> Patient Safety > Helsinki Declaration on Patient Safety in Anaesthesiology > EJA article: 10 Years of the Helsinki Declaration > References
  1. Mellin-Olsen J, Staender S, Whitaker DK, et al. The Helsinki declaration on patient safety in anaesthesiology. Eur J Anaesthesiol2010; 27:592–597.

Cited Here |View Full Text | PubMed | CrossRef

  1. Bainbridge D, Martin J, Arango M, et al. Group E-bP-oCOR. Perioperative and anaesthetic-related mortality in developed and developing countries: a systematic review and meta-analysis. Lancet2012; 380:1075–1081.

Cited Here |PubMed | CrossRef

  1. Cooper JB, Newbower RS, Long CD, et al. Preventable anesthesia mishaps: a study of human factors. Anesthesiology 1978; 49:399–406.

Cited Here |View Full Text | PubMed | CrossRef

  1. Gaba DM, Maxwell M, DeAnda A. Anesthetic mishaps: breaking the chain of accident evolution. Anesthesiology1987; 66:670–676.

Cited Here |View Full Text | PubMed | CrossRef

  1. Eichhorn JH. History of anesthesia patient safety. Int Anesthesiol Clin2018; 56:65–93.

Cited Here |View Full Text | PubMed | CrossRef

  1. Li G, Warner M, Lang BH, et al. Epidemiology of anesthesia-related mortality in the United States, 1999–2005. Anesthesiology2009; 110:759–765.

Cited Here |View Full Text | PubMed | CrossRef

  1. Cooper JB, Gaba D. No myth: anesthesia is a model for addressing patient safety. J Am Soc Anesthesiol2002; 97:1335–1337.

Cited Here

  1. Walker IA, Wilson IH. Anaesthesia in developing countries – a risk for patients. Lancet2008; 371:968–969.

Cited Here |PubMed | CrossRef

  1. Meara JG, Leather AJ, Hagander L, et al. Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet2015; 386:569–624.

Cited Here |PubMed | CrossRef

  1. Chantler C. The role and education of doctors in the delivery of healthcare. Lancet1999; 353:1178–1181.

Cited Here |View Full Text | PubMed | CrossRef

  1. Weiser TG, Regenbogen SE, Thompson KD, et al. An estimation of the global volume of surgery: a modelling strategy based on available data. Lancet2008; 372:139–144.

Cited Here |PubMed | CrossRef

  1. Mellin-Olsen J, O’sullivan E, Balogh D, et al. Guidelines for safety and quality in anaesthesia practice in the European Union: SECTION and BOARD OF ANAESTHESIOLOGY 1, European Union of Medical Specialists. Eur J Anaesthesiol 2007; 24:479–482.

Cited Here |View Full Text | PubMed | CrossRef

  1. Vimlati L, Gilsanz F, Goldik Z. Quality and safety guidelines of postanaesthesia care: working party on post anaesthesia care (approved by the European board and section of anaesthesiology, Union Européenne des Médecins Spécialistes). Eur J Anaesthesiol2009; 26:715–721.

Cited Here |View Full Text | PubMed | CrossRef

  1. Van Aken H, Staender S, Mellin-Olsen J, et al. Patient safety in anaesthesiology. Best Pract Res Clin Anaesthesiol 2011; 2:277–290.

Cited Here

  1. Sessler DI, Myles P. Novel clinical trial designs to improve the efficiency of research. Anesthesiology2020; 132:69–81.

Cited Here |View Full Text | PubMed | CrossRef

  1. Ovretveit J. The contribution of new social science research to patient safety. Soc Sci Med2009; 69:1780–1783.

Cited Here |PubMed | CrossRef

  1. Wickboldt N, Balzer F, Goncerut J, et al. A survey of standardised drug syringe label use in European anaesthesiology departments. Eur J Anaesthesiol2012; 29:446–451.

Cited Here |View Full Text | PubMed | CrossRef

  1. Balzer F, Spies C, Schaffartzik W, et al. Patient safety in anaesthesia: assessment of status quo in the Berlin-Brandenburg area, Germany. Eur J Anaesthesiol2011; 28:749–752.

Cited Here |View Full Text | PubMed | CrossRef

  1. Wu HH, Lewis SR, Čikkelová M, et al. Patient safety and the role of the Helsinki Declaration on Patient Safety in Anaesthesiology: a European survey. Eur J Anaesthesiol2019; 36:946–954.

Cited Here |View Full Text | PubMed | CrossRef

  1. Newport M, Smith AF, Lewis SR. An arrow pointing somewhere: qualitative study of the Helsinki Declaration on Patient Safety and its role in European anaesthesiology. Eur J Anaesthesiol2020; 37:1–4.

Cited Here |View Full Text | PubMed | CrossRef

  1. Hawe P. Lessons from complex interventions to improve health. Annu Rev Publ Health2015; 36:307–323.

Cited Here |PubMed | CrossRef

  1. Bate P. Context is everything. Perspectives on context2014; London: The Health Foundation, 1–29.

Cited Here

  1. Howarth E, Devers K, Moore G. Raine R, Fitzpatrick R, Barratt H, et al. Contextual issues and qualitative research. NIHR Journals Library, Challenges, solutions and future directions in the evaluation of service innovations in healthcare and public health. Southampton, UK:2016.

Cited Here

  1. Baker GR. The contribution of case study research to knowledge of how to improve quality of care. BMJ Qual Saf2011; 20: (Suppl 1): i30–i35.

Cited Here |PubMed

  1. Rodgers M, Thomas S, Harden M, et al. Developing a methodological framework for organisational case studies: a rapid review and consensus development process. Southampton (UK): NIHR Journals Library; 2016.

Cited Here

  1. Smith AF, Plunkett E. People, systems and safety: resilience and excellence in healthcare practice. Anaesthesia2019; 74:508–517.

Cited Here |View Full Text | PubMed | CrossRef

  1. Braithwaite J, Wears RL, Hollnagel E. Resilient healthcare: turning patient safety on its head. Int J Qual Health Care2015; 27:418–420.

Cited Here |PubMed | CrossRef

  1. Lawton R, Taylor N, Clay-Williams R, et al. Positive deviance: a different approach to achieving patient safety. BMJ Qual Saf2014; 23:880–883.

Cited Here |View Full Text | PubMed | CrossRef

  1. Goodwin D, Pope C, Mort M, et al. Access, boundaries and their effects: legitimate participation in anaesthesia. Sociol Health Illn2005; 27:855–871.

Cited Here |PubMed | CrossRef

  1. Smith AF, Pope C, Goodwin D, et al. Communication between anesthesiologists, patients and the anesthesia team: a descriptive study of induction and emergence. Can J Anaesth2005; 52:915–920.

Cited Here |PubMed | CrossRef

  1. Leslie M, Paradis E, Gropper MA, et al. Applying ethnography to the study of context in healthcare quality and safety. BMJ Qual Saf2014; 23:99–105.

Cited Here |View Full Text | PubMed | CrossRef

  1. Isaacs E. Jordan B. The value of rapid ethnography. Advancing Ethnography in Corporate Environments: Challenges and Emerging Opportunities. Walnut Creek, California: Left Coast Press Ltd; 2013. 92–107.

Cited Here

  1. Sexton JB, Helmreich RL, Neilands TB, et al. The Safety Attitudes Questionnaire: psychometric properties, benchmarking data, and emerging research. BMC Health Serv Res2006; 6:44.

Cited Here |PubMed | CrossRef

  1. Odell DD, Quinn CM, Matulewicz RS, et al. Association between hospital safety culture and surgical outcomes in a statewide surgical quality improvement collaborative. J Am Coll Surg2019; 229:175–183.

Cited Here |PubMed | CrossRef

  1. Jackson J, Sarac C, Flin R. Hospital safety climate surveys: measurement issues. Curr Opin Crit Care2010; 16:632–638.

Cited Here |View Full Text | PubMed | CrossRef

  1. Frankel A, Graydon-Baker E, Neppl C, et al. Patient safety leadership WalkRounds. Jt Comm J Qual Patient Saf2003; 29:16–26.

Cited Here

  1. Morello RT, Lowthian JA, Barker AL, et al. Strategies for improving patient safety culture in hospitals: a systematic review. BMJ Qual Saf2013; 22:11–18.

Cited Here |View Full Text | PubMed | CrossRef

  1. Catchpole K, Neyens DM, Abernathy J, et al. Framework for direct observation of performance and safety in healthcare. BMJ Qual Saf2017; 26:1015–1021.

Cited Here |View Full Text | PubMed | CrossRef

  1. Institute of Health Policy, Management and Evaluation. Beyond the quick fix, strategies for improving patient safety. Canada: University of Toronto; 2015.

Cited Here

  1. Gelb AW, Morriss WW, Johnson W, et al. World Health Organization–World Federation of Societies of Anaesthesiologists (WHO–WFSA) International Standards for a Safe Practice of Anesthesia. Anesth Analg2018; 126:2047–2055.

Cited Here |View Full Text | PubMed | CrossRef

  1. Baron DM, Metnitz PGH, Rhodes A, et al. Clinical guidelines: how can we improve adherence and implementation? Eur J Anaesthesiol2017; 34:329–331.

Cited Here |View Full Text | PubMed | CrossRef

  1. Gilhooly D, Green SA, McCann C, et al. Barriers and facilitators to the successful development, implementation and evaluation of care bundles in acute care in hospital: a scoping review. Implement Sci2019; 14:47–147.

Cited Here

  1. Resar RGF, Haraden C, Nolan TW. Using care bundles to improve healthcare quality. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2012.

Cited Here

  1. Choi SW, Wong GTC. Quality improvement studies – pitfalls of the before and after study design. Anaesthesia2018; 73:1432–1435.

Cited Here |View Full Text | PubMed | CrossRef

  1. Rapport F, Clay-Williams R, Churruca K, et al. The struggle of translating science into action: foundational concepts of implementation science. J Eval Clin Pract2018; 24:117–126.

Cited Here |View Full Text | PubMed | CrossRef

  1. Punjasawadwong Y, Chau-In W, Laopaiboon M, et al. Processed electroencephalogram and evoked potential techniques for amelioration of postoperative delirium and cognitive dysfunction following noncardiac and nonneurosurgical procedures in adults. Cochrane Database Syst Rev2018; 5:CD011283.

Cited Here |PubMed

  1. Punjasawadwong Y, Phongchiewboon A, Bunchungmongkol N. Bispectral index for improving anaesthetic delivery and postoperative recovery. Cochrane Database Syst Rev2014. CD003843.

Cited Here |PubMed

  1. Roth D, Pace NL, Lee A, et al. Airway physical examination tests for detection of difficult airway management in apparently normal adult patients. Cochrane Database Syst Rev2018; 5:CD008874.

Cited Here |PubMed

  1. Lewis SR, Pritchard MW, Schofield-Robinson OJ, et al. Continuation versus discontinuation of antiplatelet therapy for bleeding and ischaemic events in adults undergoing noncardiac surgery. Cochrane Database Syst Rev2018; 7:CD012584.

Cited Here |PubMed

  1. Egholm JW, Pedersen B, Moller AM, et al. Perioperative alcohol cessation intervention for postoperative complications. Cochrane Database Syst Rev2018; 11:CD008343.

Cited Here |PubMed

  1. Doleman B, Leonardi-Bee J, Heinink TP, et al. Preemptive and preventive opioids for postoperative pain in adults undergoing all types of surgery. Cochrane Database Syst Rev2018; 12:CD012624.

Cited Here |PubMed

  1. De Robertis E, Longrois D, Fuchs-Buder T. Safety and quality of procedural sedation and analgesia practice for adult patients throughout Europe: a step forward. Eur J Anaesthesiol2018; 35:1–3.

Cited Here |View Full Text | PubMed | CrossRef

  1. Smith AF, Shelly MP. Communication skills for anesthesiologists. Can J Anaesth1999; 46:1082–1088.

Cited Here |PubMed | CrossRef

  1. MacLennan AI, Smith AF. An analysis of critical incidents relevant to pediatric anesthesia reported to the UK National Reporting and Learning System, 2006–2008. Paediatr Anaesth2011; 21:841–847.

Cited Here |View Full Text | PubMed

  1. Allen D, Braithwaite J, Sandall J, et al. Towards a sociology of healthcare safety and quality. Sociol Health Illn2016; 38:181–197.

Cited Here |View Full Text | PubMed | CrossRef

  1. Montgomery A, Doulougeri K, Panagopoulou E. Implementing action research in hospital settings: a systematic review. J Health Organ Manag2015; 29:729–749.

Cited Here |PubMed | CrossRef

  1. Morton-Cooper A. Action research in healthcare. Oxford: Wiley-Blackwell; 2000.

Cited Here

  1. Smith A. In search of excellence in anesthesiology. Anesthesiology2009; 110:4–5.

Cited Here |View Full Text | PubMed | CrossRef

  1. Cooper JB, Gaba DM, Liang B, et al. The National Patient Safety Foundation agenda for research and development in patient safety. MedGenMed2000; 2:E38.

Cited Here |PubMed

  1. Mackay P. The Australian and New Zealand College of Anaesthetists (ANZCA). Safety of anaesthesia in Australia. College of Anaesthetists, A review of anaesthesia related mortality 1997–1999. Melbourne: Australian and New Zealand:2002.

Cited Here

  1. Lagasse RS. Anesthesia safety: model or myth? A review of the published literature and analysis of current original data. Anesthesiology2002; 97:1609–1617.

Cited Here |View Full Text | PubMed | CrossRef

  1. Arbous MS, Meursing AE, van Kleef JW, et al. Impact of anesthesia management characteristics on severe morbidity and mortality. Anesthesiology2005; 102:257–268. quiz 491–492.

Cited Here |View Full Text | PubMed | CrossRef

  1. Turillazzi E, Bello S, Bonsignore A, et al. Retrospective analysis of anaesthesia-related deaths during a 12-year period: looking at the data from a forensic point of view. Med Sci Law2012; 52:112–115.

Cited Here |PubMed | CrossRef

  1. McGrath BA, Wilkinson K. The NCEPOD study: on the right trach? Lessons for the anaesthetist. Br J Anaesth2015; 115:155–158.

Cited Here |View Full Text | PubMed | CrossRef

  1. Lienhart A, Auroy Y, Pequignot F, et al. Survey of anesthesia-related mortality in France. Anesthesiology2006; 105:1087–1097.

Cited Here |View Full Text | PubMed | CrossRef

  1. Liu TC, Wang JO, Chau SW, et al. Survey of 11-year anesthesia-related mortality and analysis of its associated factors in Taiwan. Acta Anaesthesiol2010; 48:56–61.

Cited Here

  1. Arbous MS, Grobbee DE, van Kleef JW, et al. Mortality associated with anaesthesia: a qualitative analysis to identify risk factors. Anaesthesia2001; 56:1141–1153.

Cited Here |View Full Text | PubMed | CrossRef

  1. McFarlane HJ, van der Horst N, Kerr L, et al. The Scottish Audit of Surgical Mortality: a review of areas of concern related to anaesthesia over 10 years. Anaesthesia2009; 64:1324–1331.

Cited Here |View Full Text | PubMed | CrossRef

  1. Goldman RL. The reliability of peer assessments of quality of care. JAMA1992; 267:958–960.

Cited Here |PubMed | CrossRef

  1. Haller G, Laroche T, Clergue F. Morbidity in anaesthesia: today and tomorrow. Best Pract Res Clin Anaesthesiol2011; 25:123–132.

Cited Here |PubMed | CrossRef

  1. Gibbs NM. Milestones in anaesthesia-related mortality and morbidity reporting in Australia. Anaesth Intensive Care2010; 38:807–808.

Cited Here |PubMed | CrossRef

  1. Kawashima Y, Takahashi S, Suzuki M, et al. Anesthesia-related mortality and morbidity over a 5-year period in 2,363,038 patients in Japan. Acta Anaesthesiol Scand2003; 47:809–817.

Cited Here |View Full Text | PubMed | CrossRef

  1. McNicol L, Mackay P. Anaesthesia-related morbidity in Victoria: a report from 1990 to 2005. Anaesth Intensive Care2010; 38:837–848.

Cited Here |PubMed | CrossRef

  1. Hohn A, Machatschek JN, Franklin J, et al. Incidence and risk factors of anaesthesia-related perioperative cardiac arrest: a 6-year observational study from a tertiary care university hospital. Eur J Anaesthesiol2018; 35:266–272.

Cited Here |View Full Text | PubMed | CrossRef

  1. Nunnally ME, O’Connor MF, Kordylewski H, et al. The incidence and risk factors for perioperative cardiac arrest observed in the national anesthesia clinical outcomes registry. Anesth Analg2015; 120:364–370.

Cited Here |View Full Text | PubMed | CrossRef

  1. Koga FA, El Dib R, Wakasugui W, et al. Anesthesia-related and perioperative cardiac arrest in low- and high-income countries: a systematic review with meta-regression and proportional meta-analysis. Medicine (Baltimore)2015; 94:e1465.

Cited Here |View Full Text | PubMed | CrossRef

  1. Aitkenhead AR. Injuries associated with anaesthesia. A global perspective. Br J Anaesth2005; 95:95–109.

Cited Here |View Full Text | PubMed | CrossRef

  1. Cook TM, Woodall N, Frerk C, et al. Fourth National Audit Project. Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 1: Anaesthesia. Br J Anaesth2011; 106:617–631.

Cited Here |View Full Text | PubMed | CrossRef

  1. Christensen RE, Baekgaard JS, Rasmussen LS. Dental injuries in relation to general anaesthesia – a retrospective study. Acta Anaesthesiol Scand2019; 63:993–1000.

Cited Here |View Full Text | PubMed | CrossRef

  1. Gaudio RM, Feltracco P, Barbieri S, et al. Traumatic dental injuries during anaesthesia: Part I: Clinical evaluation. Dent Traumatol2010; 26:459–465.

Cited Here |View Full Text | PubMed | CrossRef

  1. Bruderer U, Fisler A, Steurer MP, et al. Postdischarge nausea and vomiting after total intravenous anaesthesia and standardised PONV prophylaxis for ambulatory surgery. Acta Anaesthesiol Scand2017; 61:758–766.

Cited Here |View Full Text | PubMed | CrossRef

  1. Odom-Forren J, Jalota L, Moser DK, et al. Incidence and predictors of postdischarge nausea and vomiting in a 7-day population. J Clin Anesth2013; 25:551–559.

Cited Here |PubMed | CrossRef

  1. Chau-in W, Hintong T, Rodanant O, et al. Anesthesia-related complications of caesarean delivery in Thailand: 16,697 cases from the Thai Anaesthesia Incidents Study. J Med Assoc Thai2010; 93:1274–1283.

