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High rates of iatrogenic harm have been confirmed in observational studies of surgery. Most interventions designed to reduce this have been targeted at either workplace culture or operational systems. We hypothesised that an integrated intervention addressing both culture and system might be more effective than either approach alone.To evaluate interventions designed to improve surgical team performance by impacting culture or systems in isolation or combination.Five controlled intervention experiments, addressing system, culture or both, were performed in operating theatres. A final whole-system intervention study integrated approaches that showed benefit in these experiments. The five linked studies were subjected to a pre-planned pooled analysis to identify the effects of interventions, combinations and confounders. A qualitative interview study provided explanatory data on the mechanisms of intervention success and failure. An economic analysis was conducted.Operating theatres in five hospitals, performing orthopaedic, trauma, vascular and plastic surgery were used for the linked studies. The final study occurred in a tertiary referral neurosurgery unit.The main study subjects were clinical staff. Patient outcomes, both clinical and patient reported, were collected as secondary outcome measures.The interventions tested were (1) teamwork training (TT) based on the aviation crew resource management model, (2) the development of a set of standard operating procedures (SOPs), (3) a safety improvement programme based on lean principles, (4) TT plus SOPs and (5) TT plus lean. The final intervention used elements of all three strategies.Primary outcomes were team non-technical skills [as measured by the Oxford Non-Technical Skills (NOTECHS) II scale score] and team technical performance (via the ‘glitch count’). Secondary outcomes were compliance with the World Health Organization (WHO)’s checklist procedures, patient length of stay, readmissions, 30-day mortality, complications and patient-reported outcome measures [as measured by the European Quality of Life-5 Dimensions (EQ-5D)]. A qualitative interview study provided explanatory data on the mechanisms of intervention success and failure. An economic analysis was conducted.Direct observation of whole operations, clinical records, hospital information systems and EQ-5D questionnaires. The qualitative study used semistructured interviews.Individual studies were analysed using two-way analysis of variance, and an overall individual patient pooled analysis was performed. Methods validation studies and other analyses used chi-squared test, correlation and regression methods as appropriate.We studied 453 operations. The results of single interventions were inconsistent. TT alone improved non-technical skills and WHO compliance (p 


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Nuffield Department of Surgical Sciences, University of Oxford, John Radcliffe Hospital, Oxford, UK