Pore evolution mechanisms during directed energy deposition additive manufacturing.

Porosity in directed energy deposition (DED) deteriorates mechanical performances of components, limiting safety-critical applications. However, how pores arise and evolve in DED remains unclear. Here, we reveal pore evolution mechanisms during DED using in situ X-ray imaging and multi-physics modelling. We quantify five mechanisms contributing to pore formation, migration, pushing, growth, removal and entrapment: (i) bubbles from gas atomised powder enter the melt pool, and then migrate circularly or laterally; (ii) small bubbles can escape from the pool surface, or coalesce into larger bubbles, or be entrapped by solidification fronts; (iii) larger coalesced bubbles can remain in the pool for long periods, pushed by the solid/liquid interface; (iv) Marangoni surface shear flow overcomes buoyancy, keeping larger bubbles from popping out; and (v) once large bubbles reach critical sizes they escape from the pool surface or are trapped in DED tracks. These mechanisms can guide the development of pore minimisation strategies.

A Novel Approach to the Room of Errors (ROE): A Three-Dimensional Virtual Tour Activity to Spotlight Patient Safety Threats.

BACKGROUND: Live simulation-based activities are effective tools in teaching situational awareness to improve patient safety training in healthcare settings. The coronavirus disease 2019 (COVID-19) pandemic forced the discontinuation of these in-person sessions. We describe our solution to this challenge: an online interactive activity titled the "Virtual Room of Errors." The aim of this activity is to create an accessible and feasible method of educating healthcare providers about situational awareness in the hospital.  Materials and Methods: We applied existing three-dimensional virtual tour technology used in the real estate sector to a hospital patient room with a standardized patient and 46 intentionally placed hazards. Healthcare providers and students from our institution accessed the room online through a link where they independently navigate, and document observed safety hazards.  Results: In 2021 and 2022, a total of 510 learners completed the virtual Room of Errors (ROE). The virtual ROE increased annual participation in the activity, as compared to the in-person Room, and demonstrated learner satisfaction.  Conclusions: The virtual ROE is an accessible, feasible, and cost-effective method of educating healthcare workers on situational awareness of preventable hazards. Furthermore, the activity is a sustainable way to reach a larger number of learners from multiple disciplines, even as in-person activities resume.

Badge sign-in and report cards improve first case start times in gastrointestinal endoscopy: A prospective quality improvement study.

Background and study aims First case start (FCS) time is often a key metric used to gauge efficiency in an endoscopy suite. There are limited data on tools and methods to improve the FCS time in the endoscopy suite. Methods A prospective observational cohort study was conducted in an academic tertiary care endoscopy suite examining the effect of badge sign-in (Period 2) and badge sign-in coupled with report cards (Period 3) compared to an initial observational period (Period 1). Results After the badge sign-in reader was introduced in P2, the unit experienced a mean time savings of 5 ± 18 minutes in FCS delays compared to P1 ( P  = .03). In P3, an 8 ± 17-minute time savings in FCS time delay was observed compared to P1 ( P  = 0.0006). Sign-in compliance significantly increased for the overall unit between P2 and P3 (49 % vs. 59 %, P  = .002). Increases in first case on-time start (FCOTS) rates compared to P1 were observed for the unit, with a 14% absolute increase in P2 ( P  < .0001) and a 17 % absolute increase in P3 ( P  < .0001). FCS delays for on-time badge sign-ins were significantly lower compared to FCS delays for missed badge sign-ins and late badge sign-ins ( P  < .0001). Conclusions The use of badge sign-in and report cards improve endoscopy unit efficiency as it can increase FCOTS rates and decrease FCS time delays.

Preparing Anesthesiology Residents for Operating Room Communication Challenges: A New Approach for Conflict Resolution Training.

