The operating room (OR) has a unique set of team dynamics,

Transcription

1 ORIGINAL ARTICLES Teamwork and Error in the Operating Room Analysis of Skills and Roles K. Catchpole, PhD, A. Mishra, MRCS, A. Handa, FRCS, and P. McCulloch, FRCS AQ:3 Objective: To analyze the effects of surgical, anesthetic, and nursing teamwork skills on technical outcomes. Summary Background Data: The value of team skills in reducing adverse events in the operating room is presently receiving considerable attention. Current work has not yet identified in detail how the teamwork and communication skills of surgeons, anesthetists, and nurses affect the course of an operation. Methods: Twenty-six laparoscopic cholecystectomies and 22 carotid endarterectomies were studied using direct observation methods. For each operation, teams skills were scored for the whole team, and for nursing, surgical, and anesthetic subteams on 4 dimensions (leadership and management LM ; teamwork and cooperation; problem solving and decision making; and situation awareness). Operating time, errors in surgical technique, and other procedural problems and errors were measured as outcome parameters for each operation. The relationships between teamwork scores and these outcome parameters within each operation were examined using analysis of variance and linear regression. Results: Surgical (F(2,42) 3.32, P 0.046) and anesthetic (F(2,42) 3.26, P 0.048) LM had significant but opposite relationships with operating time in each operation: operating time increased significantly with higher anesthetic but decreased with higher surgical LM scores. Errors in surgical technique had a strong association with surgical situation awareness (F(2,42) 7.93, P 0.001) in each operation. Other procedural problems and errors were related to the intraoperative LM skills of the nurses (F(5,1) 3.96, P 0.027). Conclusions: Detailed analysis of team interactions and dimensions is feasible and valuable, yielding important insights into relationships between nontechnical skills, technical performance, and operative duration. These results support the concept that interventions designed to improve teamwork and communication may have beneficial effects on technical performance and patient outcome. (Ann Surg 2008;247: ) From the Nuffield Department of Surgery, University of Oxford, Oxford, United Kingdom. This study forms part of a program of work generously supported by the BUPA Foundation. Reprints: Ken Catchpole, PhD, Nuffield Department of Surgery, The John Radcliffe, Headington, Oxford, OX3 9DU, UK. ken.catchpole@ nds.ox.ac.uk. Copyright 2008 by Lippincott Williams & Wilkins ISSN: /08/ DOI: /SLA.0b013e ec8 The operating room (OR) has a unique set of team dynamics, as professionals from multiple disciplines, whose training and goals differ widely, are required to work in a closely coordinated fashion. However, this complex environment provides multiple opportunities for unclear communication, clashing motivations, and errors arising not from technical incompetence but from poor interpersonal skills. 1 Indeed, the OR is the most common site in hospitals for adverse events to occur, 2 between 47.7% 3 and 50.3% 4 of adverse events affecting surgical patients. At least half of these events may be preventable, 5,6 for example through corrective feedback, 7 error recovery, 8 and better team skills. 9 Teamwork and communication deficiencies have been demonstrated in trauma care, 10,11 in intensive care, 12 and in the OR. 1,13,14 The study of teamwork in medicine is a relatively new discipline and has been informed by adapting existing tools from the aviation industry, where efforts have been made to understand the role of particular skills (such as coordination, communication, leadership, situation awareness SA, conflict resolution, planning, and vigilance) in preventing serious adverse incidents. 17 Previous studies have allowed assessment of the associations between team skills and error rates, both in the surgical operative field and more widely within the OR team These studies showed that better teamwork is associated with fewer errors, 18,21 and noted that some skills, such as the ability of the surgeon to observe, understand, and predict events in the OR described as SA appear closely related to technical error rates. 21 This suggested that other aspects of teamwork performance may also have specific effects on the course of an operation and that these may differ, depending on roles in the OR team. The separate influences of surgical, anesthetic, and nursing team skills on overall intraoperative performance have not been examined previously. We suspected that simple scoring of the whole team might conceal important effects related to the impact of specific aspects of teamwork and to specific subteam behavior, whereas focusing on only 1 subteam was not representative of the process as a whole. In this study, therefore, we adapted methods used previously for measuring teamwork and performance in the OR to understand the contributions that surgical, anesthetic, and nursing subteams made to the course of an operation. METHODS We directly observed team performance, errors in surgical technique, and other procedural problems and errors, Annals of Surgery Volume 247, Number 4, April The effect of surgeons, anesthetists, and nurses teamwork skills on operative duration and errors was explored. Surgical and anesthetist leadership influences operating time; surgical awareness influences surgical errors; and nursing leadership influences errors outside the operative field. Training in these areas may result in performance improvements.

