NOTSS: Non-Technical Skills for Surgeons

NOTSS is a behaviour rating system for surgeons. The system was developed using task analysis with subject matter experts and evaluated in trials using standardized video scenarios and real operations. It allows consultant (attending) surgeons to give feedback to colleagues and trainees based on structured observations of non-technical aspects of performance during intraoperative surgery. Ratings and feedback are given on four categories of non-technical skills:

  1. Situation Awareness
  2. Decision Making
  3. Communication & Teamwork
  4. Leadership

Training in NOTSS is offered by The Royal College of Surgeons of Edinburgh.

Please email for a copy.

NOTSS Publications & Downloads

Yule, S., Rowley, D., Flin, R., Maran, N., Youngson, G., Duncan, J. & Paterson-Brown, S. (2009). Experience matters: Comparing novice and expert ratings of non-technical skills using the NOTSS system. ANZ Journal of Surgery 79, 154-160.

Yule, S., Flin, R., Maran, N., Rowley, D. , Youngson, G. & Paterson-Brown, S. (2008). Surgeons' non-technical skills in the operating room: Reliability testing of the NOTSS behaviour rating system. World Journal of Surgery, 32, 548-556.

Yule, S., Flin, R., Rowley, D., Mitchell, A., Youngson, G., Maran, N. & Paterson-Brown, S. (2008). Debriefing surgical trainees on non-technical skills (NOTSS). Cognition, Technology & Work, 10, 265-274.

Flin, R., Youngson, G. G., & Yule, S. (2007). How do surgeons make intraoperative decisions? Quality and Safety in Healthcare, 16, 235-239.

Flin, R., Yule, S., Paterson-Brown, S., Maran, N., Rowley, D. R., & Youngson, G. G. (2007). Teaching surgeons about non-technical skills. The Surgeon 5, 86-89.

Yule, S., Flin, R., Paterson-Brown, S., Maran, N., & Rowley D. (2006). Development of a rating system for surgeons' non-technical skills. Medical Education, 40, 1098-1104. Download article  (177kb)

Flin, R., Yule, S., McKenzie, L., Paterson-Brown, S. & Maran, N. (2006). Attitudes to teamwork and safety in the operating theatre. The Surgeon, 4, 145-151. Download article (359kb): Download additional tables (114kb): Download ORMAQ questionnaire (120kb)

Yule, S., Flin, R., Paterson-Brown, S. & Maran, N. (2006). Non-technical skills for surgeons in the operating room: A review of the literature. Surgery, 139, 140-149 Download pdf article (141kb)

Surgeons' News Articles

Test of cultures - NOTSS in Japan Click here for article

Lessons from the aviation industry. Download pdf article (92kb)

Advances in patient safety: non-technