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Examiner training has an inconsistent impact on subsequent performance. To understand this variation, we explored how examiners think about changing the way they assess. Method We provided comparative data to seventeen experienced examiners about their assessments, captured their sense-making processes using a modified think-aloud protocol, and identified patterns by inductive thematic analysis. Results We observed five sense-making processes: (1) testing personal relevance (2) interpretation (3) attribution (4) considering the need for change, and (5) considering the nature of change. Three observed meta-themes describe the manner of examiners' thinking: Guarded curiosity-where examiners expressed curiosity over how their judgements compared with others', but they also expressed guardedness about the relevance of the comparisons. Dysfunctional assimilation-where examiners' interpretation and attribution exhibited cognitive anchoring, personalisation, and affective bias. Moderated conservatism-where examiners expressed openness to change, but also loyalty to their judgement-framing values and aphorisms. Conclusions Our examiners engaged in complex processes as they considered changing their assessments. The 'stabilising' mechanisms some used resembled learners assimilating educational feedback. If these are typical examiner responses, they may well explain the variable impact of examiner training, and have significant implications for the pursuit of meaningful and defensible judgement-based assessment.

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Adequate haemostasis and an understanding of coagulation is a prerequisite of safe surgery. Numerous medical and pharmacological interventions render the surgical patient more likely to bleed and the surgeon must be aware of these. Transfusion of blood or blood products can facilitate surgical procedures and prove lifesaving but the practitioner must be aware of the pros and cons of their use. There must be fastidious attention to detail throughout the transfusion process to prevent transfusion incidents, clerical mistakes remaining a common source of transfusion related harm. Adjuncts to transfusion, such as cell salvage, are available and their role must be understood. Massive transfusion presents its own challenges and has its own side effect profile and the role of near patient testing utilizing thromboelastography will be considered.

The car parks at the study hospital are accessed using re-usable, machine-read tickets. In the initial phase of this study, 598 staff members were observed entering the car park, and 21.6% of them put their parking ticket in their mouth. Ultraviolet dye was used to demonstrate card-to-card cross-contamination. Swabs of the ticket machine yielded commensal bacteria: coagulase-negative staphylococci and a Bacillus sp. After placing a poster on the ticket-reading machine highlighting the potential risk of infection, a further 1366 observations demonstrated a significant and persistent decline in the proportion of staff who put their ticket in their mouth (P<0.001).