Multidisciplinary team simulation for the operating theatre: a review of the literature Shaw Boon Tan,* Guilherme Pena,†‡ Meryl Altree‡ and Guy J. Maddern†‡ *University of Adelaide, Department of Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia †University of Adelaide, Discipline of Surgery, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia and ‡Australian Safety and Efficacy Register of New Interventional Procedures – Surgical, Royal Australasian College of Surgeons, Adelaide, South Australia, Australia

Key words education, interprofessional relation, operating room, patient simulation, surgery. Correspondence Professor Guy J. Maddern, ASERNIP-S, Royal Australasian College of Surgeons, 199 Ward Street, North Adelaide, SA 5006, Australia. Email: [email protected] S. B. Tan MBBS, MSuSc; G. Pena MD; M. Altree BNg; G. J. Maddern MBBS, MS, MD, PhD, FRACS. Accepted for publication 28 October 2013. doi: 10.1111/ans.12478

Abstract Introduction: Analyses of adverse events inside the operating theatre has demonstrated that many errors are caused by failure in non-technical skills and teamwork. While simulation has been used successfully for teaching and improving technical skills, more recently, multidisciplinary simulation has been used for training team skills. We hypothesized that this type of training is feasible and improves team skills in the operating theatre. Methods: A systematic search of the literature for studies describing true multidisciplinary operating theatre team simulation was conducted in November and December 2012. We looked at the characteristics and outcomes of the team simulation programmes. Results: 1636 articles were initially retrieved. Utilizing a stepwise evaluation process, 26 articles were included in the review. The studies reveal that multidisciplinary operating theatre simulation has been used to provide training in technical and nontechnical skills, to help implement new techniques and technologies, and to identify latent weaknesses within a health system. Most of the studies included are descriptions of training programmes with a low level of evidence. No randomized control trial was identified. Participants’ reactions to the training programme were positive in all studies; however, none of them could objectively demonstrate that skills acquired from simulation are transferred to the operating theatre or show a demonstrable benefit in patient outcomes. Conclusion: Multidisciplinary operating room team simulation is feasible and widely accepted by participants. More studies are required to assess the impact of this type of training on operative performance and patient safety.

Introduction Communication errors and poor team dynamics contribute to the occurrence of adverse events in various domains of health care. This has been identified as a primary point of vulnerability for patient safety and efficiency in the operating theatre (OT).1–4 Teamwork is currently considered an integral component of patient safety and it is accepted that in addition to technical skills, cognitive and interpersonal skills are particularly important for OT teams to maintain a high level of performance.5–7 In light of their importance, the American College of Surgeons and the Association of Program Directors in Surgery in the USA in 2008 launched the Surgical Skills Curriculum phase III that © 2013 Royal Australasian College of Surgeons

integrates training in non-technical and teamwork skills.8 The Royal Australasian College of Surgeons also emphasize the importance of teamwork and non-technical skills, through core competences for trainees, which include collaboration, communication, decision making, leadership and professionalism.9 Simulation has been used successfully for training technical skills and recent studies have shown that this form of training can also be used for training team dynamics and non-technical skills.10–12 There are many examples of teamwork training simulators used in emergency medicine,13 trauma resuscitation,14 anaesthetics15 and critical care.16 In surgery, institutions are beginning to incorporate teamwork elements as part of training, but few studies focus on the multidisciplinary aspect of team training. ANZ J Surg 84 (2014) 515–522


In this review, we describe and explore the actual state of multidisciplinary team simulation in surgery. We hypothesize that multidisciplinary surgical team simulation is feasible and improves team skills in the OT.

Methods Two independent researchers performed a systematic search during November and December 2012 through Medline Ovid, EMBASE, CINAHL and the Cochrane Library. The search involved a combination of keywords and MeSH terms grouped according to target population, intervention and the outcome measured. The detailed search strategy is provided as supplementary material. By adhering strictly to inclusion/exclusion criteria, the retrieved articles were subjected to a stepwise evaluation process, beginning with title and abstract evaluation, followed by full text evaluation (Fig. 1). The selected articles were critically analysed and reference lists of the included articles were examined for additional citations.

Inclusion and exclusion criteria The criteria for inclusion were articles that (i) were written or translated to English, (ii) published in peer-review journals, (iii) con-

Fig. 1. Review process flow.

