title: Non-technical skills in minimally invasive surgery teams: a systematic review.
abstract: Root cause analyses show that up to 70 % of adverse events are caused by human error. Strong non-technical skills (NTS) can prevent or reduce these errors, considerable numbers of which occur in the operating theatre. Minimally invasive surgery (MIS) requires manipulation of more complex equipment than open procedures, likely requiring a different set of NTS for each kind of team. The aims of this study were to identify the MIS teams' key NTS and investigate the effect of training and assessment of NTS on MIS teams.
  
  
  
  The databases of PubMed, Cochrane Library, Embase, PsycINFO, and Scopus were systematically searched according to Preferred Reporting Item for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Articles containing outcome measures related to MIS teams' key NTS, training, or assessment of NTS were included.
  
  
  
  The search yielded 1984 articles, 11 of which were included. All were observational studies without blinding, and they differed in aims, types of evaluation, and outcomes. Only two studies evaluated patient outcomes other than operative time, and overall, the studies' quality of evidence was low. Different communication types were encountered in MIS compared to open surgery, mainly due to equipment- and patient-related challenges. Fixed teams improved teamwork and safety levels, while deficient planning and poor teamwork were found to obstruct workflow and increase errors. Training NTS mitigates these issues and improves staff attitudes towards NTS.
  
  
  
  MIS teams' NTS are important for workflow and prevention of errors and can be enhanced by working in fixed teams. In the technological complex sphere of MIS, communication revolves around equipment- and patient-related topics, much more so than in open surgery. In all, only a few heterogeneous-design studies have examined this. In the future, the focus should shift to systematically identifying key NTS and developing effective, evidence-based team training programmes in MIS.
authors.affiliation: Copenhagen Academy for Medical Education and Simulation (CAMES), Capital Region of Denmark, Rigshospitalet, Section 5404, Blegdamsvej 9, 2100, Copenhagen Ø, Denmark. kirsten.gjeraa@regionh.dk.|Copenhagen University, Copenhagen, Denmark. kirsten.gjeraa@regionh.dk.
authors.forename: Kirsten
authors.identifier: 0000-0001-8788-1696
authors.initials: K
authors.lastname: Gjeraa
authors.affiliation: Surgical Department, Nordsjællands Hospital, Hillerød, Denmark.
authors.forename: Lene
authors.initials: L
authors.lastname: Spanager
authors.affiliation: Copenhagen Academy for Medical Education and Simulation (CAMES), Capital Region of Denmark, Rigshospitalet, Section 5404, Blegdamsvej 9, 2100, Copenhagen Ø, Denmark.|Copenhagen University, Copenhagen, Denmark.
authors.forename: Lars
authors.initials: L
authors.lastname: Konge
authors.affiliation: Department of Cardiothoracic Surgery, University Hospital of Copenhagen, Rigshospitalet, Copenhagen Ø, Denmark.
authors.forename: René H
authors.initials: RH
authors.lastname: Petersen
authors.affiliation: Copenhagen Academy for Medical Education and Simulation (CAMES), Capital Region of Denmark, Rigshospitalet, Section 5404, Blegdamsvej 9, 2100, Copenhagen Ø, Denmark.|Copenhagen University, Copenhagen, Denmark.
authors.forename: Doris
authors.initials: D
authors.lastname: Østergaard
mesh_terms: D002983:Clinical Competence; D003142:Communication; D006801:Humans; D019300:Medical Errors / Q000517:prevention & control*; D019060:Minimally Invasive Surgical Procedures; D009873:Operating Rooms / Q000592:standards*; D017063:Outcome Assessment, Health Care; D010348:Patient Care Team / Q000592:standards*
keywords: Assessment tools; Errors; Minimally invasive surgery; Non-technical skills; Operating room; Team training