• Quality improvement
• Quality measurement
• Patient safety

We thank Pucher and Aggarwal1 for their interest in our paper and their kind words on how our research adds to the literature on this topic. We welcome the opportunity to share more detail about our study in response to their three specific questions.

The first question related to how specific distractions used in the study were chosen. These were selected after discussion with a number of local clinical colleagues, ranging from relatively junior doctors through to experienced senior consultants. The results from these focus groups indicated six common workplace distractions. These were the doctor's pager, dealing with ward telephone calls, background noise (such as the ward radio and a domestic's hoover), managing ad hoc prescription tasks and interacting with relatives. Given the commonality of these distractions, they were chosen for inclusion in the study. We accept that the nature of distractions may vary in different healthcare settings and the distractors chosen here may only be appropriate to UK-based studies. Therefore, it would be interesting to carry out a ‘straw-poll’ internationally to identify common universal distractions. However, the work of Weigl et al 2 and Pereira et al 3 in German and American healthcare settings suggests a degree of homogeneity in distractions worldwide.

The second question raised regards the feedback delivered to the intervention group. These students received a targeted critique on improving distractor management. Pucher and Aggarwal question whether this is valid as during the post-intervention ward round distractor management is once again assessed. We agree it is unsurprising that students in the intervention group got better at managing distractions, whereas those in the control group did not. Nevertheless, it is encouraging that students in the intervention group were able to display improved distractor management skills over a lag period of 1 month. This suggests true behavioural change as opposed to mere regurgitative learning. However, we would take this opportunity to reiterate that improvement in distractor management was not the primary outcome of the study. Rather, its main focus was the change in clinical error between simulations. The study shows that if students are taught how to cope with common ward-based distractions they commit fewer errors on a ward round of comparable rigour compared with students who do not receive such instruction.

Third, regarding whether selecting medical students rather than clinical staff was appropriate, the literature shows that it is junior doctors who are most susceptible to error-making within stressful environments.4 ,5 In short, we selected final year medical students purposefully in order to prepare them for managing ward round situations they will soon encounter as new doctors. We do agree that postgraduate training is also worthwhile, which is exemplified by our faculty's involvement in the Scottish Surgical Bootcamps.6 Bootcamp is an innovative simulation-rich course recommended by the Scottish Core Surgical Training Programme. It incorporates a comparable ward round experience—with the aim of imparting safe ward round skills to junior surgical trainees.

Finally, we welcome the use of objective, validated scoring scales for ward round performance and commend Pucher et al 7 in their development of the Ward NOn-TECHnical Skills (W-NOTECHS) tool. To the best of our knowledge, W-NOTECHS has been used to obtain single ‘snap shot’ performances of surgical trainees. We look forward to seeing future research that evidences the degree to which assessment and feedback using W-NOTECHS can improve ward round behaviours of individuals—be they undergraduate medical students or postgraduate doctors. Ideally such research would involve multiple centres and would provide researchers in the field of patient safety and simulation exciting opportunities for collaboration in their efforts to achieve excellence in ward round practice.