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tained a simulation component, (iv) included surgical trainees/ surgeons within a multidisciplinary OT team and (v) were published during 1990–2012. Studies that were excluded (i) did not train or evaluate multidisciplinary groups in a simulated OT environment (e.g. observation of real-life OTs, emergency department or critical care unit simulations), (ii) assessed only a single professional group (i.e. solely surgeons/surgeon-trainees dyad/anaesthetist/nursing), (iii) included non-surgeon groups as scripted confederates (i.e. actors who have been given scripted responses) and (iv) assessed only technical skills. The articles were summarized and relevant details were tabulated accordingly (Table 1).

Results What are the characteristics of the OT multidisciplinary team simulation programmes? Twenty-six articles met the inclusion criteria and were categorized into 23 programmes. Details about the simulation training programmes are shown in Table 1. Most studies used either a simulated OT or point-of-care set-up to provide simulated training. Twelve of 23 programmes were conducted in simulated OTs,17,18,21–24,30,32,33,35,37,41,42 which contained similar equipment to a fully functioning procedural theatre. Six programmes were defined as point-of-care or in situ where simulations were conducted on actual inpatient care units (OT or intensive care unit) involving local health care teams.25–28,31,34,39 Two groups used live animal and/or human cadaver models for teaching and were set-up in a wet laboratory.19,20,29 One group performed off-site simulation by using an inflatable shell containing the minimum necessary cues to provide the sense of realism of an OT.43 Several advantages were highlighted by the groups that employed point-of-care simulation. This set-up was thought to be more realistic and that it enhanced interpersonal/team dynamics by creating a more psychologically engaging learning experience. It also identified and rectified systemic problems within the hospital environment.25–27,31,32 Volk et al. described that during simulated training, inadequate signage for the emergency call button was identified and this issue was subsequently resolved by the OT administration.31 In addition, simulation at the point-of-care results in less disruption to individual work commitments because hospital staff are not taken away from work more than is absolutely necessary,31 and allows more flexibility in scheduling conflicts.26 Some authors reported that point-of-care simulation has the potential to reduce costs31,34 while others describe that it adds costs26,27 because both simulation and OT-related fixed and variable expenses must be taken into account. However, no study reported a detailed cost analysis. Another issue reported was that in situ simulation requires blocking of actual OT time otherwise used to provide care to real patients.27 The type of equipment and the level of equipment fidelity used for simulation varied greatly among the studies. Most described the use of manikins with electronically mediated physiological parameters.17,18,21–27,31–34,36,37,41 Six studies incorporated a synthetic model into their full scale team simulators.22,24–26,37,39 One used a virtual reality cholecystectomy machine21 and three programmes © 2013 Royal Australasian College of Surgeons

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Table 1 Characteristics of included studies First author, year of publication and country

Type of simulation/participants (n)†



Sexton, 1998 Switzerland17 Musson, 2004 USA18 Hansen, 2007 Norway19,20

Simulated operating theatre. n = 291

Post-course questionnaire

Participants assessed the training favourably.

Wet laboratory. n = 117 (1999–2003) 1-day course n = 312 (2003–2006) 2-day course

Post-course questionnaire 6-month follow-up systemic evaluation through phone survey

Paige, 2007 USA21

Simulated operating theatre. n = 10

Post-course questionnaire

Undre, 2007 UK22

Simulated operating theatre. n = 80

Post-course questionnaire Technical skills: (1) OSATS, ICAT-N. (2) Detailed notes of anesthetists and ODP technical skills

Participants assessed the training favourably. Team approach was perceived as vital by respondents. 94% of institutions that participated in the phone survey reported modifying their trauma protocol as a result of their teams’ participation in the course. Participants assessed the training favourably. 80% participants said that the training session would change the way they practised within the operating room. Participants assessed the training favourably. Technical skill: trainee surgeons’ scores matched those of their trainers. Trainee nurse seemed to overestimate their performance and ODPs to underestimate theirs. Non-technical skills: lower scores on leadership and decision making in the anaesthetic and surgical groups. Surgeons’ scores were lower than nurses on communication and lower than nurses and ODPs on teamwork skills. Participants assess favorably simulation scenarios as a training method. The technical skills of the surgeons improved significantly post-training as measured by expert assessors. No overall (for all professions) effect of training on non-technical skills was observed. Participants assessed the training favourably. Experts score higher than novices in technical skills. Experts score higher than novices in all the components of non-technical skills.

