***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Objective To investigate the effect of in situ simulation ( ISS ) versus off-site simulation ( OSS ) on knowledge , patient safety attitude , stress , motivation , perceptions of simulation , team performance and organisational impact . Design Investigator-initiated single-centre r and omised superiority educational trial . Setting Obstetrics and anaesthesiology departments , Rigshospitalet , University of Copenhagen , Denmark . Participants 100 participants in teams of 10 , comprising midwives , specialised midwives , auxiliary nurses , nurse anaesthetists , operating theatre nurses , and consultant doctors and trainees in obstetrics and anaesthesiology . Interventions Two multiprofessional simulations ( clinical management of an emergency caesarean section and a postpartum haemorrhage scenario ) were conducted in teams of 10 in the ISS versus the OSS setting . Primary outcome Knowledge assessed by a multiple choice question test . Exploratory outcomes Individual outcomes : scores on the Safety Attitudes Question naire , stress measurements ( State-Trait Anxiety Inventory , cognitive appraisal and salivary cortisol ) , Intrinsic Motivation Inventory and perceptions of simulations . Team outcome : video assessment of team performance . Organisational impact : suggestions for organisational changes . Results The trial was conducted from April to June 2013 . No differences between the two groups were found for the multiple choice question test , patient safety attitude , stress measurements , motivation or the evaluation of the simulations . The participants in the ISS group scored the authenticity of the simulation significantly higher than did the participants in the OSS group . Expert video assessment of team performance showed no differences between the ISS versus the OSS group . The ISS group provided more ideas and suggestions for changes at the organisational level . Conclusions In this r and omised trial , no significant differences were found regarding knowledge , patient safety attitude , motivation or stress measurements when comparing ISS versus OSS . Although participant perception of the authenticity of ISS versus OSS differed significantly , there were no differences in other outcomes between the groups except that the ISS group generated more suggestions for organisational changes . Trial registration number NCT01792674 Background There are many avoidable deaths in hospitals because the care team is not well attuned . Training in emergency situations is generally followed on an individual basis . In practice , however , hospital patients are treated by a team composed of various disciplines . To prevent communication errors , it is important to focus the training on the team as a whole , rather than on the individual . Team training appears to be important in contributing toward preventing these errors . Obstetrics lends itself to multidisciplinary team training . It is a field in which nurses , midwives , obstetricians and paediatricians work together and where decisions must be made and actions must be carried out under extreme time pressure . It is attractive to belief that multidisciplinary team training will reduce the number of errors in obstetrics . The other side of the medal is that many hospitals are buying expensive patient simulators without proper evaluation of the training method . In the Netherl and s many hospitals have 1,000 or less annual deliveries . In our small country it might therefore be more cost-effective to train obstetric teams in medical simulation centres with well trained personnel , high fidelity patient simulators , and well defined training programmes . Methods / design The aim of the present study is to evaluate the cost-effectiveness of multidisciplinary team training in a medical simulation centre in the Netherl and s to reduce the number of medical errors in obstetric emergency situations . We plan a multicentre r and omised study with the centre as unit of analysis . Obstetric departments will be r and omly assigned to receive multidisciplinary team training in a medical simulation centre or to a control arm without any team training . The composite measure of poor perinatal and maternal outcome in the non training group was thought to be 15 % , on the basis of data obtained from the National Dutch Perinatal Registry and the guidelines of the Dutch Society of Obstetrics and Gynaecology ( NVOG ) . We anticipated that multidisciplinary team training would reduce this risk to 5 % . A sample size of 24 centres with a cluster size of each at least 200 deliveries , each 12 centres per group , was needed for 80 % power and a 5 % type 1 error probability ( two-sided ) . We assumed an Intraclass Correlation Coefficient ( ICC ) value of maximum 0.08.The analysis will be performed according to the intention-to-treat principle and stratified for teaching or non-teaching hospitals . Primary outcome is the number of obstetric complications throughout the first year period after the intervention . If multidisciplinary team training appears to be effective a cost-effective analysis will be performed . Discussion If multidisciplinary team training appears to be cost-effective , this training should be implemented in extra training for gynaecologists . Trial Registration The protocol is registered in the clinical trial register number OBJECTIVE : To compare the effectiveness of  training for eclampsia  in local hospitals and a regional simulation center , with and without teamwork theory . METHODS : This study is a r and omized controlled trial of training in local hospitals and in a simulation center in the United Kingdom . Midwives and obstetricians working at participating hospitals were r and omly assigned to 24 teams . Teams were r and omly allocated to training in local hospitals or at a simulation center , and to teamwork theory or not .  