BACKGROUND: The hierarchical culture in high-stake areas such as operating rooms (ORs) may create volatile communication challenges. This unfunded exploratory study sought to establish whether a conflict resolution course was effective in preparing anesthesiology residents to handle and deescalate disagreements that may arise in the clinical environment, especially when challenging a surgeon. METHODS: Thirty-seven anesthesiology residents were assessed for ability to deescalate conflict. Nineteen had completed a conflict resolution course, and 18 had not. The 2-hour course used 10 videotaped vignettes that showed attending anesthesiologists, patients, and surgeons challenging residents in a potentially confrontational situation. Guided review of the videos and discussions was focused on how the resident could optimally engage in conflict resolution. To determine efficacy of the conflict resolution course, we used simulation-based testing. The setting was a simulated OR with loud music playing (75-80 dB) under the control of the surgeon. The music was used as a tool to create a potential, realistic confrontation with the surgeon to test conflict resolution skills. The initial evaluation of the resident was whether they ignored the music, asked for the surgeon to turn it off, or attempted to turn it off themselves. The second evaluation was whether the resident attempted to deescalate (eg, calmly negotiate for the music to be turned off or down) when the surgeon was scripted to adamantly refuse. Two trained observers evaluated residents' responses to the surgeon's refusal. RESULTS: Of the residents who experienced the confrontational situation and had not yet taken the conflict resolution course, 1 of 5 (20.0%; 95% CI, 0.5-71.6) were judged to have deescalated the situation. In comparison, of those who had taken the course, 14 of 15 (93.3%; 95% CI, 68.1-99.8) were judged to have deescalated the situation (P = .002). Only 2 of 19 (10.5%; 95% CI, 1.3-33.1) of those who completed the course ignored the music on entering the OR versus 10 of 18 (55.6%; 95% CI, 30.8-78.5) who did not complete the course (P = .004). CONCLUSIONS: This study suggests that a conflict resolution course may improve the ability of anesthesiology residents to defuse clinical conflicts. It also demonstrated the effectiveness of a novel, simulation-based assessment of communication skills used to defuse OR confrontation.

Glycothermal synthesis and photoluminescence of Mg-Si modified Ce:YAG nanophosphors.

The absorption spectrum of Ce in a YAG based host grown using the glycothermal method was modified using the addition of Mg-Si pairs. Photoluminescence intensity was dramatically improved by increasing the reaction temperature to 315 °C instead of the conventionally used 300 °C. It was found that Mg acetate and tetraethylorthosilicate (TEOS) are suitable as precursors for the glycothermal process, as EDS elemental mapping showed their homogeneous inclusion in the final product. Their addition only slightly modified the emission spectrum of Ce:YAG. It was found that increasing the reaction temperature to 315 °C yielded nanoparticles 56 ± 16 nm in size with a 3.3× enhancement in absorption and 3.7× enhancement in emission intensities compared to samples synthesized at 300 °C, and an increase in photoluminescence quantum yield from 32% to 48%. Reaction kinetics of the precursors and a proposed route for post-synthesis surface functionalization are discussed.

A new approach to infection prevention: A pilot study to evaluate a hand hygiene ambassador program in hospitals and clinics.

BACKGROUND: A pilot study was conducted to assess the perceptions of visitors, patients, and staff to the presence of a hand hygiene ambassador (HHA). METHODS: Two hundred and twenty-five entrants to various health care settings were surveyed. Only entrants who failed to clean their hands at the alcohol-based handrub (ABHR) station on entry to the lobby were offered application of ABHR by an HHA. Several questions were also asked to assess their attitudes about the presence of an HHA. RESULTS: When asked whether they think it is a good idea to have an HHA place ABHR on an entrant's hands, the majority of staff, visitors, and patients agreed. No one refused administration of handrub by the HHA. DISCUSSION: HHA programs have direct and indirect benefits. Although the cost of such an initiative should be considered prior to implementation, it should be weighed against the annual spending for health care-associated infections. CONCLUSIONS: Considering that hand hygiene compliance and health care-associated infection are clearly linked, a new approach using an HHA may help reduce infection, acting as a source of hand hygiene on entry to the hospital and possibly as a reminder to perform hand hygiene elsewhere in the hospital and clinics.

Targeted Use of Alcohol-Based Hand Rub on Gloves During Task Dense Periods: One Step Closer to Pathogen Containment by Anesthesia Providers in the Operating Room.

BACKGROUND: Anesthesia providers' hand hygiene practices in the operating room may contribute to the transmission of bacteria. There is a debate, however, over the best approaches for pathogen containment during task dense periods (induction and extubation) of anesthesia care. A novel approach to reducing pathogen spread during these task dense periods is the use of alcohol-based hand rub on gloves when it may be difficult to either change gloves or clean hands. METHODS: To evaluate the impact of alcohol-based hand rub on gloves, we estimated perforation rates of 50 gloves that were worn as pairs by volunteers for 2 hours at a time applying alcohol-based hand rub every 15 minutes (total of 8 alcohol-based hand rub applications per pair of gloves). We also identified perforation rates of 50 new, unused gloves. To evaluate the ability to perform routine anesthesia functions, volunteers were asked to pick up a coin from a table top and document whether the gloves felt normal or sticky at each 15-minute period. RESULTS: Fifty new gloves (not exposed to alcohol-based hand rub) were tested for integrity using the Food and Drug Administration-approved process, and one was found to have a microperforation. Of the 50 gloves that had been applied with alcohol-based hand rub 8 times, no microperforations were identified. All volunteers demonstrated tactile competence by picking up a coin from a table top after 8 alcohol-based hand rub applications; in addition, as the number of alcohol-based hand rub applications progressed, the volunteers reported increased stickiness. CONCLUSIONS: This study suggests that the use of alcohol-based hand rub on commonly used nitrile examination gloves does not compromise glove integrity or hamper the ability to safely perform routine anesthesia functions.

