Calcium Activity Dynamics Correlate with Neuronal Phenotype at a Single Cell Level and in a Threshold-Dependent Manner.

Calcium is a ubiquitous signaling molecule that plays a vital role in many physiological processes. Recent work has shown that calcium activity is especially critical in vertebrate neural development. Here, we investigated if calcium activity and neuronal phenotype are correlated only on a population level or on the level of single cells. Using Xenopus primary cell culture in which individual cells can be unambiguously identified and associated with a molecular phenotype, we correlated calcium activity with neuronal phenotype on the single-cell level. This analysis revealed that, at the neural plate stage, a high frequency of low-amplitude spiking activity correlates with an excitatory, glutamatergic phenotype, while high-amplitude spiking activity correlates with an inhibitory, GABAergic phenotype. Surprisingly, we also found that high-frequency, low-amplitude spiking activity correlates with neural progenitor cells and that differentiating cells exhibit higher spike amplitude. Additional methods of analysis suggested that differentiating marker tubb2b-expressing cells exhibit relatively persistent and predictable calcium activity compared to the irregular activity of neural progenitor cells. Our study highlights the value of using a range of thresholds for analyzing calcium activity data and underscores the importance of employing multiple methods to characterize the often irregular, complex patterns of calcium activity during early neural development.

A baseline assessment by healthcare professionals of Dutch pharmacotherapeutic care for the elderly with polypharmacy.

Background: Polypharmacy is common in the elderly population and is associated with an increased risk of adverse drug events. To diminish this risk, the guideline 'Polypharmacy in the Elderly' has been developed in 2012. This study examines, to what extent Dutch pharmacotherapeutic practice amongst elderly with polypharmacy mirrors the best practice described in this guideline and which barriers threaten it. Methods: An observational study was conducted in 2013/14 using a questionnaire distributed amongst Dutch healthcare professionals and elderly patients with polypharmacy. Healthcare professionals were asked about their current practice and the presence of five significant barriers, selected through a literature review and from expert opinion. These barriers are: inadequate transfer of patient records; insufficient documentation of prescribed drugs; a lack of collaboration between professionals; a failure to take a full control of the medication and insufficient involvement of the patient. The patients were asked about their experience with pharmacotherapeutic care. Results: No more than 26% of the healthcare professionals indicated that they use the guideline. The five barriers threatening the pharmacotherapeutic care were found to be present. Forty-three percent of the patients mentioned that their medication was assessed last year. Conclusion: The guideline is not used frequently by the healthcare professionals, but there is a will to improve the care by following this guideline. However, the presence of the five barriers hampers its implementation. Good management of those barriers is necessary in order to improve the collaboration between primary and secondary care and to enhance the documentation of prescribed drugs.

Validation of multisource electronic health record data: an application to blood transfusion data.

BACKGROUND: Although data from electronic health records (EHR) are often used for research purposes, systematic validation of these data prior to their use is not standard practice. Existing validation frameworks discuss validity concepts without translating these into practical implementation steps or addressing the potential influence of linking multiple sources. Therefore we developed a practical approach for validating routinely collected data from multiple sources and to apply it to a blood transfusion data warehouse to evaluate the usability in practice. METHODS: The approach consists of identifying existing validation frameworks for EHR data or linked data, selecting validity concepts from these frameworks and establishing quantifiable validity outcomes for each concept. The approach distinguishes external validation concepts (e.g. concordance with external reports, previous literature and expert feedback) and internal consistency concepts which use expected associations within the dataset itself (e.g. completeness, uniformity and plausibility). In an example case, the selected concepts were applied to a transfusion dataset and specified in more detail. RESULTS: Application of the approach to a transfusion dataset resulted in a structured overview of data validity aspects. This allowed improvement of these aspects through further processing of the data and in some cases adjustment of the data extraction. For example, the proportion of transfused products that could not be linked to the corresponding issued products initially was 2.2% but could be improved by adjusting data extraction criteria to 0.17%. CONCLUSIONS: This stepwise approach for validating linked multisource data provides a basis for evaluating data quality and enhancing interpretation. When the process of data validation is adopted more broadly, this contributes to increased transparency and greater reliability of research based on routinely collected electronic health records.

Barriers and facilitators for taking action after classroom-based crew resource management training at three ICUs.

