This article describes an intervention that combined in-situ coaching, observational audits and story-telling to educate theatre teams at University College London Hospitals about the Five steps to safer surgery (NPSA 2010). Our philosophy was to educate theatre teams about ‘what goes right’ (good catches, exemplary leadership etc) as well as ‘what could be improved’. Results showed improvements on ‘behavioural reliability’ metrics, a 68% increase in near miss reporting and a reduction in surgical harm incidents.
AmalbertiR., VincentC., AuroyY., de Saint MauriceG.2006Violations and migrations in health care: a framework for understanding and managementQuality and Safety in Health Care15(Supplement 1) i66–i71
2.
EdmondsonA.1999Psychological safety and learning behaviour in work teamsAdministrative Science Quarterly44(2) 350–83
3.
EndsleyM.R.1995Towards a theory of situation awareness in dynamic systemsHuman Factors37(1) 32–64
4.
FischhoffB., SlovicP., LichtensteinS.1978How safe is safe enough? A psychometric study of attitudes towards technological risks and benefitsPolicy Sciences9(2) 127–52
5.
HelmreichR.L., MerrittA.C.1998Culture at work in aviation and medicine. National, organizational and professional influencesAldershot, Ashgate Publishing
6.
HuY.Y., ArriagaA.F., PeyreS.E.2012Deconstructing intraoperative communication failuresJournal of Surgical Research177(1) 37–42
7.
HuY.Y., PeyreS.E., ArriagaA.F.2012War stories: a qualitative analysis of narrative teaching strategies in the operating roomAmerican Journal of Surgery203(1) 63–68
8.
KlinectJ.R., WilhelmJ.A., HelmriechR.L.1999Event and error management: Data from line operations safety audits In: Proceedings of the 10th International Symposium on Aviation PsychologyOhio State University130–36
PattersonE., WoodsD.D., CookR.I., RenderM.L.2007Collaborative cross checking to enhance resilienceCognition Technology and Work9155–62
12.
RussS.J., RoutS., SevdalisN.2013Do safety checklists improve teamwork and communication in the operating room?Annals of Surgery258(6) 856–71
13.
RussS.J., SevdalisN., MoorthyK.2015A qualitative evaluation of the barriers and facilitators toward implementation of the WHO surgical safety checklist across hospitals in England: lessons from the Surgical Checklist Implementation ProjectAnnals of Surgery261(1) 81–91
14.
ToftB., Mascie-TaylorH.2005Involuntary automaticity: a work-system induced risk to safe health careHealth Services Management Research18(4) 211–16
VincentC., BurnettS., CartheyJ.2014Safety measurement and monitoring in healthcare: a framework to guide clinical teams and healthcare organisations in maintaining safetyBritish Medical Journal Quality and Safety23(8) 670–77
