BACKGROUND:We evaluated a national, multidisciplinary in situ simulation-based team training intervention in New Zealand public hospitals. We hypothesised that outcomes for surgical patients and staff perceptions of teamwork and observed teamwork behaviours would improve after the intervention. METHODS:In a stepped-wedge cluster trial, all New Zealand's 20 District Health Boards were semi-randomised into four cohorts. Training was progressively implemented with one cohort per year. Patient outcomes were derived from a national administrative dataset. Outcome measures were intervention uptake, days alive and out of hospital at 90 days (DAOH90), pre-post staff Teamwork Perceptions Survey scores, and pre-post measures of observed teamwork performance during administration of the World Health Organisation Surgical Safety Checklist. RESULTS:Nineteen District Health Boards implemented training, and 41% of the estimated 3800 eligible staff participated. Post-intervention, DAOH90 increased 0.12 days (n=436 785 surgical cases) but we could not separate the intervention's effect from other temporal factors. Teamwork Perceptions Survey scores improved by 0.35 (95% confidence interval, 0.10-0.59) (P=0.006), 0.37 (0.12-0.63) (P=0.006), and 0.50 (0.22-0.78) (P<0.001) on a 5-point scale for 'Overall', 'Communication and Shared Mental Model', and 'Trust and Accountability', respectively. There was no important effect on observed teamwork. CONCLUSIONS:We achieved small improvements in teamwork by involving 41% of New Zealand operating theatre staff in team training. Improved patient outcomes could not be solely attributed to our intervention, potentially reflecting high baseline levels of teamwork and surgical outcomes, diluting effects of the progressive uptake of the team training over intervention periods, and other confounders including the COVID-19 pandemic. CLINICAL TRIAL REGISTRATION:ACTRN12617000017325.

INTRODUCTION:In situ simulation provides a valuable opportunity to identify latent safety threats (LSTs) in real clinical environments. Using a national simulation program, we explored latent safety threats (LSTs) identified during in situ multidisciplinary simulation-based training in operating theaters in hospitals across New Zealand. METHOD:Surgical simulations lasting between 15 and 45 minutes each were run as part of a team training course delivered in 21 hospitals in New Zealand. After surgical in situ simulations, instructors used a template to record identified LSTs in a postcourse report. We analyzed these reports using the contributory factors framework from the London Protocol to categorize LSTs. RESULTS:Of 103 postcourse reports across 21 hospitals, 77 contained LSTs ranging across all factors in the London Protocol. Common threats included staff knowledge and skills in emergencies, team factors, factors related to task or technology, and work environment threats. Team factors were also commonly reported as protecting against adverse events, in particular, creating a shared mental model. Examples of actions taken to address threats included replacing or repairing faulty equipment, clarifying emergency processes, correcting written information, and staff training for clinical emergencies. CONCLUSIONS:The pervasiveness of LSTs suggests that our results have widespread relevance to surgical departments throughout New Zealand and elsewhere and that collective solutions would be valuable. In situ simulation is an effective mechanism both for identifying threats to patient safety and to prompt initiatives for improvement, supporting the use of in situ simulation in the quality improvement cycle in healthcare.

Developing professional identity is a vital part of health professionals' education. In Auckland four tertiary institutions have partnered to run an interprofessional simulation training course called Urgent and Immediate Patient Care Week (UIPCW) which is compulsory for Year Five medical, Year Four pharmacy, Year Three paramedicine and Year Three nursing students. We sought to understand student experiences of UIPCW and how those experiences informed student ideas about professional identity and their emergent practice as health professionals within multidisciplinary teams. In 2018, we commenced ethnographic research involving participant observation, field notes, interviews, photography and observational ethnographic film. A total of 115 students participated in this research. The emergent findings concern the potentially transformative learning opportunity presented within high fidelity multi-disciplinary simulations for students to develop their professional identity in relation to peers from other professions. Our work also exposes the heightened anxiety and stress which can be experienced by students in such interdisciplinary simulations. Student experience suggests this is due to a range of factors including students having to perform in front of peers and staff in such simulation scenarios when their own professional identity and capabilities are still in emergent stages. Staff-led simulation debriefs form a critical success factor for transformative learning to be able to occur in any such simulations so that students can reflect on, and move beyond, the emotion and uncertainty of such experiences to develop future-focused concepts of professional identity and strategies to support effective interprofessional teamwork.