BACKGROUND: Given growing awareness of the crucial role of nontechnical skills in providing safe patient care, crew resource management (CRM) training is being increasingly used to improve them. Implementing the plans of action that are formulated during CRM training may constitute an important first step in the successful uptake of skills. Accordingly, understanding the factors that determine why participants do or do not carry out those plans should help improve CRM training and enhance its impact. A study was conducted to examine the impact of pretraining readiness factors and posttraining barriers and facilitators on follow-up on plans of action. METHODS: Three ICUs, each at a different nonacademic teaching hospital in The Netherlands, received two-day classroom-based CRM training in 2010. During the training, new ideas for safety initiatives were documented as concrete plans of action. All plans were categorized as individual (for example, "Always ask a colleague to double-check your medication"), team, or organizational. Two months before and three months after the CRM training, all ICU employees were asked to fill out a set of questionnaires. RESULTS: Management support for patient safety before the training was a positive determinant of the number of perceived facilitators. A significant relationship was found between the perceived barriers and facilitators after CRM training and Taking Action. More barriers were negatively associated, while more facilitators were positively associated, with Taking Action. When assessed separately, none of the readiness factors were significantly associated with taking action, while when assessed together, the readiness factors were positive related to Taking Action. DISCUSSION: To overcome the barriers and profit from the facilitators, they should be considered during the training and in regular CRM meetings afterward.

Reduction of calcium release site models via moment fitting of phase-type distributions.

Models of calcium (Ca(2 +)) release sites derived from continuous-time Markov chain (CTMC) models of intracellular Ca(2 +) channels exhibit collective gating reminiscent of the experimentally observed phenomenon of Ca(2 +) puffs and sparks. In order to overcome the state-space explosion that occurs in compositionally defined Ca(2 +) release site models, we have implemented an automated procedure for model reduction that replaces aggregated states of the full release site model with much simpler CTMCs that have similar within-group phase-type sojourn times and inter-group transitions. Error analysis based on comparison of full and reduced models validates the method when applied to release site models composed of 20 three-state channels that are both activated and inactivated by Ca(2 +). Although inspired by existing techniques for fitting moments of phase-type distributions, the automated reduction method for compositional Ca(2 +) release site models is unique in several respects and novel in this biophysical context.

Effectiveness of classroom based crew resource management training in the intensive care unit: study design of a controlled trial.

BACKGROUND: Crew resource management (CRM) has the potential to enhance patient safety in intensive care units (ICU) by improving the use of non-technical skills. However, CRM evaluation studies in health care are inconclusive with regard to the effect of this training on behaviour and organizational outcomes, due to weak study designs and the scarce use of direct observations. Therefore, the aim of this study is to determine the effectiveness and cost-effectiveness of CRM training on attitude, behaviour and organization after one year, using a multi-method approach and matched control units. The purpose of the present article is to describe the study protocol and the underlying choices of this evaluation study of CRM in the ICU in detail. METHODS/DESIGN: Six ICUs participated in a paired controlled trial, with one pre-test and two post test measurements (respectively three months and one year after the training). Three ICUs were trained and compared to matched control ICUs. The 2-day classroom-based training was delivered to multidisciplinary groups. Typical CRM topics on the individual, team and organizational level were discussed, such as situational awareness, leadership and communication. All levels of Kirkpatrick's evaluation framework (reaction, learning, behaviour and organisation) were assessed using questionnaires, direct observations, interviews and routine ICU administration data. DISCUSSION: It is expected that the CRM training acts as a generic intervention that stimulates specific interventions. Besides effectiveness and cost-effectiveness, the assessment of the barriers and facilitators will provide insight in the implementation process of CRM. TRIAL REGISTRATION: Netherlands Trial Register (NTR): NTR1976.

Predicting road quality using high resolution satellite imagery: A transfer learning approach.