Performance was evaluated before and after training with a st and ardized eclampsia scenario captured on video . Outcome measures were completion of tasks , time to completion of tasks , administration of magnesium sulfate , and quality of teamwork . RESULTS : Training was associated with an increase in completion of basic tasks ; 87 % before training and 100 % afterward . Basic tasks were completed more quickly ; 55 seconds compared with 27 seconds , P=.012 . The magnesium sulfate loading dose was administered by 61 % of teams before training and by 92 % afterward ( P=.040 ) . There was a shorter median time to administration ( 116 seconds less ; P=.011 ) . Training at the simulation center was not associated with additional improvement . Teamwork generally improved ( median global score rose from 2.5 to 4.0 ; P<.001 ) but there was no additional benefit from teamwork training . CONCLUSION : Training result ed in enhanced performance with higher rates of completion for basic tasks , shorter times to administration of magnesium sulfate , and improved teamwork . There was no additional benefit from training in a simulation center , and none from teamwork theory . CLINICAL TRIAL REGISTRATION : IS RCT N , http://is rct n.org , IS RCT N67906788 , reference number 0270030 LEVEL OF EVIDENCE : Background Ineffective management of obstetric emergencies contributes significantly to maternal and neonatal morbidity and mortality in Mexico .  PRONTO ( Programa de Rescate Obstétrico y Neonatal : Tratamiento Óptimo y Oportuno ) is a highly-realistic , low-tech simulation-based obstetric and neonatal emergency training program . A pair-matched hospital-based controlled implementation trial was undertaken in three states in Mexico , with pre/post measurement of process indicators at intervention hospitals . This report assesses the impact of PRONTO simulation training on process indicators from the pre/post study design for process indicators . Methods Data was collected in twelve intervention facilities on process indicators , including pre/post changes in knowledge and self-efficacy of obstetric emergencies and neonatal resuscitation , achievement of strategic planning goals established during training and changes in teamwork scores . Authors performed a longitudinal fixed-effects linear regression model to estimate changes in knowledge and self-efficacy and logistic regression to assess goal achievement . Results A total of 450 professionals in interprofessional teams were trained . Significant increases in knowledge and self-efficacy were noted for both physicians and nurses ( p < 0.001- 0.009 ) in all domains . Teamwork scores improved and were maintained over a three month period . A mean of 58.8 % strategic planning goals per team in each hospital were achieved . There was no association between high goal achievement and knowledge , self-efficacy , proportion of doctors or nurses in training , state , or teamwork score . Conclusions These results suggest that PRONTO ’s highly realistic , locally appropriate simulation and team training in maternal and neonatal emergency care may be a promising avenue for optimizing emergency response and improving quality of facility-based obstetric and neonatal care in re source -limited setting s . Trial registration Objective To evaluate factors contributing to obstetric emergencies , analyze the fetomaternal outcome and role of obstetric drill in facing these emergencies effectively . Material and Method Out of 10,892 deliveries , a total of 520 women were included in this prospect i ve study . Analysis of emergency obstetric conditions was done by evaluating incidence , various contributing factors , and fetomaternal outcome . Obstetric drill was conducted among residents repetitively . Pre drill and post drill assessment of confidence in clinical , knowledge , and team work skills were compared by χ2 test . Impact of drill on severe obstetric morbidities was noted . ObservationsIncidence of obstetric emergencies was found to be 4.88 % . Maternal and perinatal mortality was seen in 4.23 and 37.11 % , respectively , of these emergency obstetric women . Impact of drill showed an increase in score in knowledge ( p < 0.019 ) , confidence ( p , 0.001 ) , and team work ( p < 0.001 ) . Conclusion Active implementation of emergency obstetric care and incorporation of obstetric drill lays a strong foundation for safe fetomaternal outcome Background