Aim NetworkZ is a simulation-based multidisciplinary team-training programme designed to enhance patient safety by improving communication and teamwork in operating theatres (OTs). In partnership with the Accident Compensation Corporation, its implementation across New Zealand (NZ) began in 2017. Our aim was to explore the experiences of staff – including the challenges they faced – in implementing NetworkZ in NZ hospitals, so that we could improve the processes necessary for subsequent implementation. Method We interviewed staff from five hospitals involved in the initial implementation of NetworkZ, using the Organising for Quality model as the framework for analysis. This model describes embedding successful quality improvement as a process of overcoming six universal challenges: structure, infrastructure, politics, culture, motivation and learning. Results Thirty-one people participated. Structural support within the hospital was considered essential to maintain staff enthusiasm, momentum and to embed the programme. The multidisciplinary, simulation-based approach to team training was deemed a fundamental infrastructure for learning, with participants especially valuing the realistic in situ simulations and educational support. Participants reported positive changes to the OT culture as a result of NetworkZ and this realisation motivated its implementation. In sites with good structural support, NetworkZ implementation proceeded quickly and participants reported rapid cultural change towards improved teamwork and communication in their OTs. Conclusion Implementation challenges exist and strategies to overcome these are informing future implementation of NetworkZ. Embedding the programme as business as usual across a nation requires significant and sustained support at all levels. However, the potential gains in patient safety and workplace culture from widespread multidisciplinary team training are substantial. Trial registration number ACTRN12617000017325.

Objective. To assess pharmacy students' opinions of an interprofessional learning (IPL) course in their final year of the Bachelor of Pharmacy program at The University of Auckland. Methods. Pharmacy students participated in the second day of a two-day simulation-based course, WardSim, alongside medical and nursing students in an acute care, hospital ward setting. After finishing the course, all students were asked to complete a questionnaire. The responses of pharmacy, nursing, and medical students on the scaled questions were compared. An in-depth thematic analysis of the pharmacy students' responses to the open-ended questions was completed using an iterative process. Results. Significant differences were found among the students' responses regarding the prioritization of care, systematic assessment of patients, and communication strategies. Pharmacy students had less favourable responses regarding the IPL experience than medical and nursing students. However, overall responses were positive. Some of the themes that emerged among the pharmacy students' responses included: learning communication tools, being assertive in communicating with other health care professionals, and understanding their own and others' roles in the health care team. Furthermore, some pharmacy students reported feeling underprepared for and underutilized during patient care scenarios. Conclusion. An IPL experience in an acute patient care setting demonstrated clear and beneficial learning outcomes for pharmacy students, especially in regards to communicating and understanding their roles and those of others on their team. Tailoring the pre-work or scenarios for the IPL experience to be more pharmacy orientated and having pharmacy students participate on both days may improve the preparedness for IPL.

While the WHO Surgical Safety Checklist (the Checklist) can improve patient outcomes, variable administration can erode benefits. We sought to understand and improve how operating room (OR) staff use the Checklist. Our specific aims were to: determine if OR staff can discriminate between good and poor quality of Checklist administration using a validated audit tool (WHOBARS); to determine reliability and accuracy of WHOBARS self-ratings; determine the influence of demographic variables on ratings and explore OR staff attitudes to Checklist administration. Design Mixed methods study using WHOBARS ratings of surgical cases by OR staff and two independent observers, thematic analysis of staff interviews. Participants OR staff in three New Zealand hospitals. Outcome measures Reliability of WHOBARS for self-audit; staff attitudes to Checklist administration. Results Analysis of scores (243 participants, 2 observers, 59 cases) supported tool reliability, with 87% of WHOBARS score variance attributable to differences in Checklist administration between cases. Self-ratings were significantly higher than observer ratings, with some differences between professional groups but error variance from all raters was less than 10%. Key interview themes (33 interviewees) were: Team culture and embedding the Checklist, Information transfer and obstacles, Raising concerns and 'A tick-box exercise'. Interviewees felt the Checklist could promote teamwork and a safety culture, particularly enabling speaking up. Senior staff were of key importance in setting the appropriate tone. Conclusions The WHOBARS tool could be useful for self-audit and quality improvement as OR staff can reliably discriminate between good and poor Checklist administration. OR staff self-ratings were lenient compared with external observers suggesting the value of external audit for benchmarking. Small differences between ratings from professional groups underpin the value of including all members of the team in scoring. We identified factors explaining staff perceptions of the Checklist that should inform quality improvement interventions.