2 Catchpole et al Annals of Surgery Volume 247, Number 4, April 2008 AQ: 1 F1 using methodologies developed and described in detail in previous studies. 19,21 Data were collected as contemporaneous freeform notes, which were subsequently transcribed and evaluated. Operating time was recorded as the time the patient entered the OR until the time they were transferred from the operating table. Laparoscopic cholecystectomy and carotid endarterectomy were selected for observation in a single UK hospital system because the operations are common enough to allow data collection on frequent occasions, are moderately complex, have recognizable complications that can be monitored, and all involve surgeons, nurses, and anesthetists. Each OR team studied was derived from a pool of 54 participants, all of whom were appropriately informed and gave their consent to participate. Team Performance The Oxford NOTECHS scoring system was adapted from a similar tool in aviation and had previously been used to score OR teams. 18,19,21 NOTECHS classifies team skills into 4 dimensions: 1) leadership and management (LM), 2) teamwork and cooperation, 3) problem solving and decision making, and 4) SA. A score of between 1 and 4 is given for each dimension by semiobjective assessment of overall performance, using specific behavioral markers, with the score anchored to 1 of 4 categories (below standard 1 ; basic standard 2 ; standard 3 ; exceed 4 ). 21 The scale can be found in Figure 1. The principal observer (A.M.) was a research fellow with surgical experience, and basic observational and NOTECHS skills training. Reliability of the NO- TECHS observations was formally assessed by parallel independent scoring of an opportunity sample of cases by a human factors expert (K.C.) with no formal healthcare training but with extensive previous experience of observing in the OR using the NOTECHS system In the Oxford NOTECHS method, each of the 3 subteams (surgeons, anesthetists, and nurses) was scored on each dimension for every operation. Overall subteam performance was taken as the sum of the dimension performances (out of 16). The overall team performance was calculated from the sum of the overall subteam performance scores (out of 48). Each overall team NOTECHS dimension was scored as the sum of all the subteam performances in that dimension (out of 12). Thus, a team score was obtained in each dimension for the OR team as a whole and for each subteam of surgeons, anesthetists, and nurses. A high NOTECHS score reflects good communication, mutual support, coaching, pitfall discussion, goal setting, critical stage discussion, and an ability to recognize current and predict future surgical requirements or actions. Errors in Surgical Technique Technical performance within the operative field was assessed using the observation clinical human reliability assessment technique, which was first developed for analysis of technical errors during laparoscopic cholecsytectomy. 22,23 For laparoscopic cholecystectomy, a total of 37 key tasks were defined that were either marked as correctly performed, or as an error in surgical technique. For carotid endarterectomy, a total of 56 key tasks were defined. The total number of errors in surgical technique was then calculated for each operation. Other Procedural Problems and Errors Errors and problems outside the operative field, although potentially important to outcome, were considered to be qualitatively different from errors in surgical technique, and were measured separately. The range of possible events that needs to be captured in this category is wide, encompassing, for example, dropping a sterile piece of specialist equipment, forgetting to connect equipment power leads, or administering the wrong drug. A taxonomy, developed in previous work 19,20 and summarized in Table 1, was used to categorize and record these events. This built on previous attempts to distinguish surgical technique errors from other problems. 19 In the present study, we did not differentiate between procedural problems according to their consequences; nor did we differentiate between human errors or performance-shaping problems that came from other sources. This ensured that as much as possible of the context in which behaviors were observed was captured without discarding small but potentially consequential events. Adverse Events and Near Misses We prespecified that any intraoperative events causing harm to patients, any staff injury, and any events with obvious potential for these outcomes would be separately reported, with a brief anonymized account of the circumstances including explicit descriptions of relevant technical and team performance factors. Analysis Relationships among team performance, technical performance, and outcome were explored by analyses of the association between NOTECHS scores and the outcome measures (errors in surgical technique; other procedural problems and errors; and operating time). Team performance was analyzed as a team total (1 score), as a subteam score (3 scores), as a dimensional score (4 scores), and as individual subteam dimension score (12 scores). Analysis of variance (ANOVA) and regression models were used to assess the impact of these scores on each of the outcome measures. RESULTS Overall Results A total of 26 laparoscopic cholecystectomy and 22 carotid endarterectomy operations were studied. The mean number of errors in surgical technique per operation was 1.73 (95% confidence interval CI 0.42) and was significantly higher (t 5.71, df 46, P 0.001) for laparoscopic cholecystectomy (mean 2.62, 95% CI 0.55) than for carotid endarterectomy (mean 0.68, 95% CI 0.38). The mean number of other procedural problems and errors was 8.48 (95% CI 1.19), and these were significantly more common (t 2.25, df 46, P 0.029) during carotid endarterectomy (mean 9.91, 95% CI 1.69) than during laparoscopic cholecystectomy (mean 7.27, 95% CI 1.55). The mean operating time for laparoscopic cholecystectomy was 75.4 minutes (95% CI 6.47), and for carotid endarterectomy was minute (95% CI 11.10), which was again a significant difference (t 9.07, df 46, P 0.001). T Lippincott Williams & Wilkins

3 Annals of Surgery Volume 247, Number 4, April 2008 Teamwork and Error in the Operating Room FIGURE 1. Surgical NOTECHS measurement framework. The mean NOTECHS score for all operations was 36.9 (95% CI 1.24). Mean for laparoscopic cholecystectomy was 35.5 (95% CI 1.88), and for carotid endarterectomy was 38.7 (95% CI 1.23). Teamwork during laparoscopic cholecystectomy was more commonly scored as basic, accounting for the significant difference between NOTECHS scores for the 2 operations (t 2.87, df 46, P 0.006). The surgical subteams scored significantly higher than the other 2 subteams (surgeons vs. anesthetists, t 4.79, df 94, P 0.001; surgeons vs. nurses, t 4.24, df 94, P 0.001). The Influence of Teamwork on the Operation We explored the effects of subteam/subscale combinations on operating time, errors in surgical technique, and other procedural problems and errors, using 2-way ANOVA tests, which also examined the effect of operative type. We 2008 Lippincott Williams & Wilkins 3

4 Catchpole et al Annals of Surgery Volume 247, Number 4, April 2008 found that errors in surgical technique had a strong association with surgical SA (F(2,42) 7.93, P 0.001) and with operative type (F(1,42) 35.76, P 0.001) with an interaction (F(2,42) 6.17, P 0.004). Operating time was significantly affected by surgical LM (F(2,42) 3.32, P 0.046), with a significant effect of operative type (F(2,42) 66.44, P 0.001). Operating time was also affected by a significant interaction between operative type and anesthetic LM (F(2,42) 3.26, P 0.048), suggesting that time was affected by the anesthetist in carotid endarterectomy only. Other procedural problems and errors were affected by the LM scores of the nurses (F(5,1) 3.96, P 0.027). TABLE 1. Categories of Other Procedural Problems and Errors Absence Coordination/communication problem Distraction Equipment/workspace management problem Equipment operation problem Equipment problem Expertise/skill problem External resource problem Patient-sourced procedural difficulties Planning problem Procedure-related error Nonoperative psychomotor error Resource management problem Safety consciousness problem Vigilance/awareness problem Models of Team Performance We developed multivariate regression models by including those parameters found in the ANOVAs to be of significance. The models for operating time, errors in surgical technique, and other procedural problems and errors can be found in Table 2. The duration model (Fig. 2) suggested that improvement in surgical LM was associated with a reduction in operating time of approximately 11 minutes. Higher anesthetic LM was associated with a duration increase of 19 minutes, but this effect was found only in carotid endarterectomy. Good surgical SA resulted in less errors in surgical technique, although this association appears to be stronger in laparoscopic cholecystectomy than in carotid endarterectomy (Fig. 3). Good nursing LM was important for avoiding other procedural problems and errors, but was of less importance in carotid endarterectomy (Fig. 4), where the model was of low predictive value. Adverse Events and Near Misses One near-miss incident was observed: an intraoperative drug administration error during a carotid endarterectomy. It is necessary to intravenously infuse heparin to reduce the risk of emboli at the site of the arterial cross-clamp, and in this case, the consultant anesthetist prepared a number of syringes, including the heparin infusion and placed them on the anesthetic workstation. However, when the surgeon asked for the heparin to be given, the consultant anesthetist was absent from the OR. The anesthetic registrar selected a syringe, administered the contents, and confirmed to the surgeon that heparin had been