this review recommends using singular guidelines to standardize research, and performing artefact correction. This will improve further evaluation of the long-term effects of mental stress and its recovery.

Car drivers appear to reduce their driving speed in high task demand situations. Summala's [Safety Sci. 22 (1996) 103±117]; [in: J.A. Rothengatter, & E. Carbonell Vaya (Eds.), Tra c and Transport Psychology: Theory and Application, Pergamon, Oxford, 1997, pp. 41±52] model of behavioural adaptation (MBA) also assumes that drivers increase speed in low task demand situations or attend to additional tasks more. The present study investigated the relation between driving speed and task demands in simulated driving. Participants were observed under three speed conditions, driving fast, driving as if taking a driving test, and following a fast-driving car. The same route was driven twice under each of these speed conditions: once with and once without the concurrent performance of an auditory short-term memory task. All other things being equal, driving fast required more e ort than driving more slowly, which was not compensated for by better memory performance. This refutes one assumption of the MBA. When following a fast-driving car, participants invested less e ort than when driving fast. As auditory route guidance messages were embedded within the memory task, participants were forced to attend the memory task in all rides of the Fast and Accurate conditions, but not in the Car Following conditions. This can also explain why the memory task had no e ect on cognitive e ort. It is concluded that car drivers prioritise their task goals. Ó

This study aimed to evaluate how performance variability contributes to perioperative sentinel events occurring within the Dutch healthcare system. Although performance variability was identified as a contributing factor in almost all analysis reports, it remains unrecognized by the sentinel event analysis team. Strengthening the integration of performance variability in sentinel event analyses could improve the analyses performed, and lead to more effective improvement measures specifically aimed at optimizing human performance within the healthcare system.

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