Recognizing the importance of road infrastructure to promote human health and economic development, actors around the globe are regularly investing in both new roads and road improvements. However, in many contexts there is a sparsity-or complete lack-of accurate information regarding existing road infrastructure, challenging the effective identification of where investments should be made. Previous literature has focused on overcoming this gap through the use of satellite imagery to detect and map roads. In this piece, we extend this literature by leveraging satellite imagery to estimate road quality and concomitant information about travel speed. We adopt a transfer learning approach in which a convolutional neural network architecture is first trained on data collected in the United States (where data is readily available), and then "fine-tuned" on an independent, smaller dataset collected from Nigeria. We test and compare eight different convolutional neural network architectures using a dataset of 53,686 images of 2,400 kilometers of roads in the United States, in which each road segment is measured as "low", "middle", or "high" quality using an open, cellphone-based measuring platform. Using satellite imagery to estimate these classes, we achieve an accuracy of 80.0%, with 99.4% of predictions falling within the actual or an adjacent class. The highest performing base model was applied to a preliminary case study in Nigeria, using a dataset of 1,000 images of paved and unpaved roads. By tailoring our US-model on the basis of this Nigeria-specific data, we were able to achieve an accuracy of 94.0% in predicting the quality of Nigerian roads. A continuous case estimate also showed the ability, on average, to predict road quality to within 0.32 on a 0 to 3 scale (with higher values indicating higher levels of quality).

Fluorescent Calcium Imaging and Subsequent In Situ Hybridization for Neuronal Precursor Characterization in Xenopus laevis.

Spontaneous intracellular calcium activity can be observed in a variety of cell types and is proposed to play critical roles in a variety of physiological processes. In particular, appropriate regulation of calcium activity patterns during embryogenesis is necessary for many aspects of vertebrate neural development, including proper neural tube closure, synaptogenesis, and neurotransmitter phenotype specification. While the observation that calcium activity patterns can differ in both frequency and amplitude suggests a compelling mechanism by which these fluxes might transmit encoded signals to downstream effectors and regulate gene expression, existing population-level approaches have lacked the precision necessary to further explore this possibility. Furthermore, these approaches limit studies of the role of cell-cell interactions by precluding the ability to assay the state of neuronal determination in the absence of cell-cell contact. Therefore, we have established an experimental workflow that pairs time-lapse calcium imaging of dissociated neuronal explants with a fluorescence in situ hybridization assay, allowing the unambiguous correlation of calcium activity pattern with molecular phenotype on a single-cell level. We were successfully able to use this approach to distinguish and characterize specific calcium activity patterns associated with differentiating neural cells and neural progenitor cells, respectively; beyond this, however, the experimental framework described in this article could be readily adapted to investigate correlations between any time-series activity profile and expression of a gene or genes of interest.

Reduction of calcium release site models via fast/slow analysis and iterative aggregation/disaggregation.

Mathematical models of calcium release sites derived from Markov chain models of intracellular calcium channels exhibit collective gating reminiscent of the experimentally observed phenomenon of calcium puffs and sparks. Such models often take the form of stochastic automata networks in which the transition probabilities of each channel depend on the local calcium concentration and thus the state of the other channels. In order to overcome the state-space explosion that occurs in such compositionally defined calcium release site models, we have implemented several automated procedures for model reduction using fast/slow analysis. After categorizing rate constants in the single channel model as either fast or slow, groups of states in the expanded release site model that are connected by fast transitions are lumped, and transition rates between reduced states are chosen consistent with the conditional probability distribution among states within each group. For small problems these conditional probability distributions can be numerically calculated from the full model without approximation. For large problems the conditional probability distributions can be approximated without the construction of the full model by assuming rapid mixing of states connected by fast transitions. Alternatively, iterative aggregation/disaggregation may be employed to obtain reduced calcium release site models in a memory-efficient fashion. Benchmarking of several different iterative aggregation/disaggregation-based fast/slow reduction schemes establishes the effectiveness of automated calcium release site reduction utilizing the Koury-McAllister-Stewart method.

North Carolina's direct care workforce development journey: the case of the North Carolina New Organizational Vision Award Partner Team.

BACKGROUND: Better Jobs Better Care was a five-state direct care workforce demonstration designed to change policy and management practices that influence recruitment and retention of direct care workers, problems that continue to challenge providers. PURPOSE: One of the projects, the North Carolina Partner Team, developed a unified approach in which skilled nursing, home care, and assisted living providers could be rewarded for meeting standards of workplace excellence. This case study documents the complex adaptive system agents and processes that coalesced to result in legislation recognizing the North Carolina New Organizational Vision Award. METHODS: We used a holistic, single-case study design. Qualitative data from project work plans and progress reports as well as notes from interviews with key stakeholders and observation of meetings were coded into a simple rubric consisting of characteristics of complex adaptive systems. FINDINGS: Key system agents in the state set the stage for the successful multistakeholder coalition. These included leadership by the North Carolina Department of Health and Human Services and a several year effort to develop a unifying vision for workforce development. Grant resources were used to facilitate both content and process work. Structure was allowed to emerge as needed. The coalition's own development is shown to have changed the context from which it was derived. PRACTICE IMPLICATIONS: An inclusive and iterative process produced detailed standards and measures for the voluntary recognition process. With effective facilitation, the interests of the multiple stakeholders coalesced into a policy response that encourages practice changes. Implications for managing change-oriented coalitions are discussed.