given. Upon returning to the OR, the consultant anesthetist realized that the heparin had not been given, and that a saline solution had been infused. Heparin was then given within 3 minutes of the erroneous infusion, T2,F2 F3 F4 TABLE 2. Operating Time Linear Regression Models Constant Surgical Leadership and Management Anaesthetic Leadership and Management in Carotid Endarterectomy Contribution to Outcome Gradient % Beta N/A P Errors in Surgical Technique Constant Carotid Endarterectomy Surgical Situation Awareness Surgical Situation Awareness in Carotid Endarterectomy Contribution to Outcome Gradient % Beta N/A P Other Procedural Problems and Errors Constant Nursing Leadership and Management Nursing Leadership and Management in Carotid Endarterectomy Contribution to Outcome Gradient % Beta N/A P Lippincott Williams & Wilkins

5 Annals of Surgery Volume 247, Number 4, April 2008 Teamwork and Error in the Operating Room FIGURE 2. Effects of leadership and management of surgical (top panel) and anesthetic (bottom panel) subteams on operating time. As surgical leadership and management improves, operating time reduces in both types of operation; as anesthetic leadership and management improves, operating time increases in carotid endarterectomy only Lippincott Williams & Wilkins 5

6 Catchpole et al Annals of Surgery Volume 247, Number 4, April 2008 FIGURE 3. Effect of surgical situation awareness on errors in surgical technique. As surgical situation awareness increases, surgical errors decrease. Although still significant, the effect is considerably less marked in carotid endarterectomy. before the cross-clamp was applied, and the operation proceeded as normal without harm to the patient. The error illustrated a lapse in both teamwork and communication and situational awareness, and the successful recovery showed the value of good LM skills. This illustrates the importance of team skills in avoiding and capturing errors before they can affect the patient. DISCUSSION This study concurs with previous reports in showing that levels of team skills in OR teams correlate with the frequency of technical errors and problems occurring during operations. 19,20 Our analysis demonstrated details of this relationship that may help in defining the nature of generic problems in OR teamwork and point to appropriate remedial action. Operating time was reduced by better LM by the surgeon but was increased in carotid endarterectomy by better LM by the anesthetist. A low rate of errors in surgical technique was associated with higher situational awareness among surgeons, that is, the ability to notice what was happening, understand the implications, and think ahead. Low rates of other procedural problems and errors were related to better LM by the nurses. The method adopted for describing errors and problems in the OR, which had previously proven useful in studies of cardiac and orthopaedic surgery, highlighted the fact that errors outside the operative field are 2 to 3 times more common than errors in surgical technique. Studies of safety and error in other fields of work 6 suggest that attention to these incidents, many apparently trivial, may be important in reducing the risk of catastrophic error because small things matter 24 ; they should therefore be recorded accurately and completely. The strong influence of surgical situational awareness on errors in surgical technique accords with expectation. Lower SA was more strongly related to errors in laparoscopic cholecystectomy than in carotid endarterectomy, presumably due to the higher cognitive and psychomotor demands of laparoscopy (eg, restricted vision, access, etc). The finding that nursing LM was the main influence on the rate of other procedural problems and errors would also accord with expectation. The smaller benefit of effective nursing LM found in carotid endarterectomy was presumably because these operations, which rely more on the traditional scalpel-andsuture skills, place less importance on the availability and appropriate preparation of specialized equipment (eg, configuration of camera and monitoring equipment, predicting choice of instrument for insertion, availability of laparotomy tray). Indeed, in some laparoscopic operations where the surgeon did not have an assistant, the scrub nurse took over some of the surgical roles (such as holding the camera), placing further demands on the nurses leadership abilities. The effect of anesthetic LM on operating time is particularly interesting. Operations lasted significantly longer when this score was high, but this effect was entirely due to observations of carotid endarterectomy procedures. These operations require considerably more leadership from the 2008 Lippincott Williams & Wilkins