Cited Here |PubMed

  1. Irita K, Kawashima Y, Iwao Y, et al. Annual mortality and morbidity in operating rooms during 2002 and summary of morbidity and mortality between 1999 and 2002 in Japan: a brief review. Masui2004; 53:320–335.

Cited Here |PubMed

  1. Fasting S, Gisvold SE. Serious intraoperative problems – a five-year review of 83,844 anesthetics. Can J Anaesth2002; 49:545–553.

Cited Here |PubMed | CrossRef

  1. Belcher AW, Leung S, Cohen B, et al. Incidence of complications in the postanesthesia care unit and associated healthcare utilization in patients undergoing noncardiac surgery requiring neuromuscular blockade 2005–2013: a single center study. J Clin Anesth2017; 43:33–38.

Cited Here |PubMed | CrossRef

  1. Marr L, Lennox C, McFadyen AK. Quantifying severe maternal morbidity in Scotland: a continuous audit since 2003. Curr Opin Anaesthesiol2014; 27:275–281.

Cited Here |View Full Text | PubMed | CrossRef

  1. Arendt KW, Segal S. Present and emerging strategies for reducing anesthesia-related maternal morbidity and mortality. Curr Opin Anaesthesiol2009; 22:330–335.

Cited Here |View Full Text | PubMed | CrossRef

  1. Biccard BM, Madiba TE, Kluyts HL, et al. Perioperative patient outcomes in the African Surgical Outcomes Study: a 7-day prospective observational cohort study. Lancet2018; 391:1589–1598.

Cited Here |PubMed | CrossRef

  1. Liu Y, Xiao W, Meng LZ, et al. Geriatric anesthesia-related morbidity and mortality in China: current status and trend. Chin Med J2017; 130:2738–2749.

Cited Here |View Full Text | PubMed | CrossRef

  1. International Surgical Outcomes Study Group. Global patient outcomes after elective surgery: prospective cohort study in 27 low-, middle- and high-income countries. Br J Anaesth2016; 117:601–609.

Cited Here |View Full Text | PubMed | CrossRef

  1. Cheney FW. The American Society of Anesthesiologists Closed Claims Project: what have we learned, how has it affected practice, and how will it affect practice in the future? Anesthesiology1999; 91:552–556.

Cited Here |View Full Text | PubMed | CrossRef

  1. Peterson GN, Domino KB, Caplan RA, et al. Management of the difficult airway: a closed claims analysis. Anesthesiology2005; 103:33–39.

Cited Here |View Full Text | PubMed | CrossRef

  1. Lee LA, Posner KL, Domino KB, et al. Injuries associated with regional anesthesia in the 1980s and 1990s: a closed claims analysis. Anesthesiology2004; 101:143–152.

Cited Here |View Full Text | PubMed | CrossRef

  1. Fitzgibbon DR, Posner KL, Domino KB, et al. Chronic pain management: American Society of Anesthesiologists Closed Claims Project. Anesthesiology2004; 100:98–105.

Cited Here |View Full Text | PubMed | CrossRef

  1. Domino KB, Posner KL, Caplan RA, et al. Awareness during anesthesia: a closed claims analysis. Anesthesiology1999; 90:1053–1061.

Cited Here |View Full Text | PubMed | CrossRef

  1. Domino KB, Posner KL, Caplan RA, et al. Airway injury during anesthesia: a closed claims analysis. Anesthesiology1999; 91:1703–1711.

Cited Here |View Full Text | PubMed | CrossRef

  1. Cheney FW, Domino KB, Caplan RA, et al. Nerve injury associated with anesthesia: a closed claims analysis. Anesthesiology1999; 90:1062–1069.

Cited Here |View Full Text | PubMed | CrossRef

  1. Cheney FW, Posner K, Caplan RA, et al. Standard of care and anesthesia liability. JAMA1989; 261:1599–1603.

Cited Here |PubMed | CrossRef

  1. Staender S, Schaer H, Clergue F, et al. A Swiss anaesthesiology closed claims analysis: report of events in the years 1987–2008. Eur J Anaesthesiol2011; 28:85–91.

Cited Here |View Full Text | PubMed | CrossRef

  1. Metzner J, Posner KL, Lam MS, et al. Closed claims’ analysis. Best Pract Res Clin Anaesthesiol2011; 25:263–276.

Cited Here |PubMed | CrossRef

  1. Fornebo I, Simonsen KA, Bukholm IRK, et al. Claims for compensation after injuries related to airway management: a nationwide study covering 15 years. Acta Anaesthesiol Scand2017; 61:781–789.

Cited Here |View Full Text | PubMed | CrossRef

  1. Schaffartzik W, Hachenberg T, Neu J. Anaesthetic incidents – airway management and injuries in anaesthesia – closed claims of the North German Arbitration Board. Anasthesiol Intensivmed Notfallmed Schmerzther2011; 46:32–37. quiz 38.

Cited Here |PubMed | CrossRef

  1. Ausset S. Toward French a closed claims database? Supplemental data supporting the involvement of anaesthetists in the postoperative period. Anaesth Crit Care Pain Med2016; 35:307–309.

Cited Here |PubMed | CrossRef

  1. Genovese U, Blandino A, Midolo R, et al. Alleged malpractice in anesthesiology: analysis of a series of private insurance claims. Minerva Anestesiol2016; 82:202–209.

Cited Here |PubMed

  1. Runciman WB. Lessons from the Australian Patient Safety Foundation: setting up a national patient safety surveillance system – is this the right model? Qual Saf Healthcare2002; 11:246–251.

Cited Here

  1. Reed S, Arnal D, Frank O, et al. National critical incident reporting systems relevant to anaesthesia: a European survey. Br J Anaesth2014; 112:546–555.

Cited Here |View Full Text | PubMed | CrossRef

  1. Staender S. Incident reporting in anaesthesiology. Best Pract Res Clin Anaesthesiol2011; 25:207–214.

Cited Here |PubMed | CrossRef

  1. Wan S, Siow YN, Lee SM, et al. Audits and critical incident reporting in paediatric anaesthesia: lessons from 75,331 anaesthetics. Singapore Med J2013; 54:69–74.

Cited Here |PubMed | CrossRef

  1. McLoughlin V, Millar J, Mattke S, et al. Selecting indicators for patient safety at the health system level in OECD countries. Int J Qual Healthcare2006; 18: (Suppl 1): 14–20.

Cited Here

  1. Vincent C, Taylor-Adams S, Chapman EJ, et al. How to investigate and analyse clinical incidents: clinical risk unit and association of litigation and risk management protocol. BMJ2000; 320:777–781.

Cited Here |View Full Text | PubMed | CrossRef

  1. Tung A. Sentinel events and how to learn from them. Int Anesthesiol Clin2014; 52:53–68.

Cited Here |View Full Text | PubMed | CrossRef

  1. Runciman W. Qualitative versus quantitative research balancing cost, yield and feasibility. Anaesth Intensive Care1993; 21:502–505.

Cited Here |PubMed | CrossRef

  1. Liamputtong P. Handbook of the arts in qualitative research. Int J Soc Res Method2009; 12:176–179.

Cited Here

  1. Wacker J, Steurer J, Manser T, et al. Perceived barriers to computerised quality documentation during anaesthesia: a survey of anaesthesia staff. BMC Anesthesiol2015; 15:13.

Cited Here |PubMed | CrossRef

  1. Roehr B. US hospital incident reporting systems do not capture most adverse events. BMJ2012; 344:e386.

Cited Here |View Full Text | PubMed | CrossRef

  1. Haller G, Myles PS. Learning from incidents and near-misses reports. Anesthesiology2005; 102:1287.

Cited Here |View Full Text | PubMed | CrossRef

  1. Freestone L, Bolsin SN, Colson M, et al. Voluntary incident reporting by anaesthetic trainees in an Australian hospital. Int J Qual Healthcare2006; 18:452–457.

Cited Here

  1. Haller G, Myles PS, Stoelwinder J, et al. Integrating incident reporting into an electronic patient record system. J Am Med Inform Assn2007; 14:175–181.

Cited Here

  1. Jung JJ, Elfassy J, Juni P, et al. Adverse events in the operating room: definitions, prevalence, and characteristics. A systematic review. World J Surg2019; 43:2379–2392.

Cited Here |PubMed | CrossRef

  1. Michel P, Quenon JL, Djihoud A, et al. French national survey of inpatient adverse events prospectively assessed with ward staff. Qual Saf Healthcare2007; 16:369–377.

Cited Here

  1. Vincent C, Neale G, Woloshynowych M. Adverse events in British hospitals: preliminary retrospective record review. BMJ2001; 322:517–519.

Cited Here |View Full Text | PubMed | CrossRef

  1. Baker GR, Norton PG, Flintoft V, et al. The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada. CMAJ2004; 170:1678–1686.

Cited Here |View Full Text | PubMed | CrossRef

  1. Wilson RM, Runciman WB, Gibberd RW, et al. The quality in Australian healthcare study. Med J Aust1995; 163:458–471.

Cited Here |View Full Text | PubMed | CrossRef

  1. Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. N Engl J Med1991; 324:370–376.

Cited Here |View Full Text | PubMed | CrossRef

  1. Leape LL, Brennan TA, Laird N, et al. The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II. N Engl J Med1991; 324:377–384.

Cited Here |View Full Text | PubMed | CrossRef

  1. Halfon P, Staines A, Burnand B. Adverse events related to hospital care: a retrospective medical records review in a Swiss hospital. Int J Qual Healthcare2017; 29:527–533.

Cited Here

  1. Rutberg H, Borgstedt Risberg M, Sjodahl R, et al. Characterisations of adverse events detected in a university hospital: a 4-year study using the Global Trigger Tool method. BMJ Open2014; 4:e004879.

Cited Here

  1. Rogne T, Nordseth T, Marhaug G, et al. Rate of avoidable deaths in a Norwegian hospital trust as judged by retrospective chart review. BMJ Qual Saf2019; 28:49–55.

Cited Here |View Full Text | PubMed | CrossRef

  1. Neale G, Woloshynowych M, Vincent C. Exploring the causes of adverse events in NHS hospital practice. J R Soc Med2001; 94:322–330.

Cited Here |View Full Text | PubMed | CrossRef

  1. Gabel RA. Evolution of joint commission anesthesia clinical indicators. Am Soc Anesthesiol Newsl1994; 58:24–29.

Cited Here

  1. Haller G, Myles PS, Langley M, et al. Assessment of an unplanned admission to the intensive care unit as a global safety indicator in surgical patients. Anaesth Intensive Care2008; 36:190–200.

Cited Here |PubMed | CrossRef

  1. Haller G, Wolfe MP, Weeks R, et al. Validity of unplanned intensive care unit admission as an indicator of patient safety in surgical patients. Anesthesiology2005; 103:1121–1129.

Cited Here |View Full Text | PubMed | CrossRef

  1. Miller MR, Elixhauser A, Zhan C, et al. Patient safety indicators: using administrative data to identify potential patient safety concerns. Health Serv Res2001; 36:110–132.

Cited Here

  1. US Department of Veterans Affairs- Office of Inspector General – Office of Healthcare Inspections. Evaluation of the Veterans Health Administration’s (VHA’s) Quality Improvement Checklist (QUIC) – report no. 6HI-A28-017; November 3; 2005

Cited Here

  1. Authority H. NH Department of Health and Human ServicesCrown Publication Services, NHS performance indicators. London:2000.

Cited Here

  1. Bahtsevani C, Uden G, Willman A. Outcomes of evidence-based clinical practice guidelines: a systematic review. Int J Technol Assess Healthcare2004; 20:427–433.

Cited Here

  1. Haller G, Stoelwinder J, Myles PS, et al. Quality and safety indicators in anesthesia: a systematic review. Anesthesiology2009; 110:1158–1175.

Cited Here |View Full Text | PubMed | CrossRef

  1. Chazapis M, Gilhooly D, Smith AF, et al. Perioperative structure and process quality and safety indicators: a systematic review. Br J Anaesth2018; 120:51–66.

Cited Here |View Full Text | PubMed | CrossRef

  1. Haller G, Bampoe S, Cook T, et al. Systematic review and consensus definitions for the standardised endpoints in perioperative medicine initiative: clinical indicators. Br J Anaesth2019; 123:228–237.

Cited Here |PubMed | CrossRef

  1. Singh H, Sittig DF. Measuring and improving patient safety through health information technology: the Health IT Safety Framework. BMJ Qual Saf2016; 25:226–232.

Cited Here |View Full Text | PubMed | CrossRef

  1. Stabile M, Cooper L. Review article: the evolving role of information technology in perioperative patient safety. Can J Anaesth2013; 60:119–126.

Cited Here |PubMed | CrossRef

  1. Stockwell DC, Landrigan CP, Schuster MA, et al. Using a pediatric trigger tool to estimate total harm burden hospital-acquired conditions represent. Pediatr Qual Saf2018; 3:e081.

Cited Here

  1. Shepherd D, Friedlin J, Grannis S, et al. A comparison of automated methicillin-resistant Staphylococcus aureusidentification with current infection control practice. AMIA Annu Symp Proc 2009; 2009:594–598.

Cited Here |PubMed

  1. Nair BG, Horibe M, Newman SF, et al. Anesthesia information management system-based near real-time decision support to manage intraoperative hypotension and hypertension. Anesth Analg2014; 118:206–214.

Cited Here |View Full Text | PubMed | CrossRef

  1. Nair BG, Newman SF, Peterson GN, et al. Automated electronic reminders to improve redosing of antibiotics during surgical cases: comparison of two approaches. Surg Infect (Larchmt)2011; 12:57–63.

Cited Here |PubMed | CrossRef

  1. Nair BG, Newman SF, Peterson GN, et al. Smart Anesthesia Manager (SAM) – a real-time decision support system for anesthesia care during surgery. IEEE Trans Biomed Eng2013; 60:207–210.

Cited Here |PubMed | CrossRef

  1. Bates DW, Gawande AA. Improving safety with information technology. N Engl J Med2003; 348:2526–2534.

Cited Here |View Full Text | PubMed | CrossRef

  1. Perrow C. Normal accidents: living with high-risk technologies. New York: Basic Books; 1984.

Cited Here

  1. Reason JT. Managing the risks of organizational accidents. Aldershot: Ashgate; 1997.

Cited Here

  1. Flin R, Fletcher G, McGeorge P, et al. Anaesthetists’ attitudes to teamwork and safety. Anaesthesia2003; 58:233–242.

Cited Here |View Full Text | PubMed | CrossRef

  1. Sorra JS, Dyer N. Multilevel psychometric properties of the AHRQ hospital survey on patient safety culture. BMC Health Serv Res2010; 10:199.

Cited Here |PubMed | CrossRef

  1. Shortell SM, Kaluzny AD. Healthcare management: organization, design, and behavior. Clifton Park, NY: Thomson Delmar Learning; 2006.

Cited Here

  1. Alsalem G, Bowie P, Morrison J. Assessing safety climate in acute hospital settings: a systematic review of the adequacy of the psychometric properties of survey measurement tools. BMC Health Serv Res2018; 18:353.

Cited Here |PubMed | CrossRef

  1. Gaudry S, Messika J, Ricard JD, et al. Patient-important outcomes in randomized controlled trials in critically ill patients: a systematic review. Ann Intensive Care2017; 7:28.

Cited Here

  1. Pino C, Boutron I, Ravaud P. Inadequate description of educational interventions in ongoing randomized controlled trials. Trials2012; 13:63.

Cited Here

  1. Wittes J, Lakatos E, Probstfield J. Surrogate endpoints in clinical trials: cardiovascular diseases. Stat Med1989; 8:415–425.

Cited Here |PubMed | CrossRef

  1. Myles PS, Boney O, Botti M, et al. Systematic review and consensus definitions for the Standardised Endpoints in Perioperative Medicine (StEP) initiative: patient comfort. Br J Anaesth2018; 120:705–711.

Cited Here |View Full Text | PubMed | CrossRef

  1. Davis RE, Sevdalis N, Neale G, et al. Hospital patients’ reports of medical errors and undesirable events in their healthcare. J Eval Clin Pract2013; 19:875–881.

Cited Here |View Full Text | PubMed

  1. Weissman JS, Schneider EC, Weingart SN, et al. Comparing patient-reported hospital adverse events with medical record review: do patients know something that hospitals do not? Ann Intern Med2008; 149:100–108.

Cited Here |View Full Text | PubMed | CrossRef

  1. Vincent C, Burnett S, Carthey J. Safety measurement and monitoring in healthcare: a framework to guide clinical teams and healthcare organisations in maintaining safety. BMJ Qual Saf2014; 23:670–677.

Cited Here |View Full Text | PubMed | CrossRef

  1. Cole DA, Bersick E, Skarbek A, et al. The courage to speak out: a study describing nurses’ attitudes to report unsafe practices in patient care. J Nurs Manag2019; 27:1176–1181.

Cited Here |View Full Text | PubMed | CrossRef

  1. Dankoski ME, Bickel J, Gusic ME. Discussing the undiscussable with the powerful: why and how faculty must learn to counteract organizational silence. Acad Med2014; 89:1610–1613.

Cited Here |View Full Text | PubMed | CrossRef

  1. Srivastava R. Speaking up – when doctors navigate medical hierarchy. N Engl J Med2013; 368:302–305.

Cited Here |View Full Text | PubMed | CrossRef

  1. Raemer DB, Kolbe M, Minehart RD, et al. Improving anesthesiologists’ ability to speak up in the operating room: a randomized controlled experiment of a simulation-based intervention and a qualitative analysis of hurdles and enablers. Acad Med2016; 91:530–539.

Cited Here |View Full Text | PubMed | CrossRef

  1. Martinez W, Lehmann LS, Thomas EJ, et al. Speaking up about traditional and professionalism-related patient safety threats: a national survey of interns and residents. BMJ Qual Saf2017; 26:869–880.

Cited Here |View Full Text | PubMed | CrossRef

  1. John Wiley & Sons Publishers, Duckworth MP. O’Donohue WT, Fisher JE. Assertiveness skills and the management of related factors. General principles and empirically supported techniques of cognitive behavior therapy2009. 124–132.

Cited Here

  1. Bienefeld N, Grote G. Silence that may kill. Aviation psychology and applied human factors2012; 2:1–10.

Cited Here

  1. Pian-Smith MC, Simon R, Minehart RD, et al. Teaching residents the two-challenge rule: a simulation-based approach to improve education and patient safety. Simul Healthc2009; 4:84–91.

