Introducing TOPplus in the operating theatre

Safer Surgery: Analysing Behaviour in the Operating Theatre

Volumn , Issue , 2009, Pages 151-171

  Dekker van Doorn, Connie ^a   Wauben, Linda ^a   Bonke, Benno ^b   Kazemier, Geert ^b   Klein, Jan ^b   Balvert, Bianca ^c   Vrouenraets, Bart ^c   Huijsman, Robbert ^d   Lange, Johan ^b  

^a DELFT UNIVERSITY OF TECHNOLOGY   (Netherlands)

^b ERASMUS MEDICAL CENTER   (Netherlands)

^c ONZE LIEVE VROUWE GASTHUIS   (Netherlands)

^d ERASMUS UNIVERSITY ROTTERDAM   (Netherlands)

Author keywords

[No Author keywords available]

Indexed keywords

EID: 84866014389     PISSN: None     EISSN: None     Source Type: Book    
DOI: None     Document Type: Chapter

References (36)

1. Amalberti, R., Auroy, Y., Berwick, D. and Barach, P. (2005) Five system barriers to achieving ultrasafe health care. Annals of Internal Medicine 142(9), 756-64.
2. Argyris, C. (1991) Teaching smart people how to learn. Harvard Business Review May-June.
3. Argyris, C. and Schön, D. (1978) Organizational Learning: A Theory of Action Perspective. Reading, MA: Addison Wesley.
4. Baker, D.P., Day, R. and Salas, E. (2006) Teamwork as an essential component of high-reliability organizations. Health Services Research 41(4), Pt 2, 1576-98.
5. Batalden, P. and Splaine, M. (2002) What will it take to lead the continual improvement and innovation of health care in the twenty-first century? Quality Management in Health Care 11(1), 45-54.
6. Boonstra, J.J. (2004) Dynamics of Organizational Change and Learning. Forlag: Wiley and Sons Ltd.
7. Cuschieri, A. (2006) Nature of human error. Implications for surgical practice. Annals of Surgery 244(5), 642-8.
8. de Bruijne, M.C., Zegers, M., Hoonhout, L.H.F. and Wagner, C. (2007) Unintended Harm in Dutch Hospitals. Dossier Study of Hospital Admissions in 2004. [Onbedoelde schade in Nederlandse ziekenhuizen. Dossieronderzoek van ziekenhuisopnames in 2004.] Utrecht: EMGO Institute Amsterdam and NIVEL.
9. Fletcher, G., Flin, R., McGeorge, P., Glavin, R., Maran, N. and Patey, R. (2003) Anaesthetists Non-Technical Skills (ANTS): Evaluation of a behavioural marker system. British Journal of Anaesthesia 90(5), 580-8.
10. Flin, R. and Maran, N. (2004) Identifying and training non-technical skills for teams in acute medicine. Quality of Safety in Health Care 13 Suppl 1, i80-4.
11. Grol, R. (2001) Successes and failures in the implementation of evidence-based guidelines for clinical practice. Medical Care 39(8), Suppl 2, ii46-54.
12. Hartocollis, A. (2008) In hospitals, simple reminders reduce deadly infections. The New York Times 19 May.
13. Helmreich, R.L. (1998) Error management as organizational strategy. Proceedings of the IATA Human Factors Seminar. Bangkok, Thailand.
14. Institute of Medicine (2001) Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academic Press.
15. Joint Commission on Accreditation of Health Care Organizations (2003) Universal Protocol For Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery, [accessed August 2008].
16. Kotter, J.P. (1996) Leading Change. Boston, MA: Harvard Business Press.
17. Leggat, S.G. (2007) Effective healthcare teams require effective team members: Defining teamwork competencies. BMC Health Services Research 7, 17.
18. Lemieux-Charles, L. and McGuire, W.L. (2006) What do we know about health care team effectiveness? A review of the literature. Medical Care Research Review 63(3), 263-300.