Improving Preprocedure Time Out Compliance Using Remote Audiovisual Observation.

Health care organization leaders can help prevent surgical errors by ensuring compliance with standardized preprocedure time outs that require the active participation and engagement of the entire surgical team. Some surgical department leaders have used remote video observation without audio to monitor compliance with the time out. After a sentinel event occurred, leaders at our large academic medical center initiated a quality improvement project to audit compliance with the standardized preprocedure time out. We used remote audiovisual observation to ensure that all members of the procedure team were adhering strictly to the elements of the preprocedure time out in all invasive procedure areas. Since the beginning of this remote auditing process, team member compliance with the standardized preprocedure time out has improved.

Improving Operating Room Turnover Time in a New York City Academic Hospital via Lean.

BACKGROUND: Prolonged operating room turnover time erodes patient and employee satisfaction and value. METHODS: Lean and value stream mapping was applied to three operating room teams at an academic health center in New York City, and a solution called Performance Improvement Team (PIT Crew) was piloted. RESULTS: Overall, 10% of operating room turnover steps were considered nonvalued and were eliminated, and 25% of previously sequential steps were performed synchronously. Seven institutional dogmas were eliminated, and three hospital policies were changed. After 35 pilot turnovers, median operating room turnover time improved from 37 minutes (range, 26 to 167 minutes) in historic matched controls to 14 minutes (range, 10 to 45 minutes, p < 0.0001) for the PIT Crew. Cost of the PIT Crew was $1,298 daily, and estimated return on investment was $19,500 per day. CONCLUSIONS: Lean and value stream mapping identifies nonvalued steps in operating room turnover and affords opportunities for efficiency. Once institutional rules and dogma are changed, culture and workflow improve and turnover time substantially improves. This process adds cost but is profitable. Scalability and sustainability are under further study, as is the "halo effect" on the culture in other non-PIT Crew operating rooms.

Current hand hygiene education is suboptimal.

BACKGROUND: To address the low levels of hand hygiene compliance (HHC) at our academic medical centre, we developed an annual patient safety course required for all incoming third-year medical students. Based on previous observations of medical students, it was determined that hand hygiene (HH) would be a central component of the course. METHODS: Over a 1-year period (2015/16), we observed third- and fourth-year medical students who had participated in the annual patient safety course entering three intensive care units (ICUs) at two teaching hospitals. A total of 150 medical students failed to perform HH on entry and were subsequently asked why they did not comply. RESULTS: Of the 150 medical students observed entering an ICU without performing HH, 74.7% were male and 25.3% were female. Males cited inadequate time (21.4%), lack of role models (10.7%) and provided incorrect information regarding HH requirements (58.9%). Females cited concerns about dry or cracked skin (34.2%) and forgetting (23.7%). DISCUSSION: Our study demonstrates that even when medical students receive intensive HH education, compliance remains low. Of note, males and females offered different reasons for why they failed to perform HH. To address the suboptimal HHC, we developed an annual patient safety course required for all third-year medical students immediately prior to beginning clinical rotations. In this study, we sought to understand why medical students' HH remains suboptimal even after an intensive course.

Introductions During Time-outs: Do Surgical Team Members Know One Another's Names?