Markov chain models of coupled calcium channels: Kronecker representations and iterative solution methods.

Mathematical models of calcium release sites derived from Markov chain models of intracellular calcium channels exhibit collective gating reminiscent of the experimentally observed phenomenon of stochastic calcium excitability (i.e., calcium puffs and sparks). Calcium release site models are stochastic automata networks that involve many functional transitions, that is, the transition probabilities of each channel depend on the local calcium concentration and thus the state of the other channels. We present a Kronecker-structured representation for calcium release site models and perform benchmark stationary distribution calculations using both exact and approximate iterative numerical solution techniques that leverage this structure. When it is possible to obtain an exact solution, response measures such as the number of channels in a particular state converge more quickly using the iterative numerical methods than occupation measures calculated via Monte Carlo simulation. In particular, multi-level methods provide excellent convergence with modest additional memory requirements for the Kronecker representation of calcium release site models. When an exact solution is not feasible, iterative approximate methods based on the power method may be used, with performance similar to Monte Carlo estimates. This suggests approximate methods with multi-level iterative engines as a promising avenue of future research for large-scale calcium release site models.

Meeting the need for personal care among the elderly: does Medicaid home care spending matter?

OBJECTIVE: To determine whether Medicaid home care spending reduces the proportion of the disabled elderly population who do not get help with personal care. DATA SOURCES: Data on Medicaid home care spending per poor elderly person in each state is merged with data from the Medicare Current Beneficiary Survey for 1992, 1996, and 2000. The sample (n=6,067) includes elderly persons living in the community who have at least one limitation in activities of daily living (ADLs). STUDY DESIGN: Using a repeated cross-section analysis, the probability of not getting help with an ADL is estimated as a function of Medicaid home care spending, individual income, interactions between income and spending, and a set of individual characteristics. Because Medicaid home care spending is targeted at the low-income population, it is not expected to affect the population with higher incomes. We exploit this difference by using higher-income groups as comparison groups to assess whether unobserved state characteristics bias the estimates. PRINCIPAL FINDINGS: Among the low-income disabled elderly, the probability of not receiving help with an ADL limitation is about 10 percentage points lower in states in the top quartile of per capita Medicaid home care spending than in other states. No such association is observed in higher-income groups. These results are robust to a set of sensitivity analyses of the methods. CONCLUSION: These findings should reassure state and federal policymakers considering expanding Medicaid home care programs that they do deliver services to low-income people with long-term care needs and reduce the percent of those who are not getting help.

Measuring worker turnover in long-term care: lessons from the better jobs better care demonstration.

PURPOSE: Turnover among direct-care workers (DCWs) continues to be a challenge in long-term care. Both policy makers and provider organizations recognize this issue as a major concern and are designing efforts to reduce turnover among these workers. However, there is currently no standardized method of measuring turnover to define the scope of the problem or to assess the effectiveness of interventions. This article draws on our experience of the Better Jobs Better Care Demonstration (BJBC) to explicate some important issues in measuring and interpreting turnover related to interventions designed to improve DCW jobs. DESIGN AND METHODS: We used turnover data from a selected group of BJBC providers (N = 9) to demonstrate some of the measurement issues we uncovered in developing a turnover tracking system for BJBC. We also illustrate how the data elements collected in the tracking system make it possible to construct measures that are useful at both policy and practice levels. RESULTS: Differences in definitions of turnover and the data elements used to construct the measure can have large effects on turn over rates, how they are used, and what they mean. IMPLICATIONS: Policy makers, researchers, and managers who need comparative turnover information to address the impending demand for DCWs should be aware that turnover measures differ, and they should take steps to ensure that measures they use have common definitions and data elements.

Implementation of the Better Jobs Better Care demonstration: lessons for long-term care workforce initiatives.