Cited Here |View Full Text | PubMed | CrossRef

  1. Voogt JJ, Kars MC, van Rensen EL, et al. Why medical residents do (and don’t) speak up about organizational barriers and opportunities to improve the quality of care. Acad Med2020; 95:574–581.

Cited Here |View Full Text | PubMed

  1. Ende J. Feedback in clinical medical education. JAMA1983; 250:777–781.

Cited Here |PubMed | CrossRef

  1. Doherty C, Stavropoulou C. Patients’ willingness and ability to participate actively in the reduction of clinical errors: a systematic literature review. Soc Sci Med2012; 75:257–263.

Cited Here |PubMed | CrossRef

  1. Brennan PA, Davidson M. Improving patient safety: we need to reduce hierarchy and empower junior doctors to speak up. BMJ2019; 366:l4461.

Cited Here |View Full Text | PubMed | CrossRef

  1. Haynes AB, Edmondson L, Lipsitz SR, et al. Mortality trends after a voluntary checklist-based surgical safety collaborative. Ann Surg2017; 266:923–929.

Cited Here |View Full Text | PubMed | CrossRef

  1. Salazar MJB, Minkoff H, Bayya J, et al. Influence of surgeon behavior on trainee willingness to speak up: a randomized controlled trial. J Am Coll Surg2014; 219:1001–1007.

Cited Here |PubMed | CrossRef

  1. Novak A. Improving safety through speaking up: an ethical and financial imperative. J Healthc Risk Manag2019; 39:19–27.

Cited Here |View Full Text | PubMed

  1. Cooper J, Caplan R, Gaba D. APSF workshop engages audience in communication skills and drills. APSF Newsl2013; 27:45–72.

Cited Here

  1. Oner C, Fisher N, Atallah F, et al. Simulation-based education to train learners to ‘speak up’ in the clinical environment: results of a randomized trial. Simul Healthc2018; 13:404–412.

Cited Here |View Full Text | PubMed | CrossRef

  1. Braithwaite J, Churruca K, Ellis LA, et al. Complexity science in healthcare-aspirations, approaches, applications and accomplishments: a white paper. Sydney: Macquarie University; 2017.

Cited Here

  1. Peerally MF, Carr S, Waring J, et al. The problem with root cause analysis. BMJ Qual Saf2017; 26:417–422.

Cited Here |View Full Text | PubMed

  1. Hollnagel E, Wears RL, Braithwaite J. From Safety-I to Safety-II: a white paper. The resilient healthcare net. USA and Australia: University of Southern Denmark, University of Florida, Macquarie University; 2015.

Cited Here

  1. Dekker S. The criminalization of human error in aviation and healthcare: a review. Saf Sci2011; 49:121–127.

Cited Here |PubMed | CrossRef

  1. Makary MA, Daniel M. Medical error – the third leading cause of death in the US. BMJ2016; 353:i2139.

Cited Here |View Full Text | PubMed | CrossRef

  1. Raben DC, Bogh SB, Viskum B, et al. Learn from what goes right: a demonstration of a new systematic method for identification of leading indicators in healthcare. Reliabil Eng Syst Saf2018; 169:187–198.

Cited Here

  1. Rozin P, Royzman EB. Negativity bias, negativity dominance, and contagion. Person Soc Psychol Rev2001; 5:296–320.

Cited Here

  1. Thompson, R. F. (2015). Habituation. In International Encyclopedia of the Social & Behavioral Sciences: Second Edition(pp. 480–483). Elsevier Inc.

Cited Here

  1. Shermer M. Patternicity: finding meaningful patterns in meaningless noise. Sci Am2008; 299:48.

Cited Here |PubMed | CrossRef

  1. Hollnagel E. FRAM: the Functional Resonance Analysis Method: modelling complex socio-technical systems. Boca Raton, FL: CRC Press; 2017.

Cited Here

  1. Chuang S, Wears RL. Strategies to get resilience into everyday clinical work. Resilient healthcare, volume 2: the resilience of everyday clinical work2017; Boca Raton, FL; Rotterdam, The Netherlands: CRC Press; Balkema, 225–234.

Cited Here

  1. Pickup L, Atkinson S, Hollnagel E, et al. Blood sampling-two sides to the story. Appl Ergon2017; 59:234–242.

Cited Here |PubMed | CrossRef

  1. Kelly N, Blake S, Plunkett A. Learning from Excellence in healthcare: a new approach to incident reporting. Arch Dis Childhood2016; 101:788–791.

Cited Here |View Full Text | PubMed | CrossRef

  1. West M, Dawson J. Employee engagement and NHS performance. London: King’s Fund; 2012.

Cited Here

  1. Bushe G. Feature choice by gervase bushe foundations of appreciative inquiry: history, criticism and potential. AI Pract2012; 14:

Cited Here

  1. Jones AS, Isaac RE, Price KL, et al. Impact of positive feedback on antimicrobial stewardship in a pediatric intensive care unit: a quality improvement project. Pediatr Qual Saf2019; 4:e206.

Cited Here

  1. Mesman J. Resources of strength: an exnovation of hidden competences to preserve patient safety. A socio-cultural perspective on patient safety2011; 71–89.

Cited Here

  1. Marra AR, Dos Santos OFP, Neto MC, et al. Positive deviance: a new tool for infection prevention and patient safety. Curr Infect Dis Rep2013; 15:544–548.

Cited Here |CrossRef

  1. de Vries EN, Ramrattan MA, Smorenburg SM, et al. The incidence and nature of in-hospital adverse events: a systematic review. BMJ Qual Saf2008; 17:216–223.

Cited Here

  1. Garborg A. Weary men. Evanston, IL: Northwestern University Press; 1999.

Cited Here

  1. Jaeger FN, Pellaud N, Laville B, et al. The migration-related language barrier and professional interpreter use in primary healthcare in Switzerland. BMC Health Serv Res2019; 19:429.

Cited Here |PubMed | CrossRef

  1. Barry MJ, Edgman-Levitan S. Shared decision making – the pinnacle of patient-centered care. N Engl J Med2012; 366:780–781.

Cited Here |View Full Text | PubMed | CrossRef

  1. Frankel RM, Stein T. Getting the most out of the clinical encounter: the four habits model. Perm J1999; 3:79–88.

Cited Here

  1. Ospina NS, Phillips KA, Rodriguez-Gutierrez R, et al. Eliciting the patient’s agenda-secondary analysis of recorded clinical encounters. J Gen Intern Med2019; 34:36–40.

Cited Here |PubMed | CrossRef

  1. Sokol D. Ask your patient: what is most important to you, and why? BMJ2019; 365:l2207.

Cited Here |View Full Text | PubMed | CrossRef

  1. Epstein RM, Hadee T, Carroll J, et al. Could this be something serious? J Gen Intern Med2007; 22:1731–1739.

Cited Here |PubMed | CrossRef

  1. Morse DS, Edwardsen EA, Gordon HS. Missed opportunities for interval empathy in lung cancer communication. Arch Intern Med2008; 168:1853–1858.

Cited Here |View Full Text | PubMed | CrossRef

  1. Levinson W, Gorawara-Bhat R, Lamb J. A study of patient clues and physician responses in primary care and surgical settings. JAMA2000; 284:1021–1027.

Cited Here |View Full Text | PubMed | CrossRef

  1. Jha A, Epstein A. Hospital governance and the quality of care. Health Affairs2010; 29:182–187.

Cited Here |PubMed | CrossRef

  1. National Advisory Group on the Safety of Patients in England. An independent report to the department of health. A promise to learn – a commitment to act. Improving the safety of patients in England2013; ##DeleteExtraTag##https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/226703/Berwick_Report.pdf [Accessed 13 November 2019].

Cited Here

  1. Fisher KA, Smith KM, Gallagher TH, et al. We want to know: eliciting hospitalized patients’ perspectives on breakdowns in care. J Hosp Med2017; 12:603.

Cited Here |View Full Text | PubMed | CrossRef

  1. Fisher KA, Smith KM, Gallagher TH, et al. We want to know: patient comfort speaking up about breakdowns in care and patient experience. BMJ Qual Saf2019; 28:190–197.

Cited Here |View Full Text | PubMed | CrossRef

  1. Bittle MJ, LaMarche S. Engaging the patient as observer to promote hand hygiene compliance in ambulatory care. Jt Comm J Qual Patient Saf2009; 35:519–A513.

Cited Here |PubMed

  1. Vincent C, Phillips A, Young M. Why do people sue doctors? A study of patients and relatives taking legal action. Lancet1994; 343:1609–1613.

Cited Here |View Full Text | PubMed | CrossRef

  1. Lambert BL, Centomani NM, Smith KM, et al. The ‘Seven Pillars’ response to patient safety incidents: effects on medical liability processes and outcomes. Health Serv Res2016; 51:2491–2515.

Cited Here |PubMed | CrossRef

  1. Rall M, van Gessel E, Staender S. Education, teaching & training in patient safety. Best Pract Res Clin Anaesthesiol2011; 25:251–262.

Cited Here |PubMed | CrossRef

  1. Kirkman MA, Sevdalis N, Arora S, et al. The outcomes of recent patient safety education interventions for trainee physicians and medical students: a systematic review. BMJ Open2015; 5:e007705.

Cited Here

  1. Web of Science Group. Web of science core collection: cited reference search 2019. 2019; [Accessed 7 December 2019].

Cited Here

  1. Vincent C. Patient safety. Oxford: BMJ Books; 2010.

Cited Here

  1. Pronovost PJ, Colantuoni E. Measurence keep pace with policy. JAMA2009; 301:1273–1275.

Cited Here |View Full Text | PubMed | CrossRef

  1. Panagoti M, Khan K, Keers RN, et al. Prevalence, severity, and nature of preventable patient harm across medical care settings: systematic review and meta-analysis. BMJ2019; 366:l4185.

Cited Here |PubMed | CrossRef

  1. Woodward HI, Mytton OT, Lemer C, et al. What have we learned about interventions to reduce medical errors? Annu Rev Publ Health2010; 31:479–497.

Cited Here |PubMed | CrossRef

  1. James JT. A new, evidence-based estimate of patient harms associated with hospital care. J Patient Saf2013; 9:122–128.

Cited Here |View Full Text | PubMed

  1. Landrigan CP, Parry GJ, Bones CB, et al. Temporal trends in rates of patient harm resulting from medical care. N Engl J Med2010; 363:2124–2134.

Cited Here |View Full Text | PubMed | CrossRef

  1. Kohn LT, Corrigan JM, Donaldson MS. To err is human: building a safer health system. Washington, DC: National Academy Press; 2000.

Cited Here

  1. Department of Health. An organisation with a memory – report of an expert group on learning from adverse events in the NHS. 2000; ##DeleteExtraTag##https://improve.bmj.com/improve_post/an-organisation-with-a-memory/. [Accessed 5 October 2019].

Cited Here

  1. 2014; Leotsakos A, Ardolino A, Cheung R, et al. Educating futealthc. 7:381–388.

Cited Here

  1. UEMS – European Union of Medical Specialists (UnionEuropéenne des Médecins Spécialistes). Basel declaration – UEMS policy on continuing professional development. 2001; ##DeleteExtraTag##https://www.uems.eu/__data/assets/pdf_file/0019/1477/BASEL_DECLARATION.pdf. [Accessed 19 Septmber 2019].

Cited Here

  1. Council of Europe Committee of Ministers. Recommendation Rec(2006)7 of the Committee of Ministers to member states on management of patient safety and prevention of adverse events in healthcare. 2006; ##DeleteExtraTag##https://search.coe.int/cm/Pages/result_details.aspx?ObjectID=09000016805ae8b5. [Accessed 7 December 2019].

Cited Here

  1. Meltzer D, Walton MM, Shaw T, Barnet S, et al. Economic analysis in patient safety: a neglected necessit. Developing a national patient safety education framework for Astralia. Qual Saf Healthcare2006; 15:437–442.

Cited Here

  1. Walton MM, Shaw T, Barnet S, et al. Developing a national patient safety education framework for Australia. Qual Saf Healthcare2006; 15:437–442.

Cited Here

  1. Australian Council for Safety and Quality in Healthcare. National patient safety education framework. 2005; ##DeleteExtraTag##https://www.safetyandquality.gov.au/sites/default/files/migrated/framework0705.pdf. [Accessed 7 October 2019].

Cited Here

  1. Walton M, Woodward H, Van Staalduinen S, et al. The WHO patient safety curriculum guide for medical schools. Qual Saf Healthcare2010; 19:542–546.

Cited Here

  1. The CanMEDS 2005 Physician Competency Framework; 2005; Frank JR. The CanEDS 2005 Physician Competency Framework. Better standards. Better physicians. Better care. [Online serial].

Cited Here

  1. 2008; Frank JR, Brien S. The Safety Competencies Steering Committee, Canadian Patient Safety Institute. The safety competencies: enhancing patient safety across the health professions. ##DeleteExtraTag##https://www.patientsafetyinstitute.ca/en/toolsResources/safetyCompetencies/Pages/default.aspx. [Accessed 6 October 2019].

Cited Here

  1. Harden RM, Crosby JR, Davis MH. AMEE guide no. 14: outcome-based education: Part 1 – An introduction to outcome-based education. Med Teach1999; 21:7–14.

Cited Here |PubMed | CrossRef

  1. Teigland CL, BlasiakF RC, Wilson LA, et al. Patient safety and quality improvement education: a cross-sectional study of medical students’ preferences and attitudes. BMC Med Educ2013; 13:16.

Cited Here |PubMed | CrossRef

  1. Leung GK, Patil NG. Patient safety in the undergraduate curriculum: medical students’ perception. Hong Kong Med J2010; 16:101–105.

Cited Here |PubMed

  1. Thain S, Ang SB, Ti LK. Medical students’ preferred style of learning patient safety. BMJ Qual Saf2011; 20:201.

Cited Here |View Full Text | PubMed | CrossRef

  1. Schweizerische Akademie der Medizinischen Wissenschaften (SAMW). Aus- und Weiterbildung in Patientensicherheit und Fehlerkultur. Projekt «Zukunft Medizin Schweiz» – Phase III. 2007; ##DeleteExtraTag##http://www.samw.ch/de/Publikationen/Positionspapiere.html. [Accessed 17 November 2014].

Cited Here

  1. Working Group under a Mandate of the Joint Commission of the Swiss Medical Schools. Swiss catalogue of learning objectives for undergraduate medical training. 2008; ##DeleteExtraTag##http://sclo.smifk.ch/. [Accessed 19 September 2019].

Cited Here

  1. Staender S, Wacker J, Kolbe M. Gauinger M, Koppenberg J. Ausbildung im Thema Patientensicherheit – Fachkräfte früh für eine Sicherheitskultur sensibilisieren. Patientensicherheitsmanagement. Berlin/Boston: Walter de Gruyter GmbH; 2015. 370–376.

Cited Here

  1. Kiesewetter J, Gutmann J, Drossard S, et al. The learning objective catalogue for patient safety in undergraduate medical education–a position statement of the Committee for Patient Safety and Error Management of the German Association for Medical Education. GMS J Med Educ2016; 33:

Cited Here

  1. Goolsarran N, Hamo CE, Lane S, et al. Effectiveness of an interprofessional patient safety team-based learning simulation experience on healthcare professional trainees. BMC Med Educ2018; 18:192.

Cited Here |PubMed | CrossRef

  1. Hwang J-I, Yoon T-Y, Jin H-J, et al. Patient safety competence for final-year health professional students: perceptions of effectiveness of an interprofessional education course. J Interprof Care2016; 30:732–738.

Cited Here |PubMed | CrossRef

  1. Wacker J, Kolbe M. The challenge of learning from perioperative patient harm. Trends Anaesth Crit Care2016; 7–8:5–10.

Cited Here

  1. Pattni N, Arzola C, Malavade A, et al. Challenging authority and speaking up in the operating room environment: a narrative synthesis. Br J Anaesth2019; 122:233–244.

Cited Here |View Full Text | PubMed | CrossRef

  1. Neily J, Mills PD, Young-Xu Y, et al. Association between implementation of a medical team training program and surgical mortality. JAMA2010; 304:1693–1700.

Cited Here |View Full Text | PubMed | CrossRef

  1. Robertson ER, Morgan L, Bird S, et al. Interventions employed to improve intrahospital handover: a systematic review. BMJ Qual Saf2014; 23:600–607.

Cited Here |View Full Text | PubMed | CrossRef

  1. Pucher PH, Johnston MJ, Aggarwal R, et al. Effectiveness of interventions to improve patient handover in surgery: a systematic review. Surgery2015; 158:85–95.

Cited Here |View Full Text | PubMed | CrossRef

  1. Weinger MB, Slagle JM, Kuntz AH, et al. A multimodal intervention improves postanesthesia care unit handovers. Anesth Analg2015; 121:957–971.

Cited Here |View Full Text | PubMed | CrossRef

  1. Agarwal HS, Saville BR, Slayton JM, et al. Standardized postoperative handover process improves outcomes in the intensive care unit: a model for operational sustainability and improved team performance. Crit Care Med2012; 40:2109–2115.

Cited Here |View Full Text | PubMed | CrossRef

  1. Abookire SA, Gandhi TK, Kachalia A, et al. Creating a fellowship curriculum in patient safety and quality. Am J Med Qual2016; 31:27–30.

Cited Here |View Full Text | PubMed | CrossRef

  1. Kow AW, Ang SF, Chong CS, et al. PAtient Safety in Surgical EDucation (PASSED): A Pilot Study Using iPad Game to Teach Patient Safety in Undergraduate Medical Curriculum. Ann Acad Med Singapore2017; 46:202–206.

Cited Here |PubMed

  1. Beekman M, Emani VK, Wolford R, et al. Patient safety morning report: innovation in teaching core patient safety principles to third-year medical students. J Med Educ Curric Dev2019; 6:2382120519842539.

Cited Here

  1. Raty SR, Teal CR, Nelson EA, et al. Near-peers improve patient safety training in the preclinical curriculum. Med Educ Online2017; 22:1289315.

Cited Here |PubMed | CrossRef

  1. Ahmed M, Arora S, Baker P, et al. Building capacity and capability for patient safety education: a train-the-trainers programme for senior doctors. BMJ Qual Saf2013; 22:618–625.

Cited Here |View Full Text | PubMed | CrossRef

  1. Hammick M, Dornan T, Steinert Y. Conducting a best evidence systematic review. Part 1: From idea to data coding. BEME guide no. 13. Med Teach2010; 32:3–15.

Cited Here |PubMed | CrossRef

  1. Patey R, Flin R, Ross S, et al. WHO patient safety curriculum guide for medical schools – evaluation study. Report to WHO patient safety programme2011; ##DeleteExtraTag##https://www.who.int/patientsafety/education/curriculum/PSP_Eval_Study_Report-2011_March-2012.pdf?ua=1. [Accessed 25 September 2019].