We developed an interprofessional advanced cardiac life support (ACLS) course for final-year undergraduate nursing and medical students, aiming to increase technical resuscitation and non-technical teamwork skills. We studied the effects of the course using mixed methods, comprising the Readiness for Interprofessional Learning Scale (RIPLS), a questionnaire, and focus groups. Over eight full days, 188 students participated—comprising 59 nursing and 129 medical students (representing 69 and 68% of the total year’s cohorts, respectively). Overall RIPLS scores increased pre- to post-course by 2.13 points (from 76.41 to 78.54, p < 0.001)—being largely due to medical students’ scores (increasing by 2.50 points, p < 0.001). The study questionnaire showed agreement or strong agreement that non-technical course objectives had been achieved, and the analysis of focus group transcripts identified five themes involving communication, teamwork, leadership, value and realism, and professional roles. Both student groups reported specific insights into the skills and roles of each other. Nursing students were identified by medical students as better at drawing up drugs, setting up intravenous drips, and keeping records. Nursing students identified medical students as better at diagnosis, patient care planning, and intervention tasks such as needle insertion during pneumothorax. Both groups reported that such insights would not have occurred during uniprofessional simulation, felt that the course better prepared them for work in the clinical context, and agreed that more undergraduate interprofessional teaching using simulation should occur. Our results were instrumental in the adoption of the interprofessional ACLS course as a permanent part of our university’s undergraduate curriculum.

Objectives: Having effective communication strategies between health care professionals is vital. In undergraduate curricula, Interprofessional Learning (IPL) is one manner with which to better prepare students for their health care careers in a multidisciplinary environment. We aimed to explore pharmacy students’ opinions of an IPL course in their final year of the Bachelor of Pharmacy programme at The University of Auckland.Methods: The course was completed alongside medical and nursing students, in an acute hospital ward setting. Students completed a Likert-type questionnaire with associated open-ended questions. Responses were compared between pharmacy, nursing and medical students. An in-depth thematic analysis of the pharmacy student’s open-ended questions was completed using an iterative process.Results: Significant differences were seen in response to Likert-type questions regarding the prioritisation of care, systematic assessment of patients and communication strategies. Interesting themes emerg...

Background An interprofessional simulation 'ward call' course-WardSim-was designed and implemented for medical, pharmacy and nursing students. We evaluated this intervention and also explored students' experiences and ideas of both the course and of ward calls. Methods We used a mixed-methods cohort study design including survey and focus groups. Descriptive statistical analysis and general purpose thematic analysis were undertaken. Results Survey respondents who participated in WardSim subsequently attended more ward calls and took a more active role than the control cohort, with 34% of the intervention cohort attending ward calls under indirect supervision, compared with 15% from the control cohort (P=0.004). Focus group participants indicated that the situation they were most anxious about facing in the future was attending a ward call. They reported that their collective experiences on WardSim alleviated such anxiety because it offered them experiential learning that they could then apply in real-life situations. They said they had learnt how to work effectively with other team members, to take on a leadership role, to make differential diagnoses under pressure and to effectively communicate and seek help. Conclusions An interprofessional, simulated ward call course increased medical students' sense of preparedness for and participation in ward calls in the next calendar year.