19. Lingard, L., Regehr, G., Orser, B., Reznick, R., Baker, G. R., Doran, D., Espin, S., Bohnen, J. and Whyte, S. (2008) Evaluation of a preoperative checklist and team briefing among surgeons, nurses, and anesthesiologists to reduce failures in communication. Archives of Surgery 143(1), 12-7; discussion 18.
20. Makary, M.A., Sexton, J.B., Freischlag, J.A., Holzmueller, C.G., Millman, E.A., Rowen, L. and Pronovost, P.J. (2006) Operating room teamwork among physicians and nurses: Teamwork in the eye of the beholder. Journal of the American College of Surgeons 202(5), 746-52.
21. Mickan, S.M. and Rodger, S.A. (2005) Effective health care teams: A model of six characteristics developed from shared perceptions. Journal of Interprofessional Care 19(4), 358-70.
22. Nelson, E.C., Batalden, P.B., Huber, T.P., Mohr, J.J., Godfrey, M.M., Headrick, L.A. and Wasson, J.H. (2002) Microsystems in health care: Part 1. Learning from high-performing front-line clinical units. Joint Commission Journal on Quality Improvement 28(9), 472-93.
23. Pronovost, P.J., Berenholtz, S.M., Goeschel, C.A., Needham, D.M., Sexton, J.B., Thompson, D.A., Lubomski, L.H., Marsteller, J.A., Makary, M.A. and Hunt, E. (2006) Creating high reliability in health care organizations. Health Services Research, 41(4) Pt 2, 1599-617.
24. Reason, J. (2005) Safety in the operating theatre - Part 2: Human error and organisational failure. Quality of Safety in Health Care 14(1), 56-60.
25. Savader, S.J., Lillemoe, K.D., Prescott, C.A., Winick, A.B., Venbrux, A.C., Lund, G.B., Mitchell, S.E., Cameron, J.L. and Osterman, F.A. (1997) Laparoscopic cholecystectomy-related bile duct injuries: A health and financial disaster. Annals of Surgery 225(3), 268-73.
26. Schuster, M.A., McGlynn, E.A. and Brook, R.H. (1998) How good is the quality of health care in the United States? Milbank Q 76(4), 517-63, 509.
27. Senge, P.M. (1990) The Fifth Discipline: The Art and Practice of the Learning Organization. New York: Doubleday.
28. Sexton, J.B., Makary, M.A., Tersigni, A.R., Pryor, D., Hendrich, A., Thomas, E.J., Holzmueller, C.G., Knight, A.P., Wu, Y. and Pronovost, P.J. (2006) Teamwork in the operating room: Frontline perspectives among hospitals and operating room personnel. Anesthesiology 105(5), 877-84.
29. Smith, M.K. (2001) Donald Schön: Learning, Reflection and Change. Available at: [accessed September 2008].
30. Thomas, E.J., Sexton, J.B. and Helmreich, R.L. (2003) Discrepant attitudes about teamwork among critical care nurses and physicians. Critical Care Medicine 31(3), 956-9.
31. Undre, S. and Healey, A.N. (2006) Observational Teamwork Assessment for Surgery (OTAS). User Manual. London: Imperial College.
32. Wagner and de Bruijne(2007) Utrecht: EMGO Institute Amsterdam and NIVEL.
33. World Health Organization (2005a) Global Patient Safety Challenge: Clean Care is Safer Care. Geneva: WHO Press, pp. 1-35.
34. World Health Organization (2005b) WHO Draft Guidelines for Adverse Event Reporting and Learning Systems. Geneva: WHO Press, pp. 1-80.
35. World Health Organization (2008) WHO Guidelines for Safe Surgery 1st edition. Geneva: WHO Press, pp. 1-173.
36. Yule, S., Flin, R., Paterson-Brown, S., Maran, N. and Rowley, D. (2006) Development of a rating system for surgeons' non-technical skills. Medical Education 40(11), 1098-104.