Cited Here

  1. Mansour M, Skull A, Parker M. Evaluation of World Health Organization multi-professional patient safety curriculum topics in nursing education: pretest, posttest, none-experimental study. J Prof Nurs2015; 31:432–439.

Cited Here |View Full Text | PubMed | CrossRef

  1. Misbah S, Mahboob U. Strengths, weaknesses, opportunities, and threats analysis of integrating the World Health Organization patient safety curriculum into undergraduate medical education in Pakistan: a qualitative case study. J Educ Eval Health Prof2017; 14:

Cited Here

  1. Li G, Tao HB, Liao JZ, et al. Patient safety education among chinese medical undergraduates: an empirical study. J Huazhong Univ Sci Technol Med Sci2016; 36:780–784.

Cited Here

  1. Ginsburg LR, Dhingra-Kumar N, Donaldson LJ. What stage are low-income and middle-income countries (LMICs) at with patient safety curriculum implementation and what are the barriers to implementation? A two-stage cross-sectional study. BMJ Open2017; 7:e016110.

Cited Here

  1. Moffatt-Bruce SD, Hefner JL, Mekhjian H, et al. What is the return on investment for implementation of a crew resource management program at an academic medical center? Am J Med Qual2017; 32:5–11.

Cited Here |View Full Text | PubMed | CrossRef

  1. Nie Y, Li L, Duan Y, et al. Patient safety education for undergraduate medical students: a systematic review. BMC Med Educ2011; 11:33.

Cited Here |PubMed | CrossRef

  1. Wong BM, Etchells EE, Kuper A, et al. Teaching quality improvement and patient safety to trainees: a systematic review. Acad Med2010; 85:1425–1439.

Cited Here |View Full Text | PubMed | CrossRef

  1. Kiesewetter J, Drossard S, Manser T. Patient safety education in German speaking countries: first successes and blind spots. GMS J Med Educ2019; 36:Doc22–Doc122.

Cited Here

  1. Sujan MA, Furniss D, Anderson J, et al. Resilient healthcare as the basis for teaching patient safety – a Safety-II critique of the World Health Organisation patient safety curriculum. Saf Sci2019; 118:15–21.

Cited Here |PubMed | CrossRef

  1. Wong BM, Baum KD, Headrick LA, et al. Building the bridge to quality: an urgent call to integrate quality improvement and patient safety education with clinical care. Acad Med2020; 95:59–68.

Cited Here |View Full Text | PubMed | CrossRef

  1. American Heart Association. Advanced cardiovascular life support (ACLS). 2019; https://cpr.heart.org/en/cpr-courses-and-kits/healthcare-professional/acls. [Accessed 20 October 2019].

Cited Here

  1. Howard SK, Gaba DM, Fish KJ, et al. Anesesthesiologists to handle critical incidents. Aviat Space Environ Med1992; 63:763–770.

Cited Here |PubMed

  1. Gaba DM. Human error in anesthetic mishaps. Int Anesthesiol Clin1989; 27:137–147.

Cited Here |View Full Text | PubMed | CrossRef

  1. Flin R, Maran N. Basic concepts for crew resource management and nontechnical skills. Best Pract Res Clin Anaesthesiol2015; 29:27–39.

Cited Here |PubMed

  1. Flin R, Winter J, Cakil Sarac MR. Human factors in patient safety: review of topics and tools. Better knowledge for safer care. Geneva: World Health Organization; 2009.

Cited Here

  1. Helmreich RL, Merritt AC, Wilhelm JA. The evolution of crew resource management training in commercial aviation. Int J Aviat Psychol1999; 9:19–32.

Cited Here |PubMed | CrossRef

  1. Reznek M, Smith-Coggins R, Howard S, et al. Emergency medicine crisis resource management (EMCRM): pilot study of a simulation-based crisis management course for emergency medicine. Acad Emerg Med2003; 10:386–389.

Cited Here |PubMed | CrossRef

  1. Weaver SJ, Lyons R, DiazGranados D, et al. The anatomy of healthcare team training and the state of practice: a critical review. Acad Med2010; 85:1746–1760.

Cited Here |View Full Text | PubMed | CrossRef

  1. Lorello GR, Cook DA, Johnson RL, et al. Simulation-based training in anaesthesiology: a systematic review and meta-analysis. Br J Anaesth2014; 112:231–245.

Cited Here |View Full Text | PubMed | CrossRef

  1. Flin RH, O’Connor P, Crichton M. Safety at the sharp end: a guide to nontechnical skills. Aldershot: Ashgate; 2008.

Cited Here

  1. Flin R, Patey R, Glavin R, et al. Anaesthetists’ nontechnical skills. Br J Anaesth2010; 105:38–44.

Cited Here |View Full Text | PubMed | CrossRef

  1. Yule S, Flin R, Paterson-Brown S, et al. Nontechnical skills for surgeons in the operating room: a review of the literature. Surgery2006; 139:140–149.

Cited Here |View Full Text | PubMed | CrossRef

  1. Lyk-Jensen HT, Jepsen RM, Spanager L, et al. Assessing nurse anaesthetists’ non-technical skills in the operating room. Acta Anaesthesiol Scand2014; 58:794–801.

Cited Here |PubMed | CrossRef

  1. Flin R, Mitchell L, McLeod B. Nontechnical skills of the scrub practitioner: the SPLINTS system. ORNAC J2014; 32:33–38.

Cited Here

  1. Østergaard D, Dieckmann P, Lippert A. Simulation and CRM. Best Pract Res Clin Anaesthesiol2011; 25:239–249.

Cited Here |PubMed | CrossRef

  1. Morey JC, Simon R, Jay GD, et al. Error reduction and performance improvement in the emergency department through formal teamwork training: evaluation results of the MedTeams project. Health Serv Res2002; 37:1553–1581.

Cited Here |View Full Text | PubMed | CrossRef

  1. Higham H, Baxendale B. To err is human: use of simulation to enhance training and patient safety in anaesthesia. Br J Anaesth2017; 119:i106–i114.

Cited Here |View Full Text | PubMed | CrossRef

  1. Naik VN, Brien SE. Simulation: a means to address and improve patient safety. Can J Anesth2013; 60:192–200.

Cited Here

  1. Fanning RM, Gaba DM. The role of debriefing in simulation-based learning. Simul Healthc2007; 2:115–125.

Cited Here

  1. Weaver SJ, Dy SM, Rosen MA. Team-training in healthcare: a narrative synthesis of the literature. BMJ Qual Saf2014; 23:359–372.

Cited Here |View Full Text | PubMed | CrossRef

  1. Rosen MA, Hunt EA, Pronovost PJ, et al. In situ simulation in continuing education for the healthcare professions: a systematic review. J Cont Educ Health Prof2012; 32:243–254.

Cited Here

  1. Anderson ER, Black R, Brocklehurst P. Acute obstetric emergency drill in England and Wales: a survey of practice. BJOG2005; 112:372–375.

Cited Here |View Full Text | PubMed | CrossRef

  1. Sorensen JL, Ostergaard D, LeBlanc V, et al. Design of simulation-based medical education and advantages and disadvantages of in situ simulation versus off-site simulation. BMC Med Educ2017; 17:20.

Cited Here |PubMed | CrossRef

  1. Eppich W, Howard V, Vozenilek J, et al. Simulation-based team training in healthcare. Simul Healthc2011; 6:S14–S19.

Cited Here |View Full Text | PubMed | CrossRef

  1. Boet S, Bould MD, Layat Burn C, et al. Twelve tips for a successful interprofessional team-based high-fidelity simulation education session. Med Teach2014; 36:853–857.

Cited Here |PubMed | CrossRef

  1. Deutsch ES, Dong Y, Halamek LP, et al. Leveraging healthcare simulation technology for human factors research: closing the gap between lab and bedside. Hum Factors2016; 58:1082–1095.

Cited Here |PubMed | CrossRef

  1. Salas E, Wilson KA, Burke CS, et al. Does crew resource management training work? An update, an extension, and some critical needs. Hum Factors2006; 48:392–412.

Cited Here |PubMed | CrossRef

  1. Chung HS, Dieckmann P, Issenberg SB. It is time to consider cultural differences in debriefing. Simul Healthc2013; 8:166–170.

Cited Here |View Full Text | PubMed | CrossRef

  1. Finn R, Learmonth M, Reedy P. Some unintended effects of teamwork in healthcare. Soc Sci Med19822010; 70:1148–1154.

Cited Here |PubMed

  1. Iedema R. New approaches to researching patient safety. Soc Sci Med19822009; 69:1701–1704.

Cited Here |PubMed | CrossRef

  1. Neuhaus C, Lutnæs DE, Bergström J. Medical teamwork and the evolution of safety science: a critical review. Cognit Technol Work2020; 22:13–27.

Cited Here

  1. Siemsen IMD, Madsen MD, Pedersen LF, et al. Factors that impact on the safety of patient handovers: an interview study. Scand J Public Health2012; 40:439–448.

Cited Here |PubMed | CrossRef

  1. British Medical Association. Guidance on clinical handover for clinicians and managers. 2004.

Cited Here

  1. World Health Organization. Transitions of care. 2016.

Cited Here

  1. Manser T. Minding the gaps: moving handover research forward. Philadelphia, PA: LWW; 2011.

Cited Here

  1. Mellin-Olsen J, Staender S. The Helsinki Declaration on patient safety in anaesthesiology: the past, present and future. Curr Opin Anesthesiol2014; 27:630–634.

Cited Here |View Full Text | PubMed | CrossRef

  1. Riesenberg LA, Leitzsch J, Little BW. Systematic review of handoff mnemonics literature. Am J Med Qual2009; 24:196–204.

Cited Here |View Full Text | PubMed | CrossRef

  1. Haig KM, Sutton S, Whittington J. SBAR: a shared mental model for improving communication between clinicians. Jt Comm J Qual Patient Saf2006; 32:167–175.

Cited Here

  1. Catchpole KR, De Leval MR, McEwan A, et al. Patient handover from surgery to intensive care: using Formula 1 pit-stop and aviation models to improve safety and quality. Pediatr Anesth2007; 17:470–478.

Cited Here

  1. Manser T. Teamwork and patient safety in dynamic domains of healthcare: a review of the literature. Acta Anaesthesiol Scand2009; 53:143–151.

Cited Here |View Full Text | PubMed | CrossRef

  1. Lawrence RH, Tomolo AM, Garlisi AP, et al. Conceptualizing handover strategies at change of shift in the emergency department: a grounded theory study. BMC Health Serv Res2008; 8:256.

Cited Here |PubMed | CrossRef

  1. Manser T, Foster S, Gisin S, et al. Assessing the quality of patient handoffs at care transitions. Qual Saf Healthcare2010; 19:e44–e144.

Cited Here

  1. Raduma-Tomàs MA, Flin R, Yule S, et al. Doctors’ handovers in hospitals: a literature review. BMJ Qual Saf2011; 20:128–133.

Cited Here |View Full Text | PubMed | CrossRef

  1. McFarlane A. The impact of standardised perioperative handover protocols. J Perioper Pract2018; 28:258–262.

Cited Here

  1. Burian BK, Clebone A, Dismukes K, et al. More than a tick box: medical checklist development, design, and use. Anesth Analg2018; 126:223–232.

Cited Here |View Full Text | PubMed | CrossRef

  1. Barbeito A, Agarwala AV, Lorinc A. Handovers in perioperative care. Anesthesiol Clin2018; 36:87–98.

Cited Here

  1. Cohen MD, Hilligoss B, Amaral ACK-B. A handoff is not a telegram: an understanding of the patient is co-constructed. Crit Care2012; 16:303.

Cited Here |PubMed

  1. Britton MC, Hodshon B, Chaudhry SI. Implementing a warm handoff between hospital and skilled nursing facility clinicians. J Patient Saf2019; 15:198–204.

Cited Here |View Full Text | PubMed

  1. Manser T, Foster S, Flin R, et al. Team communication during patient handover from the operating room: more than facts and figures. Hum Factors2013; 55:138–156.

Cited Here |PubMed | CrossRef

  1. Patterson ES, Roth EM, Woods DD, et al. Handoff strategies in settings with high consequences for failure: lessons for healthcare operations. Int J Qual Health Care2004; 16:125–132.

Cited Here |View Full Text | PubMed | CrossRef

  1. Braithwaite J, Herkes J, Ludlow K, et al. Association between organisational and workplace cultures, and patient outcomes: systematic review. BMJ Open2017; 7:e017708.

Cited Here

  1. Reay G, Norris JM, Nowell L, et al. Transition in care from EMS providers to emergency department nurses: a systematic review. Prehosp Emerg Care2020; 24:421–433.

Cited Here |PubMed | CrossRef

  1. Jensen S, Lippert A, Østergaard D. Handover of patients: a topical review of ambulance crew to emergency department handover. Acta Anaesthesiol Scand2013; 57:964–970.

Cited Here |View Full Text | PubMed | CrossRef

  1. Sujan MA, Chessum P, Rudd M, et al. Managing competing organizational priorities in clinical handover across organizational boundaries. J Health Serv Res Policy2015; 20:17–25.

Cited Here |PubMed | CrossRef

  1. Møller TP, Münter KH, Østergaard D, et al. Exploring challenges and solutions in the preparation of surgical patients. Dan Med J2015; 62:A5141–A15141.

Cited Here |PubMed

  1. Nagpal K, Vats A, Ahmed K, et al. An evaluation of information transfer through the continuum of surgical care: a feasibility study. Ann Surg2010; 252:402–407.

Cited Here |View Full Text | PubMed | CrossRef

  1. Nagpal K, Arora S, Vats A, et al. Failures in communication and information transfer across the surgical care pathway: interview study. BMJ Qual Saf2012; 21:843–849.

Cited Here |View Full Text | PubMed | CrossRef

  1. Münter KH, Møller TP, Østergaard D, et al. Implementation of an electronic checklist to improve patient handover from ward to operating room. J Patient Saf2017; [Epub ahead of print].

Cited Here

  1. Cooper JB, Long CD, Newbower RS, et al. Critical incidents associated with intraoperative exchanges of anesthesia personnel. Anesthesiology1982; 56:456–461.

Cited Here |View Full Text | PubMed | CrossRef

  1. Jones PM, Cherry RA, Allen BN, et al. Association between handover of anesthesia care and adverse postoperative outcomes among patients undergoing major surgery. JAMA2018; 319:143–153.

Cited Here |View Full Text | PubMed | CrossRef

  1. Siddiqui N, Arzola C, Iqbal M, et al. Deficits in information transfer between anaesthesiologist and postanaesthesia care unit staff: an analysis of patient handover. Eur J Anaesthesiol2012; 29:438–445.

Cited Here |View Full Text | PubMed | CrossRef

  1. Boat AC, Spaeth JP. Handoff checklists improve the reliability of patient handoffs in the operating room and postanesthesia care unit. Pediatr Anesth2013; 23:647–654.

Cited Here

  1. Nagpal K, Abboudi M, Manchanda C, et al. Improving postoperative handover: a prospective observational study. Am J Surg2013; 206:494–501.

Cited Here |PubMed | CrossRef

  1. Østergaard D, Madsen MD, Petersen LF, et al. In-hospital handovers: a context-specific design process. Researching quality in care transitions2017; Berlin, Germany: Springer, 203–221.

Cited Here

  1. Wibrandt I, Lippert A. Improving patient safety in handover from intensive care unit to general ward: a systematic review. J Patient Saf2017; [Epub ahead of print].

Cited Here

  1. Larsen T, Beier-Holgersen R, Dieckmann P, et al. Conducting the emergency team: a novel way to train the team-leader for emergencies. Heliyon2018; 4:e00791.

Cited Here

  1. Edmondson AC, Bohmer RM, Pisano GP. Disrupted routines: team learning and new technology implementation in hospitals. Admin Sci Q2001; 46:685–716.

Cited Here |PubMed | CrossRef

  1. Muralidharan M, Clapp JT, Pulos BP, et al. How does training in anesthesia residency shape residents’ approaches to patient care handoffs? A single-center qualitative interview study. BMC Med Educ2018; 18:271.

Cited Here |PubMed | CrossRef

  1. Accreditation Council for Graduate Medical Education. Program requirements for graduate medical education in anaesthesiology. 2004; https://www.acgme.org/Specialties/Program-Requirements-and-FAQs-and-Applications/pfcatid/6/Anesthesiology. [Accessed 7 December 2019].

Cited Here

  1. Lane-Fall MB, Brooks AK, Wilkins SA, et al. Addressing the mandate for hand-off EducationA focused review and recommendations for anesthesia resident curriculum development and evaluation. Anesthesiology2014; 120:218–229.

Cited Here |View Full Text | PubMed | CrossRef

  1. Aylward M, Nixon J, Gladding S. An entrustable professional activity (EPA) for handoffs as a model for EPA assessment development. Acad Med2014; 89:1335–1340.

Cited Here |View Full Text | PubMed | CrossRef

  1. Starmer AJ, O’Toole JK, Rosenbluth G, et al. Development, implementation, and dissemination of the I-PASS handoff curriculum: a multisite educational intervention to improve patient handoffs. Acad Med2014; 89:876–884.

Cited Here |View Full Text | PubMed | CrossRef

  1. Ebben RH, van Grunsven PM, Moors ML, et al. A tailored e-learning program to improve handover in the chain of emergency care: a pretest posttest study. Scand J Trauma Resusc Emerg Med2015; 23:33.

Cited Here

  1. Cooper JB, Singer SJ, Hayes J, et al. Design and evaluation of simulation scenarios for a program introducing patient safety, teamwork, safety leadership, and simulation to healthcare leaders and managers. Simul Healthc2011; 6:231–238.

Cited Here |View Full Text | PubMed | CrossRef

  1. Manser T. Fragmentation of patient safety research: a critical reflection of current human factors approaches to patient handover. J Public Health Research2013; 2:e33.

Cited Here

  1. Sujan M, Spurgeon P, Inada-Kim M, et al. Clinical handover within the emergency care pathway and the potential risks of clinical handover failure (ECHO): primary research. Southampton (UK): NIHR Journals Library; 2014.

Cited Here

  1. Runciman WB, Sellen A, Webb RK, et al. The Australian Incident Monitoring Study. Errors, incidents and accidents in anaesthetic practice. Anaesth Intensive Care1993; 21:506–519.

Cited Here |PubMed | CrossRef

  1. Staender S, Davies J, Helmreich B, et al. The anaesthesia critical incident reporting system: an experience based database. Int J Med Inform1997; 47:87–90.

