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A better way: training for direct observations in healthcare
  1. Myrtede Alfred1,2,
  2. John Del Gaizo3,
  3. Falisha Kanji4,
  4. Samuel Lawton1,
  5. Ashley Caron4,
  6. Lynne S Nemeth5,
  7. A V Alekseyenko3,6,7,
  8. Daniel Shouhed4,
  9. Stephen Savage8,
  10. Jennifer T Anger9,
  11. Ken Catchpole1,
  12. Tara Cohen4
  1. 1 Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
  2. 2 Mechanical and Industrial Engineering, University of Toronto, Toronto, Ontario, Canada
  3. 3 Biomedical Informatics Center, Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
  4. 4 Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
  5. 5 College of Nursing, Medical University of South Carolina, Charleston, South Carolina, USA
  6. 6 Department of Health Care Leadership and Management, Medical Unversity of South Carolina, Charleston, South Carolina, USA
  7. 7 Department of Oral Health Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
  8. 8 Department of Surgery, Medical University of South Carolina, Charleston, South Carolina, USA
  9. 9 Urology, University of California San Diego, La Jolla, CA, USA
  1. Correspondence to Dr Tara Cohen, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, USA; tara.cohen{at}


Direct observation is valuable for identifying latent threats and elucidating system complexity in clinical environments. This approach facilitates prospective risk assessment and reveals workarounds, near-misses and recurrent safety problems difficult to diagnose retrospectively or via outcome data alone. As observers are an instrument of data collection, developing effective and comprehensive observer training is critical to ensuring the reliability of the data collection and reproducibility of the research. However, methodological rigour for ensuring these data collection properties remains a key challenge in direct observation research in healthcare. Although prior literature has offered key considerations for observational research in healthcare, operationalising these recommendations may pose a challenge and unless guidance is also provided on observer training. In this article, we offer guidelines for training non-clinical observers to conduct direct observations including conducting a training needs analysis, incorporating practice observations and evaluating observers and inter-rater reliability. The operationalisation of these guidelines is described in the context of a 5-year multisite observational study investigating technology integration in the operating room. We also discuss novel tools developed during the course our project to support data collection and examine inter-rater reliability among observers in direct observation studies.

  • surgery
  • patient safety
  • interruptions
  • qualitative research
  • human factors

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  • Contributors KC, JTA, LSN, AVA and TC designed the research study. DS, SS and JTA supported operationalisation. KC, TC, MA, FK and JDG designed the observer training course and tools. MA, JDG, FK, SL, AC, KC and TC composed the original draft of the manuscript. LSN, AVA, DS, SS, JTA, KC then reviewed, edited and approved the final submission. TC, KC, and MA are guarantors.

  • Funding This project was funded under grant number HS026491-01 from the Agency for Healthcare Research and Quality (AHRQ), US Department of Health and Human Services (HHS).

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.