BACKGROUND: Introductions are the first item of the time-out in the World Health Organization Surgical Safety Checklist (SSC). It has yet to be established that surgical teams use colleagues' names or consider the use of names important. A study was conducted to determine if using the SSC has a measurable impact on name retention and to assess if operating room (OR) personnel believe it is important to know the names of their colleagues or for their colleagues to know theirs. METHODS: All OR personnel were individually interviewed at the end of 25 surgical cases in which the SSC was used. They were asked (1) to name each OR participant, and (2) if they believed it is important to know the names of their team members and (3) for their team members to know their name. RESULTS: Of the 150 OR personnel interviewed, 147 (98%) named the surgery attending correctly. The surgery attending named only 44% of other OR staff (p <0.001). Only 62% of the OR staff correctly named the anesthesiology attending. The anesthesiology resident was the least well known but was able to name 82% of the others. The anesthesiology attending named his or her resident 100% of the time; the surgery attending correctly named his or her resident only 68% of the time (p = 0.002). CONCLUSION: This study suggests that OR personnel may consider introductions to be another bureaucratic hurdle instead of the safety check they were designed to be. It appears that this first step of the time-out is often being performed perfunctorily.

A ubiquitous but ineffective intervention: Signs do not increase hand hygiene compliance.

Proper hand hygiene is critical for preventing healthcare-associated infection, but provider compliance remains suboptimal. While signs are commonly used to remind physicians and nurses to perform hand hygiene, the content of these signs is rarely based on specific, validated health behavior theories. This observational study assessed the efficacy of a hand hygiene sign disseminated by the Centers for Disease Control and Prevention in an intensive care unit compared to an optimized evidence-based sign designed by a team of patient safety experts. The optimized sign was developed by four patient safety experts to include known evidence-based components and was subsequently validated by surveying ten physicians and ten nurses using a 10 point Likert scale. Eighty-two physicians and 98 nurses (102 females; 78 males) were observed for hand hygiene (HH) compliance, and the total HH compliance rate was 16%. HH compliance was not significantly different among the signs (Baseline 10% vs. CDC 18% vs. OIS 20%; p=0.280). The findings of this study suggest that even when the content and design of a hand hygiene reminder sign incorporates evidence-based constructs, healthcare providers comply only a fraction of the time.

"Priming" hand hygiene compliance in clinical environments.

INTRODUCTION: Effective hand hygiene is the single most important procedure in preventing hospital-acquired infections. Traditional information/education-based interventions have shown only modest benefits on compliance. This study set out to investigate whether priming via olfactory and visual cues influences hand hygiene compliance. METHOD: Randomized controlled trial set in a surgical intensive care unit (SICU) at a teaching hospital in Miami, Florida. The primary outcome data involved observations-a mix of health professionals and service users were observed entering the SICU by 2 trained observers and their hand hygiene compliance was independently verified. Interventions included either an olfactory prime (clean, citrus smell) or visual prime (male or female eyes). The primary outcome measure was hand hygiene compliance (HHC) measured by the visitor using the hand gel dispenser. RESULTS: At a 5% level there was significant evidence that a clean, citrus smell significantly improves HHC (46.9% vs. 15.0%, p = .0001). Compared to the control group, a significant improvement in HHC was seen when a picture of "male eyes" was placed over the hand gel dispenser (33.3% vs. 15.0%, p < .038). No significant improvement in HHC was seen when a picture of female eyes was placed over the same hand gel dispenser (10.0% vs. 15.0%, p = .626). CONCLUSIONS: This is one of the first studies to demonstrate that priming can influence HHC in a clinical setting. The findings suggest that priming interventions could be used to change other behaviors relevant to public health.

A New Approach to Pathogen Containment in the Operating Room: Sheathing the Laryngoscope After Intubation.

BACKGROUND: Anesthesiologists may contribute to postoperative infections by means of the transmission of blood and pathogens to the patient and the environment in the operating room (OR). Our primary aims were to determine whether contamination of the IV hub, the anesthesia work area, and the patient could be reduced after induction of anesthesia by removing the risk associated with contaminants on the laryngoscope handle and blade. Therefore, we conducted a study in a simulated OR where some of the participants sheathed the laryngoscope handle and blade in a glove immediately after it was used to perform an endotracheal intubation. METHODS: Forty-five anesthesiology residents (postgraduate year 2-4) were enrolled in a study consisting of identical simulation sessions. On entry to the simulated OR, the residents were asked to perform an anesthetic, including induction and endotracheal intubation timed to approximately 6 minutes. Of the 45 simulation sessions, 15 were with a control group conducted with the intubating resident wearing single gloves, 15 with the intubating resident using double gloves with the outer pair removed and discarded after verified intubation, and 15 wearing double gloves and sheathing the laryngoscope in one of the outer gloves after intubation. Before the start of the scenario, the lips and inside of the mouth of the mannequin were coated with a fluorescent marking gel. After each of the 45 simulations, an observer examined the OR using an ultraviolet light to determine the presence of fluorescence on 25 sites: 7 on the patient and 18 in the anesthesia environment. RESULTS: Of the 7 sites on the patient, ultraviolet light detected contamination on an average of 5.7 (95% confidence interval, 4.4-7.2) sites under the single-glove condition, 2.1 (1.5-3.1) sites with double gloves, and 0.4 (0.2-1.0) sites with double gloves with sheathing. All 3 conditions were significantly different from one another at P < 0.001. Of the 18 environmental sites, ultraviolet light detected fluorescence on an average of 13.2 (95% confidence interval, 11.3-15.6) sites under the single-glove condition, 3.5 (2.6-4.7) with double gloves, and 0.5 (0.2-1.0) with double gloves with sheathing. Again, all 3 conditions were significantly different from one another at P < 0.001. CONCLUSIONS: The results of this study suggest that when an anesthesiologist in a simulated OR sheaths the laryngoscope immediately after endotracheal intubation, contamination of the IV hub, patient, and intraoperative environment is significantly reduced.