Cited Here |PubMed | CrossRef

  1. Reed S, Arnal D, Frank O, et al. National critical incident reporting systems relevant to anaesthesia: a European survey. Br J Anaesth2013; 112:546–555.

Cited Here |View Full Text | PubMed | CrossRef

  1. Weick KE, Sutcliffe KM. Managing the unexpected: assuring high performance in an age of complexity. San Francisco: Jossey-Bass; 2001.

Cited Here

  1. Panagioti Maria KK, Keers R, Abuzour A, et al. Preventable patient harm across healthcare services: a systematic review and meta-analysis. Manchester: General Medical Council; 2017.

Cited Here

  1. Heinrich HW. Industrial accident prevention. New York: McGraw-Hill; 1931.

Cited Here

  1. Reason J. Human error: models and management. BMJ2000; 320:768–770.

Cited Here |View Full Text | PubMed | CrossRef

  1. Woods DD. Hollnagel E, Woods DD, Leveson N. Essential characteristics of resilience. Resilience engineering. Hampshire, UK: Ashgate Publishing Limited; 2006. 21–35.

Cited Here

  1. Johnson A, Lane P. Resilience work-as-done in everyday clinical work. Resilient Healthc2016; 3:71–87.

Cited Here

  1. Hollnagel E. Hollnagel E, Braithwaite J, Wears RL. Making healthcare resilient: from Safety-I to Safety-II. Resilient healthcare. Farnham, Surrey: Ashgate Publishing Limited; 2013. 3–17.

Cited Here

  1. Staender S. Safety-II and resilience: the way ahead in patient safety in anaesthesiology. Curre Opin Anesthesiol2015; 28:735–739.

Cited Here

  1. Budrevics G, O’Neill C. Changing a culture with patient safety walkarounds. Healthc Q2005; 8SpecNo:20–25.

Cited Here |PubMed | CrossRef

  1. Frankel A, Grillo SP, Pittman M, et al. Revealing and resolving patient safety defects: the impact of leadership WalkRounds on frontline caregiver assessments of patient safety. Health Serv Res2008; 43:2050–2066.

Cited Here |View Full Text | PubMed | CrossRef

  1. Singer SJ, Tucker AL. The evolving literature on safety WalkRounds: emerging themes and practical messages. BMJ Qual Saf2014; 23:789–800.

Cited Here |View Full Text | PubMed | CrossRef

  1. Stephenson AG. Mars climate orbiter mishap investigation board phase I report. Huntsville, Alabama: Marshal Space Flight Centre; 1999.

Cited Here

  1. Schiff GD. Fatal distraction: finance versus vigilance in U.S. hospitals. Int J Health Serv2000; 30:739–743.

Cited Here

  1. Wu AW. Medical error: the second victim: the doctor who makes the mistake needs help too. London, United Kingdom: British Medical Journal Publishing Group; 2000.

Cited Here

  1. Aasland O, Førde R. Impact of feeling responsible for adverse events on doctors’ personal and professional lives: the importance of being open to criticism from colleagues. BMJ Qual Saf2005; 14:13–17.

Cited Here

  1. Gazoni FM, Amato PE, Malik ZM, et al. The impact of perioperative catastrophes on anesthesiologists: results of a national survey. Anesth Analg2012; 114:596–603.

Cited Here |View Full Text | PubMed | CrossRef

  1. Scott SD, Hirschinger LE, Cox KR, et al. The natural history of recovery for the healthcare provider ‘second victim’ after adverse patient events. BMJ Qual Saf2009; 18:325–330.

Cited Here

  1. Shanafelt TD, Balch CM, Dyrbye L, et al. Special report: suicidal ideation among American surgeons. Arch Surg2011; 146:54–62.

Cited Here |View Full Text | PubMed | CrossRef

  1. Ullström S, Sachs MA, Hansson J, et al. Suffering in silence: a qualitative study of second victims of adverse events. BMJ Qual Saf2014; 23:325–331.

Cited Here |View Full Text | PubMed | CrossRef

  1. Waterman AD, Garbutt J, Hazel E, et al. The emotional impact of medical errors on practicing physicians in the United States and Canada. Jt Comm J Qual Patient Saf2007; 33:467–476.

Cited Here |PubMed | CrossRef

  1. Burlison JD, Quillivan RR, Scott SD, et al. The effects of the second victim phenomenon on work-related outcomes: connecting self-reported caregiver distress to turnover intentions and absenteeism. J Patient Saf2016; [Epub ahead of print].

Cited Here

  1. Williams ES, Manwell LB, Konrad TR, et al. The relationship of organizational culture, stress, satisfaction, and burnout with physician-reported error and suboptimal patient care: results from the MEMO study. Healthc Manag Rev2007; 32:203–212.

Cited Here

  1. West CP, Tan AD, Habermann TM, et al. Association of resident fatigue and distress with perceived medical errors. JAMA2009; 302:1294–1300.

Cited Here |View Full Text | PubMed | CrossRef

  1. Chard R. How perioperative nurses define, attribute causes of, and react to intraoperative nursing errors. AORN J2010; 91:132–145.

Cited Here |View Full Text | PubMed | CrossRef

  1. Fahrenkopf AM, Sectish TC, Barger LK, et al. Rates of medication errors among depressed and burnt out residents: prospective cohort study. BMJ2008; 336:488–491.

Cited Here |View Full Text | PubMed | CrossRef

  1. Edrees HH, Paine LA, Feroli ER, et al. Healthcare workers as second victims of medical errors. Pol Arch Med Wewn2011; 121:101–108.

Cited Here |PubMed

  1. Edrees H, Connors C, Paine L, et al. Implementing the RISE second victim support programme at the Johns Hopkins Hospital: a case study. BMJ Open2016; 6:e011708.

Cited Here

  1. Scott S. Second victim support: implications for patient safety attitudes and perceptions. Patient Saf Qual Healthc2015; 12:26–31.

Cited Here

  1. Gaba DM. Anaesthesiology as a model for patient safety in healthcare. BMJ2000; 320:785–788.

Cited Here |View Full Text | PubMed | CrossRef

  1. Pierce EC Jr. The 34th Rovenstine Lecture. 40 years behind the mask: safety revisited. Anesthesiology1996; 84:965–975.

Cited Here |View Full Text | PubMed | CrossRef

  1. American Association of Nurse Anesthetists. Standards for nurse anesthesia practice. Park Ridge, Illinois: AANA; 1974.

Cited Here

  1. Stoelting RK. Ruskin KJ, Stiegler MP, Rosenbaum SH. Patient safety. A brief history. Quality and safety. New York: Oxford University Press; 2016. 1–15.

Cited Here

  1. International Federation of Nurse Anasthetists. Code of ethics, standards of practice, monitoring, and education. Pittsburgh, PA: IFNA; 2016.

Cited Here

  1. American Society of Anesthesiologists. Standards and guidelines. Improve decision-making and promote quality outcomes with evidence-based guidance for your anestehsilogy practice. Washington: American Society of Anesthesiologists; 2019.

Cited Here

  1. Ringvold EM, Bekkevold M, Bruun AM, et al. Norwegian standard for the safe practice of anaesthesia. Acta Anaesthesiol Scand2018; 62:411–417.

Cited Here |View Full Text | PubMed | CrossRef

  1. UEMS Anesthesiology Section and European Board of Anaesthesiology (EBA) recommendations for minimal monitoring during Anaesthesia and Recovery. http://www.eba-uems.eu/resources/PDFS/safety-guidelines/EBA-Minimal-monitor.pdf. [Accessed 7 May 2019].

Cited Here

  1. Checketts M, Alladi R, Ferguson K, et al. Recommendations for standards of monitoring during anaesthesia and recovery 2015: Association of Anaesthetists of Great Britain and Ireland. Anaesthesia2016; 71:85–93.

Cited Here |View Full Text | PubMed | CrossRef

  1. Vats A, Vincent CA, Nagpal K, et al. Practical challenges of introducing WHO surgical checklist: UK pilot experience. Br Med J2010; 340:133–135.

Cited Here

  1. Degani A, Wiener EL. Cockpit checklists: concepts, design, and use. Hum Factors1993; 35:345–359.

Cited Here |PubMed | CrossRef

  1. Weiser TG, Haynes AB, Lashoher A, et al. Perspectives in quality: designing the WHO surgical safety checklist. Int J Qual Health Care2010; 22:365–370.

Cited Here |View Full Text | PubMed | CrossRef

  1. World Health Organization. WHO Safe Surgery Save Lives starter kit for surgical checklist implementation. Geneva: World Health Organization; 2009.

Cited Here

  1. 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 Healthc2005; 14:340–346.

Cited Here

  1. Safeek YM. Protocols, prompters, bundles, checklists, and triggers synopsis of a preventable mortality reduction strategy: a hospital’s senior finance leader can play an important role in the organization’s effort to prevent avoidable deaths by monitoring the monetary impact of substandard care and driving the focus on key leverage points. Healthc Financ Manage2010; 64:70–76.

Cited Here |PubMed

  1. Weerakkody RA, Cheshire NJ, Riga C, et al. Surgical technology and operatingroom safety failures: a systematic review of quantitative studies. BMJ Qual Saf2013; 22:710–718.

Cited Here |View Full Text | PubMed | CrossRef

  1. DeFontes J, Surbida S. Preoperative safety briefing project. Perm J2004; 8:21.

Cited Here |PubMed

  1. de Vries EN, Prins HA, Crolla RMPH, et al. Effect of a comprehensive surgical safety system on patient outcomes. N Engl J Med2010; 363:1928–1937.

Cited Here |View Full Text | PubMed | CrossRef

  1. Haynes A, Weiser T, Berry W, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. NEJM2009; 360:491–499.

Cited Here | View Full Text | PubMed | CrossRef

  1. Kendell J, Barthram C. Revised checklist for anaesthetic machines. Anaesthesia1998; 53:887–890.

Cited Here |View Full Text | PubMed | CrossRef

  1. Hartle A, Anderson E, Bythell V, et al. Checking anaesthetic equipment 2012. Anaesthesia2012; 67:660–668.

Cited Here |PubMed

  1. Thomassen O, Brattebo G, Heltne J-K, et al. Checklists in the operating room: help or hurdle? A qualitative study on health workers’ experiences. BMC Health Serv Res2010; 10:342.

Cited Here |PubMed

  1. Giddings A, Williamson C. The leadership and management of surgical teams. London: The Royal College of Surgeons of England; 2007.

Cited Here

  1. WHO. Safe surgery saves lives. Washington, DC: WHO; 2008.

Cited Here

  1. de Vries EN, Hollmann MW, Smorenburg SM, et al. Development and validation of the SURgical PAtient Safety System (SURPASS) checklist. BMJ Qual Saf2009; 18:121–126.

Cited Here

  1. Mehta N, Amaranathan A, Jayapal L, et al. Effect of comprehensive surgical safety system on patients’ outcome: a prospective clinical study. Cureus2018; 10:e2601–e12601.

Cited Here

  1. Storesund A, Haugen AS, Wæhle HV, et al. Validation of a Norwegian version of SURgical PAtient Safety System (SURPASS) in combination with the World Health Organizations’ Surgical Safety Checklist (WHO SSC). BMJ Open Qual2019; 8:e000488.

Cited Here

  1. Lyons MK. Eight-year experience with a neurosurgical checklist. Am J Med Qual2010; 25:285–288.

Cited Here |View Full Text | PubMed | CrossRef

  1. Connolly PJ, Kilpatrick M, Jaggi JL, et al. Feasibility of an operational standardized checklist for movement disorder surgery: a pilot study. Stereotact Funct Neurosurg2009; 87:94–100.

Cited Here |PubMed | CrossRef

  1. Lingard L, Regehr G, Cartmill C, et al. Evaluation of a preoperative team briefing: a new communication routine results in improved clinical practice. BMJ Qual Saf2011; 20:475–482.

Cited Here |View Full Text | PubMed | CrossRef

  1. Sackett DL, Rosenberg WMC, Gray JAM, et al. Evidence based medicine: what it is and what it isn’t. Br Med J1996; 312:71–72.

Cited Here |View Full Text | PubMed | CrossRef

  1. Gisvold SE, Fasting S. How do we know that we are doing a good job – can we measure the quality of our work? Best Pract Res Clin Anaesthesiol2011; 25:109–122.

Cited Here |PubMed | CrossRef

  1. Haugen AS. Impact of a surgical checklist on safety culture, morbidity, and mortality. A stepped-wedge cluster randomised controlled trial. Doctoral thesis. 2014; Bergen, Norway: Department of Clinical Sciences, University of Bergen. BORA: University of Bergen, 98.

Cited Here

  1. Moher D, Liberati A, Tetzlaff J, et al. Preferred Reporting Items for Systematic Reviews and Meta-Analyses: the PRISMA statement. BMJ2009; 339:b2535.

View Full Text | PubMed | CrossRef

  1. Abbott TEF, Ahmad T, Phull MK, et al. The surgical safety checklist and patient outcomes after surgery: a prospective observational cohort study, systematic review and meta-analysis. Br J Anaesth2018; 120:146–155.

Cited Here |View Full Text | PubMed | CrossRef

  1. Anwer M, Manzoor S, Muneer N, et al. Compliance and effectiveness of WHO surgical safety check list: a JPMC audit. Pak J Med Sci2016; 32:831–835.

Cited Here |PubMed

  1. Askarian M, Kouchak F, Palenik CJ. Effect of surgical safety checklists on postoperative morbidity and mortality rates, shiraz, faghihy hospital, a 1-year study. Qual Manag Healthc2011; 20:293–297.

Cited Here

  1. Boaz M, Bermant A, Ezri T, et al. Effect of Surgical Safety checklist implementation on the occurrence of postoperative complications in orthopedic patients. Isr Med Assoc J2014; 16:20–25.

Cited Here |PubMed

  1. Bock M, Fanolla A, Segur-Cabanac I, et al. A comparative effectiveness analysis of the implementation of surgical safety checklists in a tertiary care hospital. JAMA Surg2016; 151:639–646.

Cited Here |View Full Text | PubMed | CrossRef

  1. Bliss LA, Ross-Richardson CB, Sanzari LJ, et al. Thirty-day outcomes support implementation of a surgical safety checklist. J Am Coll Surg2012; 215:766–776.

Cited Here |PubMed | CrossRef

  1. Chhabra A, Singh A, Kuka PS, et al. Role of perioperative surgical safety checklist in reducing morbidity and mortality among patients: an observational study. Niger J Surg2019; 25:192–197.

Cited Here

  1. Chaudhary N, Varma V, Kapoor S, et al. Implementation of a surgical safety checklist and postoperative outcomes: a prospective randomized controlled study. J Gastrointest Surg2015; 19:935–942.

Cited Here |PubMed | CrossRef

  1. de Jager E, Gunnarsson R, Ho YH. Implementation of the World Health Organization surgical safety checklist correlates with reduced surgical mortality and length of hospital admission in a high-income country. World J Surg2018; 12:12.

Cited Here

  1. GlobalSurg Collaborative. Pooled analysis of WHO surgical safety checklist use and mortality after emergency laparotomy. Br J Surg2019; 106:e103–e112.

Cited Here |View Full Text | PubMed | CrossRef

  1. Haugen AS, Softeland E, Almeland SK, et al. Effect of the World Health Organization checklist on patient outcomes: a stepped wedge cluster randomized controlled trial. Ann Surg2015; 261:821–828.

Cited Here |View Full Text | PubMed | CrossRef

  1. Igaga EN, Sendagire C, Kizito S, et al. World Health Organization surgical safety checklist: compliance and associated surgical outcomes in Uganda’s referral hospitals. Anesth Analg2018; 127:1427–1433.

Cited Here |View Full Text | PubMed | CrossRef

  1. Jammer I, Ahmad T, Aldecoa C, et al. Point prevalence of surgical checklist use in Europe: relationship with hospital mortality. Br J Anaesth2015; 114:801–807.

Cited Here |View Full Text | PubMed | CrossRef

  1. Kwok AC, Funk LM, Baltaga R, et al. Implementation of the World Health Organization Surgical safety checklist, including introduction of pulse oximetry, in a resource-limited setting. Ann Surg2013; 257:633–639.

Cited Here |View Full Text | PubMed | CrossRef

  1. Lubbeke A, Hovaguimian F, Wickboldt N, et al. Effectiveness of the surgical safety checklist in a high standard care environment. Med Care2013; 51:425–429.

Cited Here |View Full Text | PubMed | CrossRef

  1. Lepanluoma M, Takala R, Kotkansalo A, et al. Surgical safety checklist is associated with improved operating room safety culture, reduced wound complications, and unplanned readmissions in a pilot study in neurosurgery. Scand J Surg2014; 103:66–72.

Cited Here |PubMed | CrossRef

  1. Mayer EK, Sevdalis N, Rout S, et al. Surgical checklist implementation project: the impact of variable WHO checklist compliance on risk-adjusted clinical outcomes after national implementation: a longitudinal study. Ann Surg2016; 263:58–63.

Cited Here |View Full Text | PubMed | CrossRef

  1. Morgan PJ, Cunningham L, Mitra S, et al. Surgical safety checklist: implementation in an ambulatory surgical facility. Can J Anaesth2013; 60:528–538.

Cited Here |PubMed | CrossRef

  1. O’Leary JD, Wijeysundera DN, Crawford MW. Effect of surgical safety checklists on pediatric surgical complications in Ontario. CMAJ2016; 188:E191–E198.

Cited Here |View Full Text | PubMed | CrossRef

  1. Ramsay G, Haynes AB, Lipsitz SR, et al. Reducing surgical mortality in Scotland by use of the WHO surgical safety checklist. Br J Surg2019; 106:1005–1011.

Cited Here |View Full Text | PubMed | CrossRef

  1. Rodella S, Mall S, Marino M, et al. Effects on clinical outcomes of a 5-year surgical safety checklist implementation experience: a large-scale population-based difference-in-differences study. Health Serv Insights2018; 11:1178632918785127–1178632918785127.

Cited Here

  1. Rodrigo-Rincon I, Martin-Vizcaino MP, Tirapu-Leon B, et al. The effects of surgical checklists on morbidity and mortality: a pre and postintervention study. Acta Anaesthesiol Scand2015; 59:205–214.

Cited Here |View Full Text | PubMed | CrossRef

  1. Rosenberg NM, Urman RD, Gallagher S, et al. Effect of an office-based surgical safety system on patient outcomes. Eplasty2012; 12:e59–e159.

Cited Here

  1. Sewell M, Adebibe M, Jayakumar P, et al. Use of the WHO surgical safety checklist in trauma and orthopaedic patients. Int Orthop (SICOT)2011; 35:897–901.