7 Annals of Surgery Volume 247, Number 4, April 2008 Teamwork and Error in the Operating Room FIGURE 4. Effect of nursing leadership and management on other procedural problems and errors. As nursing leadership and management increases, other procedural problems and errors decrease, although there may be considerable variation unaccounted for by this model. anesthetist than laparoscopic cholecystectomy, particularly in coordinating heparin, sedation, and cognitive function tests. This relationship may therefore reflect the importance of anesthetic leadership in the maintenance of quality and safety (for example, by ensuring a thorough cognitive function test) in more difficult carotid endarterectomy operations. The reverse effect with surgical leadership where higher leadership scores result in shorter operating times suggests that the natural tradeoff between the speed and safety of an operation may sometimes lead to conflict. Alternatively, it is possible that increased LM from the anesthetist was particularly required in more difficult operations. Both possibilities reinforce the view that a vital component of maintaining effective teamwork is ensuring all team members have shared goals rather than independent aims and functioning, especially in more challenging situations. 25 The Oxford NOTECHS scale has been used effectively in several types of operations and as a measure of team skills, the validity and reliability appear to be satisfactory 21 and is similar in content and application to tools adopted by other groups studying and training in OR safety worldwide. 15,26 These other tools may be more ideally suited as individual training aids, whereas the present scale could be particularly useful in hospitals for ongoing maintenance of teamwork standards in the OR because it was developed primarily as a quantitative measurement instrument and has now been used in orthopedic, cardiac, vascular, and gastrointestinal surgery. As our understanding of the complex relationship between teamwork and quality of care improves, further development of the Oxford NOTECHS scale might allow the weighting of subteams to more accurately reflect the contribution of each, where currently all are considered equally. To our knowledge, this study provides the first evidence that this might be possible, so we would welcome further use of these methods by other researchers. Our study was observational, not interventional, and the relationships described between team skills, error, and operating time should therefore be interpreted carefully. The importance of the findings is in their congruence with the conceptual model of teamwork and error on which our studies (and most others in this area) are based. In this model, surgical performance is strongly influenced by team skills, and the direct involvement of surgeons, anesthetists, and nurses in specific activities determines the extent to which their team skills influence those outcomes. Conducting this systematic analysis provided a stronger basis for these assumptions, and the fact that the observed associations generally fitted the predictions of this model so well enhances confidence in it. Team composition varied considerably during the study, making it unlikely that individual performance caused bias, and emphasizing the systemic nature of the model. The results further illustrate the importance of devel Lippincott Williams & Wilkins 7

8 Catchpole et al Annals of Surgery Volume 247, Number 4, April 2008 oping a generic set of skills to enhance teamwork and communication between team members unfamiliar with one another. The additional value in identifying the associations in the present study was to develop hypotheses that can be tested in interventional studies during which attempts to improve team skills will be made. Such interventions could include aviation-style team training programs, 27 briefing, 28 and debriefing, 29 all of which have been suggested as mechanisms by which teamwork can be encouraged and quality of care improved. 14 The relationship between intraoperative performance, the behavior of operating teams, patient safety, and the system of surgery is complex. 30 This study shows that examination of team skills of OR staff at a detailed level can be valuable in uncovering specific interactions between team and technical performance. It provides evidence that mishaps and errors outside the operative field are more common than those inside it, and that improved team skills are associated with speedier completion of operations. It provides evidence that the 3 subteams within the OR (surgeons, anesthetists, and nurses) exhibit different patterns and levels of team skills. These observations are relevant to the design of interventions to improve team skills in the OR and particularly to the models used to predict the effect of such improvement on patient safety. ACKNOWLEDGMENTS The authors thank all the surgeons, nurses, anesthetists, other staff, and patients who participated in this study for allowing us to observe their work, and the management of the Oxford Radcliffe Hospitals Trust for permission to conduct it. The authors also thank Captains Guy Hirst and Trevor Dale, of Atrainability Ltd, who helped to train the observers and provided invaluable insights from their aviation experience, and also Professor Jonathan Meakins, Nuffield Department of Surgery, for his helpful comments on earlier drafts. REFERENCES 1. Lingard L, Reznick R, Espin S, et al. Team communications in the operating room: talk patterns, sites of tension, and implications for novices. Acad Med. 2002;77: Leape LL. Error in medicine. JAMA. 1994;272: Brennan TA, Leape LL. Adverse events, negligence in hospitalized patients: results from the Harvard Medical Practice Study. Perspect Healthc Risk Manage. 