An evaluation of hand hygiene in an intensive care unit: Are visitors a potential vector for pathogens?

Patients in an intensive care unit (ICU) are frequently immunocompromised and might be highly susceptible to infection. Visitors to an ICU who do not adequately clean their hands could carry pathogenic organisms, resulting in risk to a vulnerable patient population. This observational study identifies pathogens carried on the hands of visitors into an ICU and investigates the effect of hand hygiene. Two observers, one stationed outside and one inside the ICU, evaluated whether visitors performed hand hygiene at any of the wall-mounted alcohol-based hand sanitizer dispensers prior to reaching a patient's room. Upon reaching a patient's room, the dominant hand of all of the participants was cultured. Of the 55 participating visitors, 35 did not disinfect their hands. Among the cultures of those who failed to perform hand hygiene, eight cultures grew Gram-negative rods and one grew methicillin-resistant Staphylococcus aureus. Of the cultures of the 20 individuals who performed hand hygiene, 14 (70%) had no growth on the cultures, and the remaining six (30%) showed only the usual skin flora. The visitors who do not perform hand hygiene might carry pathogens that pose a risk to ICU patients.

Crisis management on surgical wards: a simulation-based approach to enhancing technical, teamwork, and patient interaction skills.

OBJECTIVE: To establish the efficacy of simulation-based training for improving residents' management of postoperative complications on a surgical ward. BACKGROUND: Effective postoperative care is a crucial determinant of patient outcome, yet trainees learn this through the Halstedian approach. Little evidence exists on the efficacy of simulation in this safety-critical environment. METHODS: A pre-/postintervention design was employed with 185 residents from 5 hospitals. Residents participated in 2 simulated ward-based scenarios consisting of a deteriorating postoperative patient. A debriefing intervention was implemented between scenarios. Resident performance was evaluated by calibrated, blinded assessors using the validated Global Assessment Toolkit for Ward Care. This included an assessment of clinical skills (checklist of 35 tasks), team-working skills (score range 1-6 per skill), and physician-patient interaction skills. RESULTS: Excellent interrater reliability was achieved in all assessments (reliability 0.89-0.99, P < 0.001). Clinically, improvements were obtained posttraining in residents' ability to recognize/respond to falling saturations (pre = 73.7% vs post = 94.8%, P < 0.01), check circulatory status (pre = 21.1% vs post = 84.2% P < 0.001), continuously reassess patient (pre = 42.1% vs post = 100%, P < 0.001), and call for help (pre = 36.8% vs post = 89.8%, P < 0.001). Regarding teamwork, there was a significant improvement in residents' communication (pre = 1.75 vs post = 3.43), leadership (pre = 2.43 vs post = 4.20), and decision-making skills (pre = 2.20 vs post = 3.81, P < 0.001). Finally, residents improved in all elements of interaction with patients: empathy, organization, and verbal and nonverbal expression (Ps < 0.001). CONCLUSIONS: The study provides evidence for the efficacy of ward-based team training using simulation. Such exercises should be formally incorporated into training curricula to enhance patient safety in the high-risk surgical ward environment.

Using simulation technology to identify gaps between education and practice among new graduate nurses.

Applied knowledge was observed among nurse groups from a medical-surgical residency program to measure clinical performance during simulation training. Twenty groups of new graduate nurses were observed during five simulated clinical scenarios, and their performances were scored on a 24-item checklist. Nurse groups showed significant improvement (p < 0.001) in applied knowledge in four clinical domains from week 1 to week 5, and the results provided valuable information of the groups' overall performances. In two of the five scenarios, poor decisions and prioritization of competing tasks were factors associated with lower performance group scores. Complex patient conditions may pose a challenge for new graduate nurses, and standardized training during the residency program may help instructors recognize specific factors to address during the transition from education to practice.