Cited Here

  1. Tillman M, Wehbe-Janek H, Hodges B, et al. Surgical care improvement project and surgical site infections: can integration in the surgical safety checklist improve quality performance and clinical outcomes? J Surg Res2013; 184:150–156.

Cited Here |PubMed | CrossRef

  1. Toor AA, Farooka MW, Ayyaz M, et al. Preoperative antibiotic use reduces surgical site infection. J Pak Med Assoc2015; 65:733–736.

Cited Here |PubMed

  1. Urbach DR, Govindarajan A, Saskin R, et al. Introduction of surgical safety checklists in Ontario, Canada. N Engl J Med2014; 370:1029–1038.

Cited Here |View Full Text | PubMed | CrossRef

  1. van Klei WA, Hoff RG, van Aarnhem EEHL, et al. Effects of the introduction of the WHO ‘Surgical Safety Checklist’ on in-hospital mortality: a cohort study. Ann Surg2012; 255:44–49.

Cited Here |PubMed | CrossRef

  1. Weiser TG, Haynes AB, Dziekan G, et al. Effect of a 19-item surgical safety checklist during urgent operations in a global patient population. Ann Surg2010; 251:976–980.

Cited Here |View Full Text | PubMed | CrossRef

  1. Haynes AB, Berry WR, Gawande AA. What do we know about the safe surgery checklist now? Ann Surg2015; 261:829–830.

Cited Here |View Full Text | PubMed | CrossRef

 

 

  1. Conley DM, Singer SJ, Edmondson L, et al. Effective surgical safety checklist implementation. J Am Coll Surg2011; 212:873–879.

Cited Here |PubMed | CrossRef

  1. Russ S, Rout S, Caris J, et al. Measuring variation in use of the WHO surgical safety checklist in the operating room: a multicenter prospective cross-sectional study. J Am Coll Surg2015; 220:1–11.e14.

Cited Here |PubMed | CrossRef

  1. Russ SJ, Sevdalis N, Moorthy K, et al. A 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 Project’. Ann Surg2015; 261:81–91.

Cited Here |View Full Text | PubMed | CrossRef

  1. Russ S, Rout S, Sevdalis N, et al. Do safety checklists improve teamwork and communication in the operating room? A systematic review. Ann Surg2013; 248:856–871.

Cited Here |View Full Text | PubMed | CrossRef

  1. Haugen A, Høyland S, Thomassen Ø, et al. ‘It’s a State of Mind’: a qualitative study after two years’ experience with the World Health Organization’s surgical safety checklist. Cognit Technol Work2015; 17:55–62.

Cited Here

  1. Ringvold EM, Bekkevold M, Bruun AMG, et al. Norwegian standard for the safe practice of anaesthesia. Acta Anaesthesiol Scand2018; 62:411–417.

Cited Here |View Full Text | PubMed | CrossRef

  1. WHO. The WHO surgical safety checklist: adaptation guide. Geneva: World Health Organization; 2018.

Cited Here

  1. Gaba DM, Fish KJ, Howard SK, et al. Crisis management in anesthesiology E-Book. Amsterdam: Elsevier Health Sciences; 2014.

Cited Here

  1. McEvoy MD, Field LC, Moore HE, et al. The effect of adherence to ACLS protocols on survival of event in the setting of in-hospital cardiac arrest. Resuscitation2014; 85:82–87.

Cited Here |PubMed | CrossRef

  1. Goldhaber-Fiebert SN, Howard SK. Implementing emergency manuals: can cognitive aids help translate best practices for patient care during acute events? Anesth Analg2013; 117:1149–1161.

Cited Here | View Full Text | PubMed | CrossRef

  1. Hepner DL, Arriaga AF, Cooper JB, et al. Operating room crisis checklists and emergency manuals. Anesthesiology2017; 127:384–392.

Cited Here |View Full Text | PubMed | CrossRef

  1. Arriaga AF, Bader AM, Wong JM, et al. Simulation-based trial of surgical-crisis checklists. N Engl J Med2013; 368:246–253.

Cited Here |View Full Text | PubMed | CrossRef

  1. Harrison TK, Manser T, Howard SK, et al. Use of cognitive aids in a simulated anesthetic crisis. Anesth Analg2006; 103:551–556.

Cited Here |View Full Text | PubMed | CrossRef

  1. Neal JM, Hsiung RL, Mulroy MF. ASRA checklist improves trainee performance during a simulated episode of local anesthetic systemic toxicity. Reg Anesth Pain Med2012; 37:8–15.

Cited Here |View Full Text | PubMed | CrossRef

  1. Koers L, van Haperen M, Meijer CG, et al. Effect of cognitive aids on adherence to best practice in the treatment of deteriorating surgical patients: a randomized clinical trial in a simulation setting. JAMA Surg2019; 155:e194704.

Cited Here |View Full Text | PubMed | CrossRef

  1. Penguin Books Islamabad, India, Gawande A. Checklist manifesto, the (HB). 2010.

Cited Here

  1. Bourne LE Jr, Yaroush RA. Stress and cognition: a cognitive psychological perspective. 2003.

Cited Here

  1. Dismukes R, Goldsmith TE, Kochan JA. Effects of acute stress on aircrew performance: literature review and analysis of operational aspects. 2015.

Cited Here

  1. Everett TC, Morgan P, Brydges R, et al. The impact of critical event checklists on medical management and teamwork during simulated crises in a surgical daycare facility. Anaesthesia2017; 72:350–358.

Cited Here |View Full Text | PubMed | CrossRef

  1. Burden AR, Carr ZJ, Staman GW, et al. Does every code need a ‘reader?’ improvement of rare event management with a cognitive aid ‘reader’ during a simulated emergency: a pilot study. Simul Healthc2012; 7:1–9.

Cited Here |View Full Text | PubMed | CrossRef

  1. Goldhaber-Fiebert SN, Lei V, Nandagopal K, et al. Emergency manual implementation: can brief simulation-based OR staff trainings increase familiarity and planned clinical use? Jt Comm J Qual Patient Saf2015; 41:212–A217.

Cited Here |PubMed

  1. King W, Lomax S. Who should read cognitive aid prompts? Anaesthesia2017; 72:795–796.

Cited Here |View Full Text | PubMed | CrossRef

  1. Merrell SB, Gaba DM, Agarwala AV, et al. Use of an emergency manual during an intraoperative cardiac arrest by an interprofessional team: a positive-exemplar case study of a new patient safety tool. Jt Comm J Qual Patient Saf2018; 44:477–484.

Cited Here |PubMed

  1. Clebone A, Burian BK, Watkins SC, et al. The development and implementation of cognitive aids for critical events in pediatric anesthesia: the Society for Pediatric Anesthesia Critical Events Checklists. Anesth Analg2017; 124:900–907.

Cited Here |View Full Text | PubMed | CrossRef

  1. Evans D, McCahon R, Barley M, et al. Cognitive Aids in Medicine Assessment Tool (CMAT): preliminary validation of a novel tool for the assessment of emergency cognitive aids. Anaesthesia2015; 70:922–932.

Cited Here |View Full Text | PubMed | CrossRef

  1. Hales B, Terblanche M, Fowler R, et al. Development of medical checklists for improved quality of patient care. Int J Qual Health Care2007; 20:22–30.

Cited Here |View Full Text | PubMed | CrossRef

  1. Fletcher G, Flin R, McGeorge P, et al. Anaesthetists’ Non-Technical Skills (ANTS): evaluation of a behavioural marker system. Br J Anaesth2003; 90:580–588.

Cited Here |View Full Text | PubMed | CrossRef

  1. Ghaferi AA, Dimick JB. Importance of teamwork, communication and culture on failure-to-rescue in the elderly. Br J Surg2016; 103:e47–e51.

Cited Here |View Full Text | PubMed | CrossRef

  1. Marshall SD, Mehra R. The effects of a displayed cognitive aid on nontechnical skills in a simulated ‘can’t intubate, can’t oxygenate’crisis. Anaesthesia2014; 69:669–677.

Cited Here |View Full Text | PubMed | CrossRef

  1. Gaba DM, Howard SK, Fish KJ, et al. Simulation-based training in anesthesia crisis resource management (ACRM): a decade of experience. Simul Gaming2001; 32:175–193.

Cited Here |CrossRef

  1. Abir G, Austin N, Seligman KM, et al. Cognitive aids in obstetric units: design, implementation, and use. Anesth Analg2020; 130:1341–1350.

Cited Here |View Full Text | PubMed | CrossRef

  1. Huang J, Wu J, Dai C, et al. Use of emergency manuals during actual critical events in China: a multiinstitutional study. Simul Healthc2018; 13:253–260.

Cited Here |View Full Text | PubMed | CrossRef

  1. Goldhaber-Fiebert SN, Pollock J, Howard SK, et al. Emergency manual uses during actual critical events and changes in safety culture from the perspective of anesthesia residents: a pilot study. Anesth Analg2016; 123:641–649.

Cited Here |View Full Text | PubMed | CrossRef

  1. Neily J, DeRosier JM, Mills PD, et al. Awareness and use of a cognitive aid for anesthesiology. Jt Comm J Qual Patient Saf2007; 33:502–511.

Cited Here |PubMed

  1. Agarwala AV, McRichards LK, Rao V, et al. Bringing perioperative emergency manuals to your institution: a ‘How To’ from concept to implementation in 10 steps. Jt Comm J Qual Patient Saf2019; 45:170–179.

Cited Here |PubMed

  1. Alidina S, Goldhaber-Fiebert SN, Hannenberg AA, et al. Factors associated with the use of cognitive aids in operating room crises: a cross-sectional study of US hospitals and ambulatory surgical centers. Implement Sci2018; 13:50.

Cited Here

  1. Gleich SJ, Pearson AC, Lindeen KC, et al. Emergency manual implementation in a large academic anesthesia practice: strategy and improvement in performance on critical steps. Anesth Analg2019; 128:335–341.

Cited Here |View Full Text | PubMed | CrossRef

  1. Eberl S, Koers L, Van Haperen M, et al. Cognitive aids:’a must’for procedures performed by multidisciplinary sedation teams outside the operation room? Case Rep2017; 2017:bcr-2017-221645.

Cited Here

  1. Ramirez M, Grantham C. Crisis checklists for the operating room, not with a simulator. J Am Coll Surg2012; 215:302–303.

Cited Here |PubMed | CrossRef

  1. Ranganathan P, Phillips JH, Attaallah AF, et al. The use of cognitive aid checklist leading to successful treatment of malignant hyperthermia in an infant undergoing cranioplasty. Anesth Analg2014; 118:1387.

Cited Here |View Full Text | PubMed | CrossRef

  1. Goldhaber-Fiebert SN, Macrae C. Emergency manuals: how quality improvement and implementation science can enable better perioperative management during crises. Anesthesiol Clin2018; 36:45–62.

Cited Here

  1. Powell BJ, Waltz TJ, Chinman MJ, et al. A refined compilation of implementation strategies: results from the Expert Recommendations for Implementing Change (ERIC) project. Implement Sci2015; 10:21.

Cited Here

  1. Hendrickx J. Anesthetic monitoring recommendations: How consistent are they across the globe? APSF Newsletter2019; 34:34–36.

Cited Here

  1. American Society of Anesthesiologists: Standards for basic anesthetic monitoring. 2015. https://www.asahq.org/standards-and-guidelines/standards-for-basic-anesthetic-monitoring. [Accessed 7 December 2019]

Cited Here

  1. Anaesthesiologists HKCo. Guidelines on monitoring in anaesthesia. Version 5. 2017; ##DeleteExtraTag##https://www.hkca.edu.hk/ANS/standard_publications/guidep01.pdf. [Accessed 7 May 2019].
  2. Gelb A, Morriss W, Johnson W, et al. International Standards for a Safe Practice of Anesthesia Workgroup. World Health Organization–World Federation of Societies of Anaesthesiologists (WHO–WFSA) International Standards for a Safe Practice of Anesthesia. Can J Anesth2018; 65:698–708.

Cited Here

  1. Dilger JP. From individual to population: the minimum alveolar concentration curve. Curr Opin Anesthesiol2006; 19:390–396.

Cited Here |View Full Text | PubMed | CrossRef

  1. Katoh T, Ikeda K. The effects of fentanyl on sevoflurane requirements for loss of consciousness and skin incision. Anesthesiology1998; 88:18–24.

Cited Here |View Full Text | PubMed | CrossRef

  1. Avidan MS, Jacobsohn E, Glick D, et al. Prevention of intraoperative awareness in a high-risk surgical population. N Engl J Med2011; 365:591–600.

Cited Here |View Full Text | PubMed | CrossRef

  1. Chortkoff BS, Gonsowski CT, Bennett HL, et al. Subanesthetic concentrations of desflurane and propofol suppress recall of emotionally charged information. Anesth Analg1995; 81:728–736.

Cited Here |View Full Text | PubMed | CrossRef

  1. Jin Z, Feldman J, Gan TJ. Depth of Anesthesia Monitoring—Why Not a Standard of Care? APSF Newsletter2019; 34:43–44.

Cited Here

  1. Stoelting RK. Monitoring of neuromuscular blockade: what would you expect if you were the patient. APSF Newsl2016; 30:45–47.

Cited Here

  1. NHS Digital. Hospital admitted patient care activity, 2017–18. 2018; ##DeleteExtraTag##https://digital.nhs.uk/data-and-information/publications/statistical/hospital-admitted-patient-care-activity/2017-18[Accessed 7 December 2019].

Cited Here

  1. Griffiths P, Maruotti A, Saucedo AR, et al. Nurse staffing, nursing assistants and hospital mortality: retrospective longitudinal cohort study. BMJ Qual Saf2019; 28:609–617.

Cited Here |View Full Text | PubMed | CrossRef

  1. Volchenboum SL, Mayampurath A, Göksu-Gürsoy G, et al. Association between in-hospital critical illness events and outcomes in patients on the same ward. JAMA2016; 316:2674–2675.

Cited Here |View Full Text | PubMed | CrossRef

  1. Bannard-Smith J, Lighthall GK, Subbe CP, et al. Clinical outcomes of patients seen by rapid response teams: a template for benchmarking international teams. Resuscitation2016; 107:7–12.

Cited Here |PubMed | CrossRef

  1. Foraida MI, DeVita MA, Braithwaite RS, et al. Improving the utilization of medical crisis teams (condition C) at an urban tertiary care hospital. J Crit Care2003; 18:87–94.

Cited Here |View Full Text | PubMed | CrossRef

  1. Lee A, Bishop G, Hillman K, et al. The medical emergency team. Anaesth Intensive Care1995; 23:183–186.

Cited Here |PubMed | CrossRef

  1. Priestley G, Watson W, Rashidian A, et al. Introducing critical care outreach: a ward-randomised trial of phased introduction in a general hospital. Intensive Care Med2004; 30:1398–1404.

Cited Here |View Full Text | PubMed

  1. DeVita MA, Bellomo R, Hillman K, et al. Findings of the first consensus conference on medical emergency teams. Crit Care Med2006; 34:2463–2478.

Cited Here |View Full Text | PubMed | CrossRef

  1. Olsen SL, Søreide E, Hillman K, et al. Succeeding with rapid response systems-a never-ending process: a systematic review of how health-care professionals perceive facilitators and barriers within the limbs of the RRS. Resuscitation2019; 144:75–90.

Cited Here |PubMed | CrossRef

  1. Kipnis P, Turk BJ, Wulf DA, et al. Development and validation of an electronic medical record-based alert score for detection of inpatient deterioration outside the ICU. J Biomed Inform2016; 64:10–19.

Cited Here |PubMed | CrossRef

  1. Odell M. Patient-and relative-activated critical care outreach: a 7-year service review. Br J Nurs2019; 28:116–121.

Cited Here |PubMed | CrossRef

  1. Royal College of Physicians, London, Williams B, Alberti G, Ball C, et al. National Early Warning Score (NEWS), standardising the assessment of acuteillness severity in the NHS. 2012.

Cited Here

  1. Frost SA, Chapman A, Aneman A, et al. Hospital outcomes associated with introduction of a two-tiered response to the deteriorating patient. Crit Care Resusc2015; 17:77.

Cited Here |PubMed

  1. Subbe CP, Bannard-Smith J, Bunch J, et al. Quality metrics for the evaluation of rapid response systems: proceedings from the third international consensus conference on rapid response systems. Resuscitation2019; 141:1–12.

Cited Here |PubMed | CrossRef

  1. Douw G, Huisman-de Waal G, van Zanten AR, et al. Capturing early signs of deterioration: the dutch-early-nurse-worry-indicator-score and its value in the rapid response system. J Clin Nurs2017; 26:2605–2613.

Cited Here |View Full Text | PubMed | CrossRef

  1. Subbe CP, Welch JR. Failure to rescue: using rapid response systems to improve care of the deteriorating patient in hospital. Clin Risk2013; 19:6–11.

Cited Here |CrossRef

  1. DeVita MA, Smith GB, Adam SK, et al. Identifying the hospitalised patient in crisis’ – a consensus conference on the afferent limb of rapid response systems. Resuscitation2010; 81:375–382.

Cited Here |PubMed | CrossRef

  1. Subbe CP, Duller B, Bellomo R. Effect of an automated notification system for deteriorating ward patients on clinical outcomes. Crit Care2017; 21:52.

Cited Here |PubMed | CrossRef

  1. Martin HA, Ciurzynski SM. Situation, background, assessment, and recommendation–guided huddles improve communication and teamwork in the emergency department. J Emerg Nurs2015; 41:484–488.

Cited Here |View Full Text | PubMed | CrossRef

  1. Subbe CP, Kellett J, Barach P, et al. Crisis checklists for in-hospital emergencies: expert consensus, simulation testing and recommendations for a template determined by a multiinstitutional and multidisciplinary learning collaborative. BMC Health Serv Res2017; 17:334.

Cited Here |PubMed

  1. Pearse W, Oprescu F, Endacott J, et al. Advance care planning in the context of clinical deterioration: a systematic review of the literature. Palliat Care2019; 12:1178224218823509.

Cited Here

  1. Oglesby KJ, Durham L, Welch J, et al. ‘Score to Door Time’, a benchmarking tool for rapid response systems: a pilot multicentre service evaluation. Crit Care2011; 15:R180.

Cited Here |PubMed | CrossRef

  1. Solomon RS, Corwin GS, Barclay DC, et al. Effectiveness of rapid response teams on rates of in-hospital cardiopulmonary arrest and mortality: a systematic review and meta-analysis. J Hosp Med2016; 11:438–445.

Cited Here |View Full Text | PubMed | CrossRef

  1. De Jong A, Jung B, Daurat A, et al. Effect of rapid response systems on hospital mortality: a systematic review and meta-analysis. Intensive Care Med2016; 42:615–617.