Background: Simulation has been used to investigate clinical questions in anesthesia, surgery, and related disciplines, but there are few data demonstrating that results apply to clinical settings. We asked "would results of a simulation-based study justify the same principal conclusions as those of a larger clinical study?"Methods: We compared results from a randomized controlled trial in a simulated environment involving 80 cases at three centers with those from a randomized controlled trial in a clinical environment involving 1,075 cases. In both studies, we compared conventional methods of anesthetic management with the use of a multimodal system (SAFERsleep (R); Safer Sleep LLC, Nashville, Tennessee) designed to reduce drug administration errors. Forty anesthesiologists each managed two simulated scenarios randomized to conventional methods or the new system. We compared the rate of error in drug administration or recording for the new system versus conventional methods in this simulated randomized controlled trial with that in the clinical randomized controlled trial (primary endpoint). Six experts were asked to indicate a clinically relevant effect size.Results: In this simulated randomized controlled trial, mean (95% CI) rates of error per 100 administrations for the new system versus conventional groups were 6.0 (3.8 to 8.3) versus 11.6 (9.3 to 13.8; P = 0.001) compared with 9.1 (6.9 to 11.4) versus 11.6 (9.3 to 13.9) in the clinical randomized controlled trial (P = 0.045). A 10 to 30% change was considered clinically relevant. The mean (95% CI) difference in effect size was 27.0% (-7.6 to 61.6%).Conclusions: The results of our simulated randomized controlled trial justified the same primary conclusion as those of our larger clinical randomized controlled trial, but not a finding of equivalence in effect size.

We read with interest the recent article by Suvikas-Peltonen et al 1 reviewing 26 studies of which 12 concerned incorrect practices that led to microbial contamination. Our study ‘Anaesthetic drug administration as a potential contributor to healthcare-associated infections: a prospective simulation-based evaluation of aseptic techniques in the administration of anaesthetic drugs’2 was one of the 12 reviewed articles. We would like to clarify …

Background The aseptic techniques of anesthesiologists in the preparation and administration of injected medications have not been extensively investigated, but emerging data demonstrate that inadvertent lapses in aseptic technique may be an important contributor to surgical site and other postoperative infections. Methods A prospective, open, microbiological audit of 303 cases in which anesthesiologists were asked to inject all bolus drugs, except propofol and antibiotics, through a 0.2-µm filter was performed. The authors cultured microorganisms, if present, from the 0.2-µm filter unit and from the residual contents of the syringes used for drawing up or administering drugs. Participating anesthesiologists rated ease of use of the filters after each case. Results Twenty-three anesthesiologists each anesthetized up to 25 adult patients. The authors isolated microorganisms from filter units in 19 (6.3%) of 300 cases (3 cases were excluded), including Staphylococcus capitis, Staphylococcus warneri, Staphylococcus epidermidis, Staphylococcus haemolyticus, Micrococcus luteus/lylae, Corynebacterium, and Bacillus species. The authors collected used syringes at the end of each case and grew microorganisms from residual drug in 55 of these 2,318 (2.4%) syringes including all the aforementioned microorganisms and also Kocuria kristinae, Staphylococcus aureus, and Staphylococcus hominus. Participants’ average rating of ease of use of the filter units was 3.5 out of 10 (0 being very easy and 10 being very difficult). Conclusions Microorganisms with the potential to cause infection are being injected (presumably inadvertently) into some patients during the administration of intravenous drugs by bolus during anesthesia. The relevance of this finding to postoperative infections warrants further investigation.

In January 2015, the US Food and Drug Administration (FDA) reported that at least 40 patients had received non-sterile intravenous fluids, resulting in associated adverse events and one death. The offending products were produced for educational purposes by a company supplying the growing healthcare simulation market, and were not intended for patients. The plastic bags, labelled to mimic sterile 0.9% saline solution, contaminated the medication supply chain in 22 locations.1 Although the sequence of events is not yet clear, the supply shortage of 0.9% saline in the USA2 may have been a contributory factor. The presence of fake products was a latent condition or ‘resident pathogen’3 which in certain circumstances led to error and patient harm. Harbingers of the tragic events above have been reported, such as the discovery of demonstration adrenaline syringes on an emergency trolley for clinical use and the treatment of anaphylaxis with an Epipen subsequently found to be an inactive training device.4 An editorial on unintended consequences of simulation5 highlighted administration of fake medications as a potential hazard to patients, and simulating medications has been an active topic in the simulation community, for example on the Society For Simulation in Healthcare Listserve. Simulation-based activities are common in healthcare education and an expanding evidence base suggests they are also useful for improving patient safety6 ,7 and for detecting latent safety threats in new products.8 Debate continues on how accurately the clinical environment should be recreated to achieve educational objectives and to enable transfer of learning to the workplace.9 One approach is to use clinical areas for simulation activities (in situ) as opposed to using separate, dedicated simulation spaces.10 Medication errors are a persistent and important problem in healthcare.11 Simulation-based education in any location often incorporates medication, …

