Unintended harm to patients in operating theatres is common. Correlations have been demonstrated between teamwork skills and error rates in theatres. This was a single-institution uncontrolled before-after study of the effects of ''non-technical'' skills training on attitudes, teamwork, technical performance and clinical outcome in laparoscopic cholecystectomy (LC) and carotid endarterectomy (CEA) operations. The setting was the theatre suite of a UK teaching hospital. Attitudes were measured using the Safety Attitudes Questionnaire (SAQ). Teamwork was scored using the Oxford Non-Technical Skills (NOTECHS) method. Operative technical errors (OTEs), non-operative procedural errors (NOPEs), complications, operating time and length of hospital stay (LOS) were recorded. A 9 h classroom non-technical skills course based on aviation ''Crew Resource Management'' (CRM) was offered to all staff, followed by 3 months of twice-weekly coaching from CRM experts. Forty-eight procedures (26 LC and 22 CEA) were studied before intervention, and 55 (32 and 23) afterwards. Nontechnical skills and attitudes improved after training (NOTECHS increase 37.0 to 38.7, t = 22.35, p = 0.021, SAQ teamwork climate increase 64.1 to 69.2, t = 22.95, p = 0.007). OTEs declined from 1.73 to 0.98 (u = 1071, p = 0.009), and NOPEs from 8.48 to 5.16 per operation (t = 4.383, p,0.001). These effects were stronger in the LC group than in CEA procedures. The operating time was unchanged, and a non-significant reduction in LOS was observed. Non-technical skills training improved technical performance in theatre, but the effects varied between teams. Considerable cultural resistance to adoption was encountered, particularly among medical staff. Debriefing and challenging authority seemed more difficult to introduce than other parts of the training. Further studies are needed to define the optimal training package, explain variable responses and confirm clinical benefit.We studied personnel performing laparoscopic cholecystectomy (LC) and carotid endarterectomy (CEA) procedures in the theatre suites of a major UK teaching hospital. These procedures were selected to minimise difficulties in evaluating performance caused by variations in the operative procedure. All CEA operations were performed in one theatre while the LC procedures were mostly done in three others, one of which was designated a day-case theatre. All CEA operations were elective or semielective procedures performed or directly supervised by consultant vascular surgeons. About 20% of LC were performed by experienced trainees without supervision, and a similar percentage were ''hot'' procedures. There were no major differences in availability and quality of equipment between the LC theatres except that intraoperative cholangiography was difficult to perform in the day-case theatre. The consultant surgical and anaesthetic staff and senior theatre nurses were largely constant throughout the study, but junior staff turnover was relatively high, typical of UK practice. The day-case theat...

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Non-technical skills are an important component of surgical skill, particularly in relation to the development and maintenance of a surgeon's situational awareness. Experience from other industries suggests that it may be possible to improve the ability of surgeons to manage their own situation awareness, through training, intraoperative briefings and intraoperative workload management. In the future, it may be possible to use non-technical performance as a surrogate measure for technical performance, either for early identification of surgical difficulties, or as a method of evaluation by which non-surgically trained observers.

Patient safety will benefit from an approach to human error that examines systemic causes, rather than blames individuals. This study describes a direct observation methodology, based on a threat and error model, prospectively to identify types and sources of systems failures in paediatric cardiac surgery. Of substantive interest were the range, frequency and types of failures that could be identified and whether minor failures could accumulate to form more serious events, as has been the case in other industries. Check lists, notes and video recordings were employed to observe 24 successful operations. A total of 366 failures were recorded. Coordination and communication problems, equipment problems, a relaxed safety culture, patient-related problems and perfusion-related problems were most frequent, with a smaller number of skill, knowledge and decision-making failures. Longer and more risky operations were likely to generate a greater number of minor failures than shorter and lower risk operations, and in seven higher-risk cases frequently occurring minor failures accumulated to threaten the safety of the patient. Non-technical errors were more prevalent than technical errors and task threats were the most prevalent systemic source of error. Adverse events in surgery are likely to be associated with a number of recurring and prospectively identifiable errors. These may be co-incident and cumulative human errors predisposed by threats embedded in the system, rather than due to individual incompetence or negligence. Prospectively identifying and reducing these recurrent failures would lead to improved surgical standards and enhanced patient safety.

Aviation-style teamwork training can increase compliance and team performance, but this was influenced by the attitude and collaboration of key individuals, and the effect was reduced by significant latent failures. This study demonstrates the need to improve organizational and personal management factors in the National Health Service if training in patient safety is to be effective and sustained. It also shows the influence of working conditions on clinical studies of quality improvement.