PURPOSE: Better Jobs Better Care (BJBC) was a long-term care workforce demonstration that sought to improve recruitment and retention of direct care workers by changing public policy and management practice. The purpose of this article is to document and assess BJBC's implementation, analyze factors affecting implementation, and draw lessons from it for other long-term care workforce initiatives. DESIGN AND METHODS: We analyzed qualitative data from project work plans and progress reports, and notes from telephone and in-person interviews with project staff, coalition stakeholders, and state policy experts. We abstracted the data, categorized it, and summarized it by state in matrices for analysis. RESULTS: The five BJBC projects did implement their demonstration plans. Factors that affected project implementation included having demonstration resources; strong, stable leadership; strong coalitions that included key stakeholders; a neutral lead agency; clear goals; effective process; and a favorable state history and context. IMPLICATIONS: BJBC demonstrated that recruitment and retention is a long-term care industry problem, not just a nursing home problem. Future initiatives should: recognize that workforce policy and management practice change is difficult and takes time, obtain funding, develop strategies specific to the state history and context, engage key stakeholders, and develop relationships among stakeholders.

What do direct care workers say would improve their jobs? Differences across settings.

PURPOSE: The study's goals were to understand what changes in management practices would most improve the jobs of frontline workers from the perspective of workers themselves and to analyze differences across settings. DESIGN AND METHODS: The baseline survey of direct care workers (N=3,468) conducted as part of the National Study of the Better Jobs Better Care demonstration asked the following: "What is the single most important thing your employer could do to improve your job as a direct care worker?" We coded the open-ended responses and grouped them into categories. We then compared the percentages of workers recommending changes in these categories across settings and interpreted them in the context of previous conceptual frameworks. RESULTS: Across settings, workers called for more pay and better work relationships including communication; supervision; and being appreciated, listened to, and treated with respect. The fraction of workers calling for these changes and additional specific changes differed substantially across nursing facilities, assisted living facilities, and home care agencies. IMPLICATIONS: To increase retention of frontline workers, policy makers should design public policies and management practices to increase pay and to improve work relationships. However, specific strategies should differ across settings.

Why was this transfusion given? Identifying clinical indications for blood transfusion in health care data.

BACKGROUND: To enhance the utility of transfusion data for research, ideally every transfusion should be linked to a primary clinical indication. In electronic patient records, many diagnostic and procedural codes are registered, but unfortunately, it is usually not specified which one is the reason for transfusion. Therefore, a method is needed to determine the most likely indication for transfusion in an automated way. STUDY DESIGN AND METHODS: An algorithm to identify the most likely transfusion indication was developed and evaluated against a gold standard based on the review of medical records for 234 cases by 2 experts. In a second step, information on misclassification was used to fine-tune the initial algorithm. The adapted algorithm predicts, out of all data available, the most likely indication for transfusion using information on medical specialism, surgical procedures, and diagnosis and procedure dates relative to the transfusion date. RESULTS: The adapted algorithm was able to predict 74.4% of indications in the sample correctly (extrapolated to the full data set 75.5%). A kappa score, which corrects for the number of options to choose from, was found of 0.63. This indicates that the algorithm performs substantially better than chance level. CONCLUSION: It is possible to use an automated algorithm to predict the indication for transfusion in terms of procedures and/or diagnoses. Before implementation of the algorithm in other data sets, the obtained results should be externally validated in an independent hospital data set.

Job perceptions and intent to leave among direct care workers: evidence from the better jobs better care demonstrations.

PURPOSE: We assess how perceived rewards and problems with caregiving work and supervision relate to intent to leave among direct care workers who are employed in provider organizations participating in the Better Jobs Better Care (BJBC) demonstration; we also examine how these relationships vary by provider type. DESIGN AND METHODS: Direct care workers from 50 skilled nursing facilities, 39 home care agencies, 40 assisted living facilities, and 10 adult day services in five states completed a paper survey administered prior to the implementation of the BJBC interventions in each organization. We include direct care workers (n = 3,039) with complete data in the analyses using multinomial regression clustered by provider organization to compare those not at all likely to leave and those very likely to leave in the next year with a middle referent group who are somewhat likely to leave. RESULTS: Logistic regression results were that work overload and lack of upward mobility increased intent to leave. Respondents with positive assessments of their supervisor, who valued helping others, and for whom the income was perceived as rewarding were less likely to be in the very likely to quit category and more likely to be in the stable category. Some differences between provider types are observed, especially between home care workers and those employed in facilities. IMPLICATIONS: These findings provide support for many of the management-practice improvements taking place in the field, including those implemented in the BJBC demonstration. Follow-up surveys will provide insight into their effectiveness.