Non-technical skills: (1) Modified NOTECHS

Koutantji, 2008 UK23

Simulated operating theatre. n = 34

Post-course questionnaires Technical skills: (1) Modified OSATS Non-technical skills: (1) Modified NOTECHS (pre- and post-training assessment)

Powers, 2008 USA24

Simulated operating theatre. n = 20

Post-course questionnaire Technical skills: (1) Rating scale modified from OSATS, ICEPS and procedure-specific global rating scale. (2) Objective time measurement to complete the task. Non-technical skills: (1) Modified NOTECHS. (2) Essential item checklists Pre- and post-course questionnaires on participant’s self-efficacy for performing targeted teamwork competencies

Paige, 2009 USA25,26

Point-of-care simulation. n = 45 (module 1 = 38; module 2 = 39)

Rodriguez-Paz, 2009 USA27

Point-of-care simulation. n = Not detailed.

No formal assessment. Analyses of participants’ experiences, concerns over safety issues

O’Regan, 2010 Canada (Abstract)28

Point-of-care simulation. n=6

Post-course questionnaire

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Improvement in self-reported efficacy after module 1 and further improvement after module 2 Participants’ reported improvements in self-efficacy were confirmed by direct observation. Twenty potential defects were identified (six of them concerning teamwork and communication) and corrected, resulting in the creation of a Multidisciplinary Safety Checklist and Protocol. Participants assessed the training favourably. Latent systemic errors were revealed what motivated changes in organization and equipment.


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Table 1 Continued First author, year of publication and country

Type of simulation/participants (n)†



Respondents assessed the training favourably. Improvement in operating time, extent of lymph node dissection and surgeon skills. Improvement in technical and communication skills of scope operators and nurses. Participants assessed the training favourably. Participants assessed the training favourably. Poor signage to code switches in the OT was identified and corrected. Participants assessed the training favourably. Improvement in adherence to key processes with the use of checklist. Participants assessed the training favourably. Positive shift in group cohesion over time. Participants assessed the training favourably. Projected impact of the training on future practice and improved confidence in management of acute airway situation. Participants assessed the training favourably. Only one aspect of team communication improved between the two surveys, that is, improved teamwork concepts. Perceived relevance to current practice and feasible to change teamwork behaviour in cardiac surgery. Participants assessed the training favourably. Simulation enhanced all NOTECHS scores in team communication, situation awareness, team skill, leadership and decision making. More than 50% reduction in the time to defibrillation in the post training scenario. Participants assessed the training favourably. Urology junior technical performance was significantly worse than senior resident performance. Urology and anaesthetist resident level of training did not correlate with non-technical performance rated by expert faculty. Non-technical performance self-assessment by urology residents was consistently higher than faculty rating. Participants assessed the training favourably. Most of participants felt the training would improve overall patient outcomes.

Kinoshita, 2010 Japan29

Wet laboratory. n = 80

Pre- and post-course (6–10 months after training) questionnaires filled out by representative surgeon from each hospital

Vincent, 2010 UK30 Volks, 2011 USA31

Simulated operating theatre. n = Not detailed Point-of-care simulation. n = 59

Post-course questionnaire

Ziewacz, 2011 USA32

Simulated operating theatre. n = 11

Post-course questionnaire Failure of adherence to key processes of crisis checklist

Klipfel, 2011 USA33

Simulated operating theatre. n = 38 (participated of the simulation training).

Pre and post-course (2 weeks and 2 months after simulation training) questionnaires

Mehta, 2012 UK34

Point-of-care simulation. n = 78

Post-course questionnaire

Stevens, 2012 USA35

Simulated operating theatre. n = 27 (participated of the simulation)

Pre- and post-course (6 months after trainig) questionnaires (operating room teamwork survey) Interviews

Patki, 2012 UK36

Set-up not detailed. n = Not detailed Two surgical teams

Post-course questionnaire Technical skills: (1) Robotic de docking and removal time. (2) Time for resuscitation the simulated patient.