Unexpected obstetric emergencies threaten the safety of pregnant women . As emergencies are rare , they are difficult to learn . Therefore , simulation-based medical education ( SBME ) seems relevant . In non- systematic review s on SBME , medical simulation has been suggested to be associated with improved learner outcomes . However , many questions on how SBME can be optimized remain unanswered . One unresolved issue is how ' in situ simulation ' ( ISS ) versus ' off site simulation ' ( OSS ) impact learning . ISS means simulation-based training in the actual patient care unit ( in other words , the labor room and operating room ) . OSS means training in facilities away from the actual patient care unit , either at a simulation centre or in hospital rooms that have been set up for this purpose . Methods and design The objective of this r and omized trial is to study the effect of ISS versus OSS on individual learning outcome , safety attitude , motivation , stress , and team performance amongst multi-professional obstetric-anesthesia teams . The trial is a single-centre r and omized superiority trial including 100 participants . The inclusion criteria were health-care professionals employed at the department of obstetrics or anesthesia at Rigshospitalet , Copenhagen , who were working on shifts and gave written informed consent . Exclusion criteria were managers with staff responsibilities , and staff who were actively taking part in preparation of the trial . The same obstetric multi-professional training was conducted in the two simulation setting s. The experimental group was exposed to training in the ISS setting , and the control group in the OSS setting . The primary outcome is the individual score on a knowledge test . Exploratory outcomes are individual scores on a safety attitudes question naire , a stress inventory , salivary cortisol levels , an intrinsic motivation inventory , results from a question naire evaluating perceptions of the simulation and suggested changes needed in the organization , a team-based score on video-assessed team performance and on selected clinical performance . Discussion The perspective is to provide new knowledge on context ual effects of different simulation setting s . Trial registration ClincialTrials.gov NCT01792674 BACKGROUND Birth trauma is a low-frequency , high-severity event , making obstetrics a major challenge for patient safety . Yet , few strategies have been shown to eliminate preventable perinatal harm . Interdisciplinary team training was prospect ively evaluated to assess the relative impact of two different learning modalities to improve nontechnical skills (NTS)--the cognitive and interpersonal skills , such as communication and teamwork , that supplement clinical and technical skills and are necessary to ensure safe patient care . METHODS Between 2005 and 2008 , perinatal morbidity and mortality data were prospect ively collected using the Weighted Adverse Outcomes Score ( WAOS ) and a culture of safety survey ( Safety Attitudes Question naire ) at three small-sized community hospitals . In a small cluster r and omized clinical trial conducted in the third quarter of 2007 , one of the hospitals served as a control group and two served as the treatment intervention sites -- one hospital received the TeamSTEPPS didactic training program and one hospital received both the TeamSTEPPS program along with a series of in-situ simulation training exercises . RESULTS A statistically significant and persistent improvement of 37 % in perinatal morbidity was observed between the pre- and postintervention for the hospital exposed to the simulation program . There were no statistically significant differences in the didactic-only or the control hospitals . Baseline perceptions of culture of safety were high at all three hospitals , and there were no significant changes . CONCLUSIONS A comprehensive interdisciplinary team training program using in-situ simulation can improve perinatal safety in the hospital setting . This is the first evidence providing a clear association between simulation training and improved patient outcomes . Didactics alone were not effective in improving perinatal outcomes ABSTRACT Objective : Prompt recognition and response to  postpartum hemorrhage ( PPH ) are vital in preventing maternal morbidity and mortality . We conducted a multi-center study to evaluate in situ simulation and team training for PPH among experienced clinical teams in non-academic hospitals in urban and rural communities . Methods : A longitudinal intervention study was performed in six Oregon community hospitals . All teams responded to an in situ simulated delivery and postpartum hemorrhage using trained actors and an obstetric birthing simulator , followed by a debriefing and training session . The simulation scenario was then repeated in 9–12 months . All sessions were digitally video recorded and independently review ed by two obstetricians using a structured evaluation form . P 
    Output:
    
The most reliable tools identified were the Clinical Teamwork Scale , the Global Assessment of Obstetric Team Performance , and the Global Rating Scale of performance .