Cited Here |PubMed | CrossRef

  1. Maharaj R, Raffaele I, Wendon J. Rapid response systems: a systematic review and meta-analysis. Crit Care2015; 19:254.

Cited Here |PubMed | CrossRef

  1. Hillman K, Chen J, Cretikos M, et al. MERIT study investigators. Introduction of the medical emergency team (MET) system: a cluster-randomised controlled trial. Lancet2005; 365:2091–2097.

Cited Here |PubMed | CrossRef

  1. Shankar-Hari M, Harrison DA, Rowan KM, et al. Estimating attributable fraction of mortality from sepsis to inform clinical trials. J Crit Care2018; 45:33–39.

Cited Here |View Full Text | PubMed | CrossRef

  1. Jones D, Hicks P, Currey J, et al. Findings of the first ANZICS conference on the role of intensive care in Rapid Response Teams. Anaesth Intensive Care2015; 43:369–379.

Cited Here |PubMed | CrossRef

  1. Wade DM, Mouncey PR, Richards-Belle A, et al. Effect of a nurse-led preventive psychological intervention on symptoms of posttraumatic stress disorder among critically ill patients: a randomized clinical trial. JAMA2019; 321:665–675.

Cited Here |View Full Text | PubMed | CrossRef

  1. Pearse RM, Moreno RP, Bauer P, et al. Mortality after surgery in Europe: a 7 day cohort study. Lancet2012; 380:1059–1065.

Cited Here |PubMed | CrossRef

  1. Ghaferi AA, Birkmeyer JD, Dimick JB. Complications, failure to rescue, and mortality with major inpatient surgery in medicare patients. Ann Surg2009; 250:1029–1034.

Cited Here |View Full Text | PubMed | CrossRef

  1. Ludikhuize J, Smorenburg SM, de Rooij SE, et al. Identification of deteriorating patients on general wards; measurement of vital parameters and potential effectiveness of the Modified Early Warning Score. J Crit Care2012; 27:424.e7–424.e13.

Cited Here |CrossRef

  1. Subbe CP, Gao H, Harrison DA. Reproducibility of physiological track-and-trigger warning systems for identifying at-risk patients on the ward. Intensive Care Med2007; 33:619–624.

Cited Here |View Full Text | PubMed | CrossRef

  1. Posthuma LM, Visscher MJ, Hollmann MW, et al. Monitoring of high-and intermediate-risk surgical patients. Anesth Analg2019; 129:1185–1190.

Cited Here |View Full Text | PubMed | CrossRef

  1. Aiken LH, Sloane DM, Bruyneel L, et al. Nurse staffing and education and hospital mortality in nine European countries: a retrospective observational study. Lancet2014; 383:1824–1830.

Cited Here |PubMed | CrossRef

  1. Heller AR, Mees ST, Lauterwald B, et al. Detection of deteriorating patients on surgical wards outside the ICU by an automated MEWS-based early warning system with paging functionality. Ann Surg2020; 271:100–105.

Cited Here |View Full Text | PubMed | CrossRef

  1. Devereaux P, Xavier D, Pogue J, et al. Characteristics and short-term prognosis of perioperative myocardial infarction in patients undergoing noncardiac surgery: a cohort study. Ann Intern Med2011; 154:523–528.

Cited Here |View Full Text | PubMed | CrossRef

  1. Watkinson P, Barber V, Price J, et al. A randomised controlled trial of the effect of continuous electronic physiological monitoring on the adverse event rate in high risk medical and surgical patients. Anaesthesia2006; 61:1031–1039.

Cited Here |View Full Text | PubMed | CrossRef

  1. Li T, Divatia S, McKittrick J, et al. A pilot study of respiratory rate derived from a wearable biosensor compared with capnography in emergency department patients. Open Access Emerg Med2019; 11:103.

Cited Here

  1. McGillion MH, Duceppe E, Allan K, et al. Postoperative remote automated monitoring: need for and state of the science. Can J Cardiol2018; 34:850–862.

Cited Here |PubMed | CrossRef

  1. Michard F, Sessler D. Ward monitoring 3.0. Br J Anaesth2018; 121:999–1001.

Cited Here |View Full Text | PubMed | CrossRef

  1. Breteler MJ, Huizinga E, van Loon K, et al. Reliability of wireless monitoring using a wearable patch sensor in high-risk surgical patients at a step-down unit in the Netherlands: a clinical validation study. BMJ Open2018; 8:e020162.

Cited Here

  1. Granholm A, Pedersen N, Lippert A, et al. Respiratory rates measured by a standardised clinical approach, ward staff, and a wireless device. Acta Anaesthesiol Scand2016; 60:1444–1452.

Cited Here |View Full Text | PubMed | CrossRef

  1. Hernandez-Silveira M, Ahmed K, Ang S-S, et al. Assessment of the feasibility of an ultra-low power, wireless digital patch for the continuous ambulatory monitoring of vital signs. BMJ Open2015; 5:e006606.

Cited Here

  1. Bedoya AD, Clement ME, Phelan M, et al. Minimal impact of implemented early warning score and best practice alert for patient deterioration. Crit Care Med2019; 47:49–55.

Cited Here |View Full Text | PubMed | CrossRef

  1. Mok W, Wang W, Cooper S, et al. Attitudes towards vital signs monitoring in the detection of clinical deterioration: scale development and survey of ward nurses. Int J Qual Health Care2015; 27:207–213.

Cited Here |View Full Text | PubMed | CrossRef

  1. Badawy J, Nguyen OK, Clark C, et al. Is everyone really breathing 20 times a minute? Assessing epidemiology and variation in recorded respiratory rate in hospitalised adults. BMJ Qual Saf2017; 26:832–836.

Cited Here | View Full Text | PubMed | CrossRef

  1. Cooper SJR, Cant RP, Sparkes LM. Respiratory rate records: the repeated rate? J Clin Nurs2014; 23:1236–1238.

Cited Here |View Full Text | PubMed | CrossRef

  1. Downey C, Tahir W, Randell R, et al. Strengths and limitations of early warning scores: a systematic review and narrative synthesis. Int J Nurs Stud2017; 76:106–119.

Cited Here |PubMed | CrossRef

  1. Ayad S, Khanna AK, Iqbal SU, et al. Characterisation and monitoring of postoperative respiratory depression: current approaches and future considerations. Br J Anaesth2019; 123:378–391.

Cited Here |View Full Text | PubMed | CrossRef

  1. Sasaki N, Meyer MJ, Eikermann M. Postoperative respiratory muscle dysfunctionpathophysiology and preventive strategies. Anesthesiology2013; 118:961–978.

Cited Here |View Full Text | PubMed | CrossRef

  1. Posthuma LM, Visscher MJ, Lirk PB, et al. Insights into postoperative respiration by using continuous wireless monitoring of respiratory rate on the postoperative ward: a cohort study. J Clin Monit Comput2019; [Epub ahead of print].

Cited Here

  1. Finlay GD, Rothman MJ, Smith RA. Measuring the modified early warning score and the Rothman index: advantages of utilizing the electronic medical record in an early warning system. J Hosp Med2014; 9:116–119.

Cited Here |View Full Text | PubMed | CrossRef

  1. Seferovic PM, Ponikowski P, Anker SD, et al. Clinical practice update on heart failure 2019: pharmacotherapy, procedures, devices and patient management. An expert consensus meeting report of The Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail2019; 21:1169–1186.

Cited Here |View Full Text | CrossRef

  1. Massaroni C, Lo Presti D, Formica D, et al. Non-contact monitoring of breathing pattern and respiratory rate via RGB signal measurement. Sensors2019; 19:2758.

Cited Here

  1. Curry JP, Jungquist CR. A critical assessment of monitoring practices, patient deterioration, and alarm fatigue on inpatient wards: a review. Patient Saf Surg2014; 8:29.

Cited Here

  1. Clifton L, Clifton DA, Pimentel MA, et al. Predictive monitoring of mobile patients by combining clinical observations with data from wearable sensors. IEEE J Biomed Health Inform2013; 18:722–730.

Cited Here

  1. Sessler DI, Saugel B. Beyond ‘failure to rescue’: the time has come for continuous ward monitoring. Br J Anaesth2019; 122:304–306.

Cited Here |View Full Text | PubMed | CrossRef

  1. Ruppel H, Funk M, Whittemore R, et al. Critical care nurses’ clinical reasoning about physiologic monitor alarm customisation: an interpretive descriptive study. J Clin Nurs2019; 28:3033–3041.

Cited Here |View Full Text | PubMed | CrossRef

  1. Jeskey M, Card E, Nelson D, et al. Nurse adoption of continuous patient monitoring on acute postsurgical units: managing technology implementation. J Nurs Manag2011; 19:863–875.

Cited Here |View Full Text | PubMed | CrossRef

  1. Prgomet M, Cardona-Morrell M, Nicholson M, et al. Vital signs monitoring on general wards: clinical staff perceptions of current practices and the planned introduction of continuous monitoring technology. Int J Qual Health Care2016; 28:515–521.

Cited Here |View Full Text | PubMed | CrossRef

  1. Downey C, Brown J, Jayne D, et al. Patient attitudes towards remote continuous vital signs monitoring on general surgery wards: an interview study. Int J Med Inform2018; 114:52–56.

Cited Here |PubMed | CrossRef

  1. Slight SP, Franz C, Olugbile M, et al. The return on investment of implementing a continuous monitoring system in general medical–surgical units. Crit Care Med2014; 42:1862–1868.

Cited Here |View Full Text | PubMed | CrossRef

  1. Taenzer AH, Pyke JB, McGrath SP, et al. Impact of pulse oximetry surveillance on rescue events and intensive care unit transfersa before-and-after concurrence study. Anesthesiology2010; 112:282–287.

Cited Here |View Full Text | PubMed | CrossRef

  1. Nolan JP, Soar J, Smith GB, et al. Incidence and outcome of in-hospital cardiac arrest in the United Kingdom National Cardiac Arrest Audit. Resuscitation2014; 85:987–992.

Cited Here |PubMed | CrossRef

  1. Larsen MP, Eisenberg MS, Cummins RO, et al. Predicting survival from out-of-hospital cardiac arrest: a graphic model. Ann Emerg Med1993; 22:1652–1658.

Cited Here |PubMed | CrossRef

  1. Bircher NG, Chan PS, Xu Y. Delays in cardiopulmonary resuscitation, defibrillation, and epinephrine administration all decrease survival in in-hospital cardiac arrest. Anesthesiology2019; 130:414–422.

Cited Here |View Full Text | PubMed | CrossRef

  1. Sandroni C, Ferro G, Santangelo S, et al. In-hospital cardiac arrest: survival depends mainly on the effectiveness of the emergency response. Resuscitation2004; 62:291–297.

Cited Here |PubMed | CrossRef

  1. Løfgren B, Larsen C, Rasmussen M, et al. Limited knowledge of the crash call number among hospital staff – a call for standardisation. Resuscitation2010; 81:S28.

Cited Here |CrossRef

  1. Panesar SS, Ignatowicz AM, Donaldson LJ. Errors in the management of cardiac arrests: an observational study of patient safety incidents in England. Resuscitation2014; 85:1759–1763.

Cited Here |PubMed | CrossRef

  1. Lauridsen KG, Løfgren B. A call for 2222 in European hospitals – a reply to letter by Dr Whitaker. Resuscitation2016; 107:e19.

Cited Here |PubMed | CrossRef

  1. Whitaker DK. Reply to Letter: a call for 2222 in European hospitals. Resuscitation2016; 107:e21.

Cited Here |PubMed | CrossRef

  1. Wismar M, Maier CB, Glinos IA, et al. Health professional mobility and health systems. Evidence from 17 European countries: WHO Regional Office for Europe. 2011.

Cited Here

  1. Leotsakos A, Zheng H, Croteau R, et al. Standardization in patient safety: the WHO High 5 s project. Int J Qual Health Care2014; 26:109–116.

Cited Here |View Full Text | PubMed | CrossRef

  1. Rothwell P, Udwadia Z, Jackson E, et al. Cardiac arrest telephone numbers. Lancet1990; 335:1407.

Cited Here |PubMed | CrossRef

  1. Beshyah SA, Schiff R, Al-Jehani FS. National crash call number is needed. BMJ1996; 313:429.

Cited Here |View Full Text | PubMed | CrossRef

  1. Whitaker DK, Nolan JP, Castrén M, et al. Implementing a standard internal telephone number 2222 for cardiac arrest calls in all hospitals in Europe. Resuscitation2017; 115:A14–A15.

Cited Here |PubMed | CrossRef

  1. Agency NPS. Establishing a standard crash call telephone number in hospitals. 2004.

Cited Here

  1. Giusti GD, Reitano B, Lusignani M, et al. Italian in-hospital emergency number: a call for action. Resuscitation2019; 140:84–85.

Cited Here |PubMed | CrossRef

  1. Trenkler S, Simonova J, Grochova M. Implementing the standardised cardiac arrest call telephone number for all European hospitals–2222. Resuscitation2017; 112:e5.

Cited Here |PubMed | CrossRef

  1. Pincock S.. Colin Murdoch. Lancet2008; 371:1994.

Cited Here |PubMed | CrossRef

  1. Whitaker DK, Brattebo G, Smith AF, et al. The Helsinki Declaration on patient safety in anaesthesiology: putting words into practice. Best Pract Res Clin Anaesthesiol2011; 25:277–290.

Cited Here |PubMed | CrossRef

  1. Whitaker D, Brattebo G, Trenkler S, et al. The European Board of Anaesthesiology recommendations for safe medication practice: first update. Eur J Anaesthesiol2017; 34:4–7.

Cited Here |View Full Text | PubMed | CrossRef

  1. Yamamoto M, Ishikawa S, Makita K. Medication errors in anesthesia: an 8-year retrospective analysis at an urban university hospital. J Anesth2008; 22:248–252.

Cited Here |PubMed | CrossRef

  1. Webster CS, Merry AF, Larsson L, et al. The frequency and nature of drug administration error during anaesthesia. Anaesth Intensive Care2001; 29:494–500.

Cited Here |PubMed | CrossRef

  1. Nanji KC, Patel A, Shaikh S, et al. Evaluation of perioperative medication errors and adverse drug events. Anesthesiology2016; 124:25–34.

Cited Here |View Full Text | PubMed | CrossRef

  1. Sanduende-Otero Y, Villalón-Coca J, Romero-García E, et al. Patterns in medication incidents: a 10-yr experience of a cross-national anaesthesia incident reporting system. Br J Anaesth2019; 124:197–205.

Cited Here |PubMed | CrossRef

  1. Grigg EB, Roesler A. Anesthesia medication handling needs a new vision. Anesth Analg2018; 126:346–350.

Cited Here |View Full Text | PubMed | CrossRef

  1. Whitaker DK. Drug error and drug cupboard arrangements. Anaesthesia2019; 74:1201.

Cited Here |View Full Text | PubMed | CrossRef

  1. Grigg EB, Martin LD, Ross FJ, et al. Assessing the impact of the anesthesia medication template on medication errors during anesthesia: a prospective study. Anesth Analg2017; 124:1617–1625.

Cited Here |View Full Text | PubMed | CrossRef

  1. Almghairbi DS, Sharp L, Griffiths R, et al. An observational feasibility study of a new anaesthesia drug storage tray. Anaesthesia2018; 73:356–364.

Cited Here |View Full Text | PubMed | CrossRef

  1. Webster CS, Larsson L, Frampton CM, et al. Clinical assessment of a new anaesthetic drug administration system: a prospective, controlled, longitudinal incident monitoring study. Anaesthesia2010; 65:490–499.

Cited Here |View Full Text | PubMed | CrossRef

  1. Stucki C, Sautter AM, Favet J, et al. Microbial contamination of syringes during preparation: the direct influence of environmental cleanliness and risk manipulations on end-product quality. Am J Health Syst Pharm2009; 66:2032–2036.

Cited Here |View Full Text | PubMed | CrossRef

  1. Gargiulo DA, Mitchell SJ, Sheridan J, et al. Microbiological contamination of drugs during their administration for anesthesia in the operating room. Anesthesiology2016; 124:785–794.

Cited Here |View Full Text | PubMed | CrossRef

  1. Feinmann J. Doctors call for ban on multidose vials after hepatitis C outbreak in US. BMJ2010; 341:c4057.

Cited Here |View Full Text | PubMed | CrossRef

  1. Breton S, van Vlymen J, Xia S, et al. A survey of medication preparation and administration practices among members of the Canadian Anesthesiologists’ Society. Can J Anaesth2018; 65:1100–1109.

Cited Here |PubMed | CrossRef

  1. Thomas A, Taylor R. An analysis of patient safety incidents associated with medications reported from critical care units in the North West of England between 2009 and 2012. Anaesthesia2014; 69:735–745.

Cited Here |View Full Text | PubMed | CrossRef

  1. Cook T, Wilkes A, Bickford Smith P, et al. Multicentre clinical simulation evaluation of the ISO 80369-6 neuraxial non-Luer connector. Anaesthesia2019; 74:619–629.

Cited Here |View Full Text | PubMed | CrossRef

  1. Kossover-Smith RA, Coutts K, Hatfield KM, et al. One needle, one syringe, only one time? A survey of physician and nurse knowledge, attitudes, and practices around injection safety. Am J Infect Control2017; 45:1018–1023.

Cited Here |View Full Text | PubMed | CrossRef

  1. Nathanson M, Andrzejowski J, Dinsmore J, et al. Guidelines for safe transfer of the brain-injured patient: trauma and stroke, 2019. Anaesthesia2020; 75:234–246.

Cited Here |PubMed | CrossRef

  1. Benhamou D, Piriou V, De Vaumas C, et al. Ready-to-use prefilled syringes of atropine for anaesthesia care in French hospitals – a budget impact analysis. Anaesth Crit Care Pain Med2017; 36:115–121.

Cited Here |PubMed | CrossRef

  1. Yang Y, Rivera AJ, Fortier CR, et al. A human factors engineering study of the medication delivery process during an anesthetic: self-filled syringes versus prefilled syringes. Anesthesiology2016; 124:795–803.

Cited Here |View Full Text | PubMed | CrossRef

  1. Shelton CL, McBain SC, Mortimer F, et al. A new role for anaesthetists in environmentally-sustainable healthcare. Anaesthesia2019; 74:1091–1094.

Cited Here |View Full Text | PubMed | CrossRef

  1. Shida K, Suzuki T, Sugahara K, et al. Current situation survey of the measures to prevent medication errors in the operating room: report of the Japan Society of Anesthesiologists Safety Commission Working Group for consideration of recommendations for color coding of prepared syringe labels for prevention of medication errors. Masui2016; 65:542–547.