Post-course questionnaire

Non-technical skills: (1) NOTECHS Lee, 2012 Canada37

Simulated operating room. n = 16

Post-course questionnaire Technical skills: (1) Task-specific checklist. (2) 5-point Likert style Global rating scale. (3) Amount of blood loss. Non-technical skills: (1) NOTSS (2) ANTS

Kellicut, 2012 USA (Abstract)38

Set-up not detailed. n = 220 military personnel in Iraq

Post-course questionnaire

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Multidisciplinary team simulation


Table 1 Continued First author, year of publication and country

Type of simulation/participants (n)†


Lane, 2012 UK (Abstract)39

Point-of-care simulation. n = 29

Post-course questionnaire

Harris, 2012 UK40

Post-course questionnaire

Acero, 2012 USA41

Off-site simulation: inflatable shell – distributed simulation (DS) n = Not detailed Simulated operating theatre. n = 171

Acero, 2012 USA (Abstract)42

Set-up not detailed. n = 490

Post-course questionnaire Number of essential emergency steps and the time to steps during the simulation was measured. Follow-up survey up to 20 months after simulation

Post-course questionnaire Number of essential emergency steps and the time to complete steps during the simulation Pre- and post-training knowledge procedural-based questions


Participants assessed the training favourably. All participants evaluated the scenario as having a positive impact on their practice. Most of participants reported the training sessions as effective in increasing their confidence in attending similar real clinical scenarios. Surgeons supported the use of DS in the training and assessment of both technical and non-technical skills. Participants assessed the training favourably. All OR teams completed more essentials steps and in less time in ‘warm’ versus ‘cold’ scenarios. Participants reported feeling more comfortable with their role in an OR emergency post-training. Increase in correct responses in the knowledge test after training. Participants assessed the training favourably. All OR teams completed more essentials steps in less time in ‘warm’ versus ‘cold’ scenarios. Improvement in team preparedness, role and procedural awareness and clinical outcomes during actual OR emergencies based on participant’s self-report follow-up survey completed by 81 participants.

†Total number of health professional involved in the simulation. ANTS, anaesthetic non-technical skills for nurses; ICAT-N, Imperial College Assessment of Technical Skills for Nurses; ICEPS, Imperial College Evaluation of Procedure-Specific Skill; NOTECH, non-technical skills; NOTSS, non-technical skills for surgeons; ODP, operating department practitioner; OR, operating room; OSATS, Objective Structured Assessment of Technical Skills; OT, operating theatre.

were conducted using live porcine models.19,20,29,40 Two studies utilized surgical robots.33,36 Only one study described the use of low fidelity equipment to provide a high fidelity learning experience. This study was carried out on a basic cardiopulmonary resuscitation manikin where a malignant hyperthermia scenario was simulated with an esophageal temperature probe placed in warm water, adding hot water to manipulate the temperature.28 Two studies were conducted to evaluate the safety of introducing new technologies into the OT.27,29 This type of multidisciplinary simulation allowed the identification of possible errors or hazards before clinically implementing the new device. One of them facilitated the introduction of a new intraoperative high-dose-rate radiation therapy device, whereby 20 potential defects were identified of which six were concerning teamwork and communication. As a consequence of the simulation session, a checklist was created to prevent potential harm.27 One common point among the groups was the high value given to the debriefing session. Sixteen groups described the use of debriefing after simulation.17,18,21–28,31,33–37,39,41 This was considered as important as the actual simulation.31,37 Several articles described the use of video recordings to facilitate discussion and teaching during the debriefing.17,18,21,23–27,31,33–37,39,41 © 2013 Royal Australasian College of Surgeons

What stressors can be introduced into the simulated training? Crisis situations were described by 19 of 23 programmes.17–28,31–37,39,41,42 The crisis were a medical or surgical situation, such as cardiac arrhythmia, arrest or ischaemia,21–23,25–27,32,35,36,39,42 haemorrhage,17–20,22–24,32,34,35,37,41,42 malignant hyperthermia,28,32 pneumothorax,17,18,25,26 anaphylaxis,25,26,32,42 respiratory distress,17,18,25–27,31,32,34 perforation of gall bladder23 or an external problem, such as failure with laparoscopic equipment22,24,37 and missing instruments.24 Undre et al. described introduction of crises specifically designed to challenge a subteam. Challenges such as unsterile sets for the operating department practitioners (ODPs) and nurses; difficult intubation for the anaesthetic team; intraoperatory haemorrhage for the surgical group and cardiac arrest for the whole team.22 In two studies, the crises were dependent on participants’ responses. They followed a specific algorithm based on the respective institution’s protocols.21,31 In one, the team was challenged with a simulated patient who had a low serum potassium, which resulted in rapid atrial fibrillation after the surgeon began the procedure. If the team did not recognize and correct the low potassium level or treat the atrial fibrillation, the scenario deteriorated into ventricular tachycardia.21