AIM: Unintended patient harm is a major contributor to poor outcomes for surgical patients and often reflects failures in teamwork. To address this we developed a Multidisciplinary Operating Room Simulation (MORSim) intervention to improve teamwork in the operating room (OR) and piloted it with 20 OR teams in two of the 20 District Health Boards in New Zealand prior to national implementation. In this study, we describe the experience of those exposed to the intervention, challenges to implementing changes in clinical practice and suggestions for successful implementation of the programme at a regional or national level.METHODS: We undertook semi-structured interviews of a stratified random sample of MORSim participants 3-6 months after they attended the course. We explored their experiences of changes in clinical practice following MORSim. Interviews were recorded, transcribed and analysed using a general inductive approach to develop themes into which interview data were coded. Interviews continued to the point of thematic saturation.RESULTS: Interviewees described adopting into practice many of the elements of the MORSim intervention and reported positive experiences of change in communication, culture and collaboration. They described sharing MORSim concepts with colleagues and using them in teaching and orientation of new staff. Reported barriers to uptake included uninterested colleagues, limited team orientation, communication hierarchies, insufficient numbers of staff exposed to MORSim and failure to prioritise time for team information sharing such as pre-case briefings.CONCLUSION: MORSim appears to have had lasting effects on reported attitudes and behaviours in clinical practice consistent with more effective teamwork and communication. This study adds to the accumulating body of evidence on the value of simulation-based team training and offers suggestions for implementing widespread, regular team training for OR teams.

BACKGROUND:Realising the full potential of the WHO Surgical Safety Checklist (SSC) to reduce perioperative harm requires the constructive engagement of all operating room (OR) team members during its administration. To facilitate research on SSC implementation, a valid and reliable instrument is needed for measuring OR team behaviours during its administration. We developed a behaviourally anchored rating scale (BARS) for this purpose.METHODS:We used a modified Delphi process, involving 16 subject matter experts, to compile a BARS with behavioural domains applicable to all three phases of the SSC. We evaluated the instrument in 80 adult OR cases and 30 simulated cases using two medical student raters and seven expert raters, respectively. Intraclass correlation coefficients were calculated to assess inter-rater reliability. Internal consistency and instrument discrimination were explored. Sample size estimates for potential study designs using the instrument were calculated.RESULTS:The Delphi process resulted in a BARS instrument (the WHOBARS) with five behavioural domains. Intraclass correlation coefficients calculated from the OR cases exceeded 0.80 for 80% of the instrument's domains across the SSC phases. The WHOBARS showed high internal consistency across the three phases of the SSC and ability to discriminate among surgical cases in both clinical and simulated settings. Fewer than 20 cases per group would be required to show a difference of 1 point between groups in studies of the SSC, where α=0.05 and β=0.8.CONCLUSION:We have developed a generic instrument for comprehensively rating the administration of the SSC and informing initiatives to realise its full potential. We have provided data supporting its capacity for discrimination, internal consistency and inter-rater reliability. Further psychometric evaluation is warranted.