Cited Here |PubMed

  1. Wheeler DW, Degnan BA, Sehmi JS, et al. Variability in the concentrations of intravenous drug infusions prepared in a critical care unit. Intensive Care Med2008; 34:1441–1447.

Cited Here |View Full Text | PubMed | CrossRef

  1. Barker P, Creasey PE, Dhatariya K, et al. Membership of the Working Party. Peri-operative management of the surgical patient with diabetes 2015: Association of Anaesthetists of Great Britain and Ireland. Anaesthesia2015; 70:1427–1440.

Cited Here |View Full Text | PubMed | CrossRef

  1. Dunne T, Whitaker D. Prefilled insulin syringes. Anaesthesia2016; 71:349–350.

Cited Here |View Full Text | PubMed | CrossRef

  1. Merry AF, Webster CS, Mathew DJ. A new, safety-oriented, integrated drug administration and automated anesthesia record system. Anesth Analg2001; 93:385–390. 383rd contents page.

Cited Here |View Full Text | PubMed | CrossRef

  1. Evley R, Russell J, Mathew D, et al. Confirming the drugs administered during anaesthesia: a feasibility study in the pilot National Health Service sites, UK. Br J Anaesth2010; 105:289–296.

Cited Here |View Full Text | PubMed | CrossRef

  1. Hinkelbein J, Lamperti M, Akeson J, et al. European Society of Anaesthesiology and European Board of Anaesthesiology guidelines for procedural sedation and analgesia in adults. Eur J Anaesthesiol2018; 35:6–24.

Cited Here |View Full Text | PubMed | CrossRef

  1. [No authors listed]. Practice Guidelines for Moderate Procedural Sedation and Analgesia 2018: a report by the American Society of Anesthesiologists Task Force on Moderate Procedural Sedation and Analgesia, the American Association of Oral and Maxillofacial Surgeons, American College of Radiology, American Dental Association, American Society of Dentist Anesthesiologists, and Society of Interventional Radiology. Anesthesiology2018; 128:437–479.

Cited Here |View Full Text | PubMed

  1. Committee ASoP, Early DS, Lightdale JR, et al. Guidelines for sedation and anesthesia in GI endoscopy. Gastrointest Endosc2018; 87:327–337.

Cited Here |PubMed | CrossRef

  1. Sneyd JR. Making sense of propofol sedation for endoscopy. Br J Anaesth2017; 118:6–7.

Cited Here |View Full Text | PubMed | CrossRef

  1. Leslie K, Allen ML, Hessian EC, et al. Safety of sedation for gastrointestinal endoscopy in a group of university-affiliated hospitals: a prospective cohort study. Br J Anaesth2017; 118:90–99.

Cited Here |View Full Text | PubMed | CrossRef

  1. Barends CRM, Absalom AR, Struys M. Drug selection for ambulatory procedural sedation. Curr Opin Anaesthesiol2018; 31:673–678.

Cited Here |View Full Text | PubMed | CrossRef

  1. Raeder J. Procedural sedation in ambulatory anaesthesia: what’s new? Curr Opin Anaesthesiol2019; 32:743–748.

Cited Here |View Full Text | PubMed | CrossRef

  1. Sahinovic MM, Struys M, Absalom AR. Clinical pharmacokinetics and pharmacodynamics of propofol. Clin Pharmacokinet2018; 57:1539–1558.

Cited Here |PubMed | CrossRef

  1. Absalom AR, Glen JI, Zwart GJ, et al. Target-controlled infusion: a mature technology. Anesth Analg2016; 122:70–78.

Cited Here |View Full Text | PubMed | CrossRef

  1. Eleveld DJ, Colin P, Absalom AR, et al. Pharmacokinetic-pharmacodynamic model for propofol for broad application in anaesthesia and sedation. Br J Anaesth2018; 120:942–959.

Cited Here |View Full Text | PubMed | CrossRef

  1. Eleveld DJ, Proost JH, Vereecke H, et al. An allometric model of remifentanil pharmacokinetics and pharmacodynamics. Anesthesiology2017; 126:1005–1018.

Cited Here |View Full Text | PubMed | CrossRef

  1. Kim TK, Obara S, Egan TD, et al. Disposition of remifentanil in obesity: a new pharmacokinetic model incorporating the influence of body mass. Anesthesiology2017; 126:1019–1032.

Cited Here |View Full Text | PubMed | CrossRef

  1. LaPierre CD, Johnson KB, Randall BR, et al. An exploration of remifentanil-propofol combinations that lead to a loss of response to esophageal instrumentation, a loss of responsiveness, and/or onset of intolerable ventilatory depression. Anesth Analg2011; 113:490–499.

Cited Here |View Full Text | PubMed

  1. Jalili M, Bahreini M, Doosti-Irani A, et al. Ketamine-propofol combination (ketofol) vs propofol for procedural sedation and analgesia: systematic review and meta-analysis. Am J Emerg Med2016; 34:558–569.

Cited Here |View Full Text | PubMed | CrossRef

  1. Forster C, Vanhaudenhuyse A, Gast P, et al. Intravenous infusion of lidocaine significantly reduces propofol dose for colonoscopy: a randomised placebo-controlled study. Br J Anaesth2018; 121:1059–1064.

Cited Here |View Full Text | PubMed | CrossRef

  1. Weerink MAS, Struys M, Hannivoort LN, et al. Clinical pharmacokinetics and pharmacodynamics of dexmedetomidine. Clin Pharmacokinet2016; 56:893–913.

Cited Here |PubMed | CrossRef

  1. Colin PJ, Hannivoort LN, Eleveld DJ, et al. Dexmedetomidine pharmacokinetic-pharmacodynamic modelling in healthy volunteers: 1. Influence of arousal on bispectral index and sedation. Br J Anaesth2017; 119:200–210.

Cited Here |View Full Text | PubMed | CrossRef

  1. Colin PJ, Hannivoort LN, Eleveld DJ, et al. Dexmedetomidine pharmacodynamics in healthy volunteers: 2. Haemodynamic profile. Br J Anaesth2017; 119:211–220.

Cited Here |View Full Text | PubMed | CrossRef

  1. Hannivoort LN, Eleveld DJ, Proost JH, et al. Development of an optimized pharmacokinetic model of dexmedetomidine using target-controlled infusion in healthy volunteers. Anesthesiology2015; 123:357–367.

Cited Here |View Full Text | PubMed | CrossRef

  1. Weerink MAS, Barends CRM, Muskiet ERR, et al. Pharmacodynamic interaction of remifentanil and dexmedetomidine on depth of sedation and tolerance of laryngoscopy. Anesthesiology2019; 131:1004–1017.

Cited Here |View Full Text | PubMed | CrossRef

  1. Lodenius A, Ebberyd A, Hardemark Cedborg A, et al. Sedation with dexmedetomidine or propofol impairs hypoxic control of breathing in healthy male volunteers: a nonblinded, randomized crossover study. Anesthesiology2016; 125:700–715.

Cited Here |View Full Text | PubMed | CrossRef

  1. Tanious MK, Beutler SS, Kaye AD, et al. New hypnotic drug development and pharmacologic considerations for clinical anesthesia. Anesthesiol Clin2017; 35:e95–e113.

Cited Here

  1. Borkett KM, Riff DS, Schwartz HI, et al. A Phase IIa, randomized, double-blind study of remimazolam (CNS 7056) versus midazolam for sedation in upper gastrointestinal endoscopy. Anesth Analg2015; 120:771–780.

Cited Here |View Full Text | PubMed | CrossRef

  1. Pambianco DJ, Borkett KM, Riff DS, et al. A phase IIb study comparing the safety and efficacy of remimazolam and midazolam in patients undergoing colonoscopy. Gastrointest Endosc2016; 83:984–992.

Cited Here |PubMed | CrossRef

  1. Parida S, Kundra P, Mohan VK, et al. Standards of care for procedural sedation: focus on differing perceptions among societies. Indian J Anaesth2018; 62:493–496.

Cited Here |PubMed | CrossRef

  1. World Health Organization. 63rd World health assembly. Availability, safety and quality of blood products. 2010.

Cited Here

  1. Shander A, Goodnough LT, Javidroozi M, et al. Iron deficiency anemia-bridging the knowledge and practice gap. Transfus Med Rev2014; 28:156–166.

Cited Here |PubMed | CrossRef

  1. Muñoz M, Gómez-Ramírez S, Campos A, et al. Preoperative anaemia: prevalence, consequences and approaches to management. Blood Transfus2015; 13:370.

Cited Here |PubMed

  1. AABB. Standards for a patient blood management program. 2014.

Cited Here

  1. Government of Western Australia Department of Health. Patient blood management guidelines and standards. https://ww2.health.wa.gov.au/Articles/N_R/Patient-blood-management-guidelines-and-standards[Accessed 7 December 2019].

Cited Here

  1. Mueller MM, Van Remoortel H, Meybohm P, et al. Patient blood management: recommendations from the 2018 Frankfurt consensus conference. JAMA2019; 321:983–997.

Cited Here |View Full Text | PubMed | CrossRef

  1. Goodnough LT, Schrier SL. Evaluation and management of anemia in the elderly. Am J Hematol2014; 89:88–96.

Cited Here |View Full Text | PubMed | CrossRef

  1. Auerbach M, Macdougall IC. Safety of intravenous iron formulations: facts and folklore. Blood Transfus2014; 12:296–300.

Cited Here |PubMed

  1. Froessler B, Palm P, Weber I, et al. The important role for intravenous iron in perioperative patient blood management in major abdominal surgery: a randomized controlled trial. Ann Surg2016; 264:41–46.

Cited Here |View Full Text | PubMed | CrossRef

  1. Munoz M, Acheson AG, Auerbach M, et al. International consensus statement on the peri-operative management of anaemia and iron deficiency. Anaesthesia2017; 72:233–247.

Cited Here |View Full Text | PubMed | CrossRef

  1. Quintana-Diaz M, Fabra-Cadenas S, Gomez-Ramirez S, et al. A fast-track anaemia clinic in the Emergency Department: feasibility and efficacy of intravenous iron administration for treating sub-acute iron deficiency anaemia. Blood Transfus2016; 14:126–133.

Cited Here |PubMed

  1. Meybohm P, Goehring M, Choorapoikayil S, et al. Feasibility and efficiency of a preoperative anaemia walk-in clinic: secondary data from a prospective observational trial. Br J Anaesth2017; 118:625–626.

Cited Here |View Full Text | PubMed | CrossRef

  1. Spahn DR, Schoenrath F, Spahn GH, et al. Effect of ultra-short-term treatment of patients with iron deficiency or anaemia undergoing cardiac surgery: a prospective randomised trial. Lancet2019; 393:2201–2212.

Cited Here |PubMed | CrossRef

  1. Sehat K, Evans R, Newman J. Hidden blood loss following hip and knee arthroplasty: correct management of blood loss should take hidden loss into account. J Bone Joint Surg Br2004; 86:561–565.

Cited Here |View Full Text | PubMed | CrossRef

  1. Moulton MJ, Creswell LL, Mackey ME, et al. Reexploration for bleeding is a risk factor for adverse outcomes after cardiac operations. J Thorac Cardiovasc Surg1996; 111:1037–1046.

Cited Here |View Full Text | PubMed | CrossRef

  1. Meybohm P, Choorapoikayil S, Wessels A, et al. Washed cell salvage in surgical patients: a review and meta-analysis of prospective randomized trials under PRISMA. Medicine (Baltimore)2016; 95:e4490.

Cited Here |View Full Text | PubMed | CrossRef

  1. Raad S, Elliott R, Dickerson E, et al. Reduction of laboratory utilization in the intensive care unit. J Intensive Care Med2017; 32:500–507.

Cited Here |View Full Text | PubMed | CrossRef

  1. Westphal S, Zacharowski K, Kudraschow A, et al. Comparison of open and closed, invasive pressure monitoring devices in Patient Blood Management – review of engineering, outcome, patient safety and economic viability. Anästh Intensivmed2018; 59:1–7.

Cited Here

  1. Weber CF, Gorlinger K, Meininger D, et al. Point-of-care testing: a prospective, randomized clinical trial of efficacy in coagulopathic cardiac surgery patients. Anesthesiology2012; 117:531–547.

Cited Here |View Full Text | PubMed | CrossRef

  1. Munoz M, Gomez-Ramirez S, Kozek-Langeneker S. Preoperative haematological assessment in patients scheduled for major surgery. Anaesthesia2016; 71: (Suppl 1): 19–28.

Cited Here |View Full Text | PubMed | CrossRef

  1. Kozek-Langenecker SA, Ahmed AB, Afshari A, et al. Management of severe perioperative bleeding: guidelines from the European Society of Anaesthesiology: first update 2016. Eur J Anaesthesiol2017; 34:332–395.

Cited Here |View Full Text | PubMed | CrossRef

  1. Ker K, Prieto-Merino D, Roberts I. Systematic review, meta-analysis and meta-regression of the effect of tranexamic acid on surgical blood loss. Br J Surg2013; 100:1271–1279.

Cited Here |View Full Text | PubMed | CrossRef

  1. Hebert PC, Wells G, Blajchman MA, et al. A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion Requirements in Critical Care Investigators, Canadian Critical Care Trials Group. N Engl J Med1999; 340:409–417.

Cited Here |View Full Text | PubMed | CrossRef

  1. Hajjar LA, Vincent JL, Galas FR, et al. Transfusion requirements after cardiac surgery: the TRACS randomized controlled trial. JAMA2010; 304:1559–1567.

Cited Here |View Full Text | PubMed | CrossRef

  1. Carson JL, Terrin ML, Noveck H, et al. Liberal or restrictive transfusion in high-risk patients after hip surgery. N Engl J Med2011; 365:2453–2462.

Cited Here |View Full Text | PubMed | CrossRef

  1. Villanueva C, Colomo A, Bosch A, et al. Transfusion strategies for acute upper gastrointestinal bleeding. N Engl J Med2013; 368:11–21.

Cited Here |View Full Text | PubMed | CrossRef

  1. Goodnough LT, Shieh L, Hadhazy E, et al. Improved blood utilization using real-time clinical decision support. Transfusion2014; 54:1358–1365.

Cited Here |View Full Text | PubMed | CrossRef

  1. Goodnough TL, Baker AS, Shah N. How I use clinical decision support to improve red blood cell utilization. Transfusion2016; 56:2406–2411.

Cited Here |View Full Text | PubMed | CrossRef

  1. Leahy MF, Hofmann A, Towler S, et al. Improved outcomes and reduced costs associated with a health-system-wide patient blood management program: a retrospective observational study in four major adult tertiary-care hospitals. Transfusion2017; 57:1347–1358.

Cited Here |View Full Text | PubMed | CrossRef

  1. Leahy MF, Roberts H, Mukhtar SA, et al. A pragmatic approach to embedding patient blood management in a tertiary hospital. Transfusion2014; 54:1133–1145.

Cited Here |View Full Text | PubMed | CrossRef

  1. Meybohm P, Herrmann E, Steinbicker AU, et al. Patient blood management is associated with a substantial reduction of red blood cell utilization and safe for patient’s outcome. a prospective, multicenter cohort study with a noninferiority design. Ann Surg2016; 264:203–211.

Cited Here |View Full Text | PubMed | CrossRef

  1. Gross I, Seifert B, Hofmann A, et al. Patient blood management in cardiac surgery results in fewer transfusions and better outcome. Transfusion2015; 55:1075–1081.

Cited Here |View Full Text | PubMed | CrossRef

  1. Mehra T, Seifert B, Bravo-Reiter S, et al. Implementation of a patient blood management monitoring and feedback program significantly reduces transfusions and costs. Transfusion2015; 55:2807–2815.

Cited Here |View Full Text | PubMed | CrossRef

  1. Oliver JC, Griffin RL, Hannon T, et al. The success of our patient blood management program depended on an institution-wide change in transfusion practices. Transfusion2014; 54:2617–2624.

Cited Here |PubMed | CrossRef

  1. So-Osman C, Nelissen RG, Koopman-van Gemert AW, et al. Patient blood management in elective total hip- and knee-replacement surgery (part 2): a randomized controlled trial on blood salvage as transfusion alternative using a restrictive transfusion policy in patients with a preoperative hemoglobin above 13 g/dl. Anesthesiology2014; 120:852–860.

Cited Here |View Full Text | PubMed | CrossRef

  1. Theusinger OM, Kind SL, Seifert B, et al. Patient blood management in orthopaedic surgery: a four-year follow-up of transfusion requirements and blood loss from 2008 to 2011 at the Balgrist University Hospital in Zurich, Switzerland. Blood Transfus2014; 12:195–203.

Cited Here |PubMed

  1. Meybohm P, Herrmann E, Steinbicker AU, et al. Patient blood management is associated with a substantial reduction of red blood cell utilization and safe for patient’s outcome. Ann Surg2016; 264:203–211.

Cited Here |View Full Text | PubMed | CrossRef

  1. Keding V, Zacharowski K, Bechstein WO, et al. Patient blood management improves outcome in oncologic surgery. World J Surg Oncol2018; 16:159.

Cited Here

  1. Althoff FC, Neb H, Herrmann E, et al. Multimodal patient blood management program based on a three-pillar strategy: a systematic review and meta-analysis. Ann Surg2019; 269:794–804.

Cited Here |View Full Text | PubMed | CrossRef

  1. Meybohm P, Richards T, Isbister J, et al. Patient blood management bundles to facilitate implementation. Transfus Med Rev2017; 31:62–71.

Cited Here |PubMed | CrossRef

  1. European Commission. Supporting patient blood management (PBM) in the EU – a practical implementation guide for hospitals. 2017 https://ec.europa.eu/health/sites/health/files/blood_tissues_organs/docs/2017_eupbm_hospitals_en.pdf[Accessed 7 December 2019]

Cited Here

  1. European Commission. Building National Programmes of Patient Blood Management (PBM) in the EU A guide for health authorities. 2017; ##DeleteExtraTag##https://op.europa.eu/en/publication-detail/-/publication/5ec54745-1a8c-11e7-808e-01aa75ed71a1/language-en[Accessed 7 December 2019].

Cited Here

  1. National Blood Authority Australia. Patient blood management guidelines. https://www.nba.gov.au/patient-blood-management-pbm[Accessed 7 December 2019].

Cited Here

  1. Padhi S, Kemmis-Betty S, Rajesh S, et al. Guideline Development Group. Blood transfusion: summary of NICE guidance. BMJ2015; 351:h5832.

Cited Here |View Full Text | PubMed | CrossRef