1991;11: Wilson RM, Runciman WB, Gibberd RW, et al. The quality in Australian Health Care Study. Med J Aust. 1995;163: Healey MA, Shackford SR, Osler TM, et al. Complications in surgical patients. Arch Surg. 2002;137: Macarthur DC, Nixon SJ, Aitken RJ. Avoidable deaths still occur after large bowel surgery. Scottish Audit of Surgical Mortality, Royal College of Surgeons of Edinburgh. Br J Surg. 1998;85: Way LW, Stewart L, Gantert W, et al. Causes and prevention of laparoscopic bile duct injuries: analysis of 252 cases from a human factors and cognitive psychology perspective. Ann Surg. 2003;237: de Leval MR, Carthey J, Wright DJ, et al. Human factors and cardiac surgery: a multicenter study. J Thorac Cardiovasc Surg. 2000;119: Helmreich RL, Schaefer H-G. Team performance in the operating room. In: Bogner MS, ed. Human Error in Medicine. Hillsdale, NJ: Laurence Erlbaum Associates; 1994: Michaelson M, Levi L. Videotaping in the admitting area: a most useful tool for quality improvement of the trauma care. Eur J Emerg Med. 1997;4: Santora TA, Trooskin SZ, Blank CA, et al. Video assessment of trauma response: adherence to ATLS protocols. Am J Emerg Med. 1996;14: Howard SK, Gaba DM, Fish KJ, et al. Anesthesia crisis resource management training: teaching anesthesiologists to handle critical incidents. Aviat Space Environ Med. 1992;63: Christian CK, Gustafson ML, Roth EM, et al. A prospective study of patient safety in the operating room. Surgery. 2006;139: Sexton JB, Thomas EJ, Helmreich RL. Error, stress and teamwork in medicine and aviation: cross sectional surveys. BMJ. 2000;320: Fletcher GCL, Flin RH, Glavin RJ, et al. Anaesthetists Non-Technical Skills (ANTS): evaluation of a behavioural marker system. Br J Anaesth. 2003;90: Guerlain S, Adams RB, Turrentine FB, et al. Assessing team performance in the operating room: development and use of a black-box recorder and other tools for the intraoperative environment. J Am Coll Surg. 2005;200: Helmreich RL. On error management: lessons from aviation. BMJ. 2000;320: Catchpole K, Godden PJ, Giddings AEB, et al. Identifying and reducing errors in the operating theatre. PS Patient Safety Research Programme. Available at: publications.htm. 19. Catchpole K, Giddings AE, Wilkinson M, et al. Improving patient safety by identifying latent failures in successful operations. Surgery. 2007; 142: Catchpole KR, Giddings AE, de Leval MR, et al. Identification of systems failures in successful paediatric cardiac surgery. Ergonomics. 2006;49: Mishra A, Catchpole K, Dale T, et al. The influence of non-technical performance on technical outcome in laparoscopic cholecystectomy. Surg Endosc. 2008;22: Tang B, Hanna GB, Joice P, et al. Identification and categorization of technical errors by observational clinical human reliability assessment (OCHRA) during laparoscopic cholecystectomy. Arch Surg. 2004;139: Joice P, Hanna GB, Cuschieri A. Errors enacted during endoscopic surgery a human reliability analysis. Appl Ergon. 1998;29: Woods D, Patterson E. How unexpected events produce an escalation of cognitive and coordinative demands. In: Hancock PA, Desmond PA, eds. Stress Workload and Fatigue. Hillsdale, NJ: Lawrence Erlbaum; 2004: Undre S, Sevdalis N, Healey AN, et al. Teamwork in the operating theatre: cohesion or confusion? J Eval Clin Pract. 2006;12: Yule S, Flin R, Paterson-Brown S, et al. Development of a rating system for surgeons non-technical skills. Med Educ. 2006;40: Hamman WR. The complexity of team training: what we have learned from aviation and its applications to medicine. Qual Saf Health Care. 2004;13(suppl 1):i72 i Lingard L, Espin S, Rubin B, et al. Getting teams to talk: development and pilot implementation of a checklist to promote interprofessional communication in the OR. Qual Saf Health Care. 2005;14: Wilshaw G, Bohannon N. Reflective practice and team teaching in mental health care. Nurs Stand. 2003;17: Calland JF, Guerlain S, Adams RB, et al. A systems approach to surgical safety. Surg Endosc. 2002;16: AQ: Lippincott Williams & Wilkins

9 JOBNAME: AUTHOR QUERIES PAGE: 1 SESS: 1 OUTPUT: Fri Feb 1 04:50: /balt6/z7c aos/z7c aos/z7c00408/z7c z AUTHOR QUERIES AUTHOR PLEASE ANSWER ALL QUERIES 1 AQ3 Please spell out BUPA. AQ1 Kindly define NOTECHS. AQ2 Kindly check whether the information added to reference 21 by the copyeditor is accurate.