How were participants and multidisciplinary team training assessed? The assessment tools varied across the groups depending on the purpose of the study. Assessments were carried out at different levels of the system, from the individual to the whole surgical team and in relation to technical or non-technical skills. Assessment of technical performance of participants varied from simple measurements of the time to complete a task,24,29,35,44 checklists,22,24,32,37 detailed notes of technical performances22 to the use of robust psychometrically valid tools such as the OSATS (Objective Structured Assessment of Technical Skills).22–24 Non-technical skills assessment was carried out by different tools ranging from direct subjective observation,35 participants perception of the improvement in certain non-technical skills elements21,23–26,35,36 to the use of a valid and reliable tool such as the NOTECHS (non-technical skills)22–24,36 and the NOTSS (non-technical skills for surgeons). Details of these assessment tools are beyond the scope of this review. According to Kirkpatrick’s training evaluation typology, an educational exercise may be assessed at four levels: reaction, learning, behaviour and results/organizational impact.45 All selected studies evaluated the multidisciplinary simulation training at the reaction level by collecting participants’ perception of the training. In general, participants assessed the multidisciplinary team simulation favourably as an educational resource. Trainees reported that the training prompted realistic responses from them17,18,23,24,28,31,32,34,36,40 that they believed it would change their practice17–21,25,26,32,34,35,38,39 and that the multidisciplinary approach added realism.20,26,31,44 Only six studies assessed the training at the learning and behaviour level and no study was designed to demonstrate changes in behaviour in a real OT. Two groups assessed non-technical skills pre- and post-intervention using a valid tool with conflicting results. Patki et al. demonstrated that simulation enhanced all NOTECHS scores in team communication, situation awareness, team skill, leadership and decision making in a simulated environment.36 Koutanji et al. described that there was no significant overall effect of training on non-technical skills. Indeed, training had a differential effect on decision making across professional groups with surgeon’s performance improving and anaesthetist’s deteriorating after simulation training.23 Two studies analysed self-reported perception of nontechnical skills improvement after simulation training. Paige et al. described that participants’ self-reported confidence in performing team-based competencies improved from the first scenario to the second within a module and between modules, which was confirmed by direct observation.25,26 Stevens et al. conducted an interview 6 months after the simulation training and approximately half of the participants gave examples of how they changed their own behaviour directly as a result of the training. The most common examples were being able to speak up more readily, communicating more clearly by addressing team members by names and paying more attention to ‘closing the loop’ in verbal communication.35 Acero et al. reported improvement in participants’ knowledge, measured by a procedural based pre- and post-intervention questionnaire, and in team performance. This author conducted two simulation sessions of a repeated scenario and observed participants improvement in the number of mitigating steps necessary for the procedure, including identifying a team leader.41,42 Furthermore, the authors describe improvement in

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team preparedness, role and procedural awareness and clinical outcomes during actual OT emergencies based on a participants selfreported survey delivered up to 20 months post-training.42 With regards to organizational impact, none of the studies was designed to measure the benefit of multidisciplinary team training in terms of patient’s outcomes. Mehta et al.34 described reduction in airway-related mortality during the study period suggesting a possible impact of the training programme. Hansen et al.19,20 conducted a phone survey with medical directors or attending surgeons at participating hospitals 6 months after the trauma course that used simulation and found that 17 out of 18 institutions reported modifying their trauma protocols as a result of their teams’ participation in the course. The most common change reported was standardization of surgical instrument trays for damage control procedures.