To the Editor: With great interest, we followed the recent publication of Gargiulo et al.1 reporting on perioperative microbiological contamination during drug application. Bacterial contaminants were detected in 6.3% of patients and in 2.4% of sampled syringes. These numbers are alarming, suggesting a potential role of intraoperative management in postoperative infections. The study inherits an interesting design including close-to-real-life conditions. However, there remains some source of bias that is not completely addressable in this setting, and the number of contaminations may even be higher. Especially high contamination rates of propofol are a known problem related to its formulation; consequently, propofol syringes should be prepared directly before application and used propofol syringes should be disposed immediately. Although even the laboratory environment of drug preparation may inherit a, very low, bacterial contamination risk, syringe handling is a key element in this context.2 Compared to the study by Gargiulo et al.,1 other authors observed higher contamination rates of syringes,2–4 and as the study was performed unblinded, there is a high probability of a relevant Hawthorne effect. Additionally, some aspects are not completely reported in study description:

AIMSWe ran a Multidisciplinary Operating Room Simulation (MORSim) course for 20 complete general surgical teams from two large metropolitan hospitals. Our goal was to improve teamwork and communication in the operating room (OR). We hypothesised that scores for teamwork and communication in the OR would improve back in the workplace following MORSim. We used an extended Behavioural Marker Risk Index (BMRI) to measure teamwork and communication, because a relationship has previously been documented between BMRI scores and surgical patient outcomes.METHODSTrained observers scored general surgical teams in the OR at the two study hospitals before and after MORSim, using the BMRI.RESULTSAnalysis of BMRI scores for the 224 general surgical cases before and 213 cases after MORSim showed BMRI scores improved by more than 20% (0.41 v 0.32, p<0.001). Previous research suggests that this improved teamwork score would translate into a clinically important reduction in complications and mortality in surgical patients.CONCLUSIONSWe demonstrated an improvement in scores for teamwork and communication in general surgical ORs following our intervention. These results support the use of simulation-based multidisciplinary team training for OR staff to promote better teamwork and communication, and potentially improve outcomes for general surgical patients.

AIMS:Communication failures in healthcare are frequent and linked to adverse events and treatment errors. Simulation-based team training has been proposed to address this. We aimed to explore the feasibility of a simulation-based course for all members of the operating room (OR) team, and to evaluate its effectiveness.METHODS:Members of experienced OR teams were invited to participate in three simulated clinical events using an integrated surgical and anesthesia model. We collected information on costs, Behavioural Marker of Risk Index (BMRI) (a measure of team information sharing) and participants' educational gains.RESULTS:We successfully recruited 20 full OR teams. Set up costs were NZ$50,000. Running costs per course were NZ$4,000, excluding staff. Most participants rated the course highly. BMRI improved significantly (P = 0.04) and thematic analysis identified educational gains for participants.CONCLUSION:We demonstrated feasibility of multidisciplinary simulation-based training for surgeons, anesthetists, nurses and anaesthetic technicians. The course showed evidence of participant learning and we obtained useful information on cost. There is considerable potential to extend this type of team-based simulation to improve the performance of OR teams and increase safety for surgical patients.

Abstract Background: Effective teamwork is important for patient safety, and verbal communication underpins many dimensions of teamwork. The validity of the simulated environment would be supported if it elicited similar verbal communications to the real setting. The authors hypothesized that anesthesiologists would exhibit similar verbal communication patterns in routine operating room (OR) cases and routine simulated cases. The authors further hypothesized that anesthesiologists would exhibit different communication patterns in routine cases (real or simulated) and simulated cases involving a crisis. Methods: Key communications relevant to teamwork were coded from video recordings of anesthesiologists in the OR, routine simulation and crisis simulation and percentages were compared. Results: The authors recorded comparable videos of 20 anesthesiologists in the two simulations, and 17 of these anesthesiologists in the OR, generating 400 coded events in the OR, 683 in the routine simulation, and 1,419 in the crisis simulation. The authors found no significant differences in communication patterns in the OR and the routine simulations. The authors did find significant differences in communication patterns between the crisis simulation and both the OR and the routine simulations. Participants rated team communication as realistic and considered their communications occurred with a similar frequency in the simulations as in comparable cases in the OR. Conclusion: The similarity of teamwork-related communications elicited from anesthesiologists in simulated cases and the real setting lends support for the ecological validity of the simulation environment and its value in teamwork training. Different communication patterns and frequencies under the challenge of a crisis support the use of simulation to assess crisis management skills.