Double gloves: a randomized trial to evaluate a simple strategy to reduce contamination in the operating room.

BACKGROUND: Oral flora, blood-borne pathogens, and bacterial contamination pose a direct risk of infection to patients and health care workers. We conducted a study in a simulated operating room using a newly validated technology to determine whether the use of 2 sets of gloves, with the outer set removed immediately after endotracheal intubation, may reduce this risk. METHODS: Forty-one anesthesiology residents (PGY 2-4) were enrolled in a study consisting of individual or group simulation sessions. On entry to the simulated operating room, the residents were asked to perform an anesthetic induction and tracheal intubation timed to approximately 6 minutes; they were unaware of the study design. Of the 22 simulation sessions, 11 were conducted with the intubating resident wearing single gloves, and 11 with the intubating resident using double gloves with the outer pair removed after verified intubation. Before the start of the scenario, we coated the lips and inside of the mouth of the mannequin with a fluorescent marking gel as a surrogate pathogen. After the simulation, an observer examined 40 different sites using a handheld ultraviolet light in the operating room to determine the transfer of surrogate pathogens to the patient and the patient's environment. Residents who wore double gloves were instructed by a confederate nurse to remove the outer set immediately after completion of the intubation. Forty sites of potential intraoperative pathogen spread were identified and assigned a score. RESULTS: The difference in the rate of contamination between anesthesiology residents who wore single gloves versus those with double gloves was clinically and statistically significant. The number of sites that were contaminated in the operating room when the intubating resident wore single gloves was 20.3 ± 1.4 (mean ± SE); the number of contaminated sites when residents wore double gloves was 5.0 ± 0.7 (P < 0.001). CONCLUSIONS: The results of this study suggest that when an anesthesiologist wears 2 sets of gloves during laryngoscopy and intubation and then removes the outer set immediately after intubation, the contamination of the intraoperative environment is dramatically reduced.

The use of a novel technology to study dynamics of pathogen transmission in the operating room.

Pathogenic organisms have been found in the intraoperative environment, potentially posing a risk of infection that could cause morbidity and mortality. In an effort to understand how a patient's bacteria can be spread throughout the operating room with the anesthesia provider as a vector, we conducted a study using recently developed experimental technology in a simulated operating room environment with a high-fidelity human patient simulator.

Improving surgical ward care: development and psychometric properties of a global assessment toolkit.

OBJECTIVE: To develop a toolkit that covers the clinical, nontechnical, and empathic skills required for effective, safe surgical ward care. BACKGROUND: Despite the explosion of interest in patient safety, little attention has been placed on the skill set required for safe and effective surgical ward care. Currently, there is a lack of a systematic approach to improving ward care via assessing and improving residents' ward care skills. METHODS: A comprehensive evidence-based and expert-derived toolkit was developed, including a novel clinical checklist for ward care (Clinical Skills Assessment for Ward Care: C-SAW-C); a novel team assessment scale for wards rounds (Teamwork Skills Assessment for Ward Care: T-SAW-C); and a revised version of a physician-patient interaction scale (Physician-Patient Interaction Global Rating Scale: PP-GIS). Interassessor reliability (κ, intraclass correlation), internal consistency (Cronbach α), and convergent validity (Pearson r correlations) were evaluated statistically in 38 simulated scenarios (during which a patient rapidly deteriorated) involving 185 residents. RESULTS: Excellent interassessor reliability was obtained for C-SAW-C [median κ = 0.89; median intraclass correlation coefficient (ICC) = 0.94], T-SAW-C (median ICC = 0.99), and the revised PP-GIs (κ = 1.00; ICC = 0.98 or higher). Internal consistency was also very high for all team skills assessed by T-SAW-C (Cronbach α range 0.87-0.94 across 6 skills) and the revised PP-GIS (Cronbach α = 0.96)-all P's < 0.001. Significant positive correlations were obtained between the 3 assessments (r = 0.73-0.92, P < 0.001) thus showing evidence for convergent validity. CONCLUSIONS: We developed a toolkit that captures comprehensively the skills that are required for safe and effective ward care, including the high-risk situation where a patient decompensates. The toolkit offers a systematic evaluation of the quality and safety of surgical ward care and can be used to train and debrief residents' skills and performance.