Discussion Simulation is playing an increasingly important role in surgical training programmes around the world. It has been used successfully for training technical skills and recent studies have shown that this form of training can also be used for training team dynamics and non-technical skills.10–12 Multidisciplinary OT team training using high-fidelity simulation was first attempted in 1990s at the University of Basel as the Team Oriented Medical Simulation (TOMS) programme in collaboration with the University of Texas.17,18,46 Following on this programme, OT team simulation has been used to provide training in technical and non-technical skills and to identify latent weaknesses within a health system. It has also been used to identify errors during the implementation of new techniques and technologies so that they can be prevented. The current state of multidisciplinary team training for surgery is still in its infancy but the number of publications in the last few years has increased significantly. Multidisciplinary team simulation can take place in a simulation centre, at the point of care or even off-site and may employ high- or low-fidelity equipment in an attempt to recreate the theatre atmosphere in which training is more likely to be transferable to a clinical setting.47 It is not clear to what extent the use of sophisticated equipment and in situ simulation add to realism and if the additional realism improves outcomes. The sole manuscript included in this review that reported the use of low-fidelity equipment described it reached high level of psychological fidelity, as the participants considered the experience similar to a real perioperative crisis. In choosing the equipment fidelity for a simulation, it is important to consider the purpose and aims of the simulation activity, the unit of participation, the experience level of simulation participants and the type of knowledge, skills and attitudes addressed in simulation, as participants may perceive the simulation differently depending on their personal experience. Powers et al.24 reports that the mean scores for face validity of the scenario (laparoscopic cholecystectomy) was lower for expert surgeons, intermediate for novice surgeons and higher for nurses. The nurses scored the realism of the abdominal model significantly higher than surgeons, and the author speculates this happened because of the less direct contact nurses have with the abdomen in real life. Furthermore, different training goal may require different equipment.47 For instance, if the primary © 2013 Royal Australasian College of Surgeons

Multidisciplinary team simulation

goal of the simulation is to provide initial training in team dynamics and communication, a simpler model may be suitable. On the other hand, if the training aims for full mission simulation, in which technical and non-technical skills of different groups will be assessed, more sophisticated equipment may be required. Most important is to design sound scenarios with appropriate crises capable of temporarily suspending participant disbelief and ensuring they behave in simulation as they would in real life. One common point among the groups is the high value given to the debriefing session, which may be facilitated by video recordings of the simulation session. A structured debriefing gives trainees the opportunity to analyse and reflect on their performance, receive feedback and discuss what happened, hence resulting in higher levels of retention.31 Most of the groups used video recording systems to facilitate the debriefing. Research from different areas of health care has shown that feedback is the single most important feature of simulation-based medical education towards the goal of effective learning and that it is effective regardless of the format.48 A comparative study in anaesthesia crisis management simulation demonstrated that the addition of video review did not offer any advantage over oral feedback alone.49 A key limitation of this review is that all selected manuscripts represent studies with a low level of evidence. They are descriptions of training programmes or case-series, either post-test or pre-test/ post-test, where the groups shared the experiences they had with multidisciplinary team simulation for the OT. No randomized controlled trial or cohort study was found. Only two manuscripts used a validated tool to measure the ability of participants to learn and retain the non-technical skills elements in the simulation environment.23,36 The majority of studies were limited to the measurement of trainees’ impressions and reactions to the training programme. Although positive feedback from the trainees and empowerment of the simulation participant is important, reactions to training have demonstrated relatively weak relationships to learning and transfer of learned knowledge, skills and attitude to the daily work environment.50 None of the selected studies was designed to demonstrate any direct and objective link between multidisciplinary team training and patient outcomes. This review shows that multidisciplinary team training for surgery is feasible, well received by the participants and should be tailored to conditions and experiences within organizations.51

Conclusion This study revealed a range of characteristics of team simulators designed by different institutions around the world. Although still at its infancy, surgical team simulations is feasible and have received largely positive reactions from participants and some have reported changes to their behaviour and interaction within a team environment from this form of learning. Whether this change translates to actual practice is largely unknown at this stage and what effect it has on patient outcome is ultimately the question to be answered. Therefore, we suggest that future research should approach multidisciplinary team simulation for OT in a more standardized and scientific manner, seeking to measure the impact of this training on actual operative performance.

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Multidisciplinary team simulation for the operating theatre: a review of the literature.

Analyses of adverse events inside the operating theatre has demonstrated that many errors are caused by failure in non-technical skills and teamwork. ...
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