ABSTRACT
The wider team's professional and organisational learning would therefore be lost to the detriment of future patient safety. The UK Governmental report in 2000 into learning from adverse events within the National Health Service (NHS) stated that too often in the past we have witnessed tragedies which could have been avoided had the lessons of past experience been properly learned. In response to this recommendation, QinetiQ has been working with the Royal Cornwall Hospital (RCH), Truro, to develop and trial a series of tools that enable surgical teams to review and enhance performance. Prior to conducting a surgical procedure this team does not usually engage in any pre-briefing activity. A teamwork model was developed specifically for surgical teams, to provide the topics for review. Staff at RCH has reacted positively to the concept of Team Self-Review, although there was an initial Hawthorne effect evident when QinetiQ were facilitating the reviews.