Implementation of Crew Resource Management: A Qualitative Study in 3 Intensive Care Units.

OBJECTIVES: Classroom-based crew resource management (CRM) training has been increasingly applied in health care to improve safe patient care. Crew resource management aims to increase participants' understanding of how certain threats can develop as well as provides tools and skills to respond to such threats. Existing literature shows promising but inconclusive results that might be explained by the quality of the implementation. The present research systematically describes the implementation from the perspective of 3 trained intensive care units (ICUs). METHODS: The design of the study was built around 3 stages of implementation: (1) the preparation, (2) the actions after the CRM training, and (3) the plans for the future. To assess all stages in 3 Dutch ICUs, 12 semistructured interviews with implementation leaders were conducted, the End-of-Course Critique questionnaire was administered, and objective measurements consisting of the number and types of plans of action were reported. RESULTS: The results categorize initiatives that all 3 ICUs successfully launched, including the development of checklists, each using a different implementation strategy. All ICUs have taken several steps to sustain their approach for the foreseeable future. Three similarities between the units were seen at the start of the implementation: (1) acknowledgment of a performance gap in communication, (2) structural time allocated for CRM, and (3) a clear vision on how to implement CRM. CONCLUSIONS: This study shows that CRM requires preparation and implementation, both of which require time and dedication. It is promising to note that all 3 ICUs have developed multiple quality improvement initiatives and aim to continue doing so.

New Evidence on the Green House Model of Nursing Home Care: Synthesis of Findings and Implications for Policy, Practice, and Research.

OBJECTIVE: To synthesize new findings from the THRIVE Research Collaborative (The Research Initiative Valuing Eldercare) related to the Green House (GH) model of nursing home care and broadly consider their implications. DATA SOURCES: Interviews and observations conducted in GH and comparison homes, Minimum Data Set (MDS) assessments, Medicare data, and Online Survey, Certification and Reporting data. STUDY DESIGN: Critical integration and interpretation of findings based on primary data collected 2011-2014 in 28 GH homes (from 16 organizations), and 15 comparison nursing home units (from 8 organizations); and secondary data derived from 2005 to 2010 for 72 GH homes (from 15 organizations) and 223 comparison homes. PRINCIPAL FINDINGS: Implementation of the GH model is inconsistent, sometimes differing from design. Among residents of GH homes, adoption lowers hospital readmissions, three MDS measures of poor quality, and Part A/hospice Medicare expenditures. Some evidence suggests the model is associated with lower direct care staff turnover. CONCLUSIONS: Recommendations relate to assessing fidelity, monitoring quality, capitalizing opportunities to improve care, incorporating evidence-based practices, including primary care providers, supporting high-performance workforce practices, aligning Medicare financial incentives, promoting equity, informing broad culture change, and conducting future research.

Crew resource management training in the intensive care unit. A multisite controlled before-after study.

INTRODUCTION: There is a growing awareness today that adverse events in the intensive care unit (ICU) are more often caused by problems related to non-technical skills than by a lack of technical, or clinical, expertise. Team training, such as crew resource management (CRM), aims to improve these non-technical skills. The present study evaluated the effectiveness of CRM in the ICU. METHODS: Six ICUs participated in a paired controlled trial, with one pretest and two post-test measurements (after 3 and 12 months). Three ICUs received CRM training and were compared with a matched control unit. The 2-day classroom-based training was delivered to multidisciplinary groups (ie, ICU physicians, nurses, managers). All levels of Kirkpatrick's evaluation framework were assessed using a mixed method design, including questionnaires, observations and routinely administered patient outcome data. RESULTS: Level I-reaction: participants were very positive directly after the training. Level II-learning: attitudes towards behaviour aimed at optimising situational awareness were relatively high at baseline and remained stable. Level III-behaviour: self-reported behaviour aimed at optimising situational awareness improved in the intervention group. No changes were found in observed explicit professional oral communication. Level IV-organisation: patient outcomes were unaffected. Error management culture and job satisfaction improved in the intervention group. Patient safety culture improved in both control and intervention units. CONCLUSIONS: We can conclude that CRM, as delivered in the present study, does not change behaviour or patient outcomes by itself, yet changes how participants think about errors and risks. This indicates that CRM requires a combination with other initiatives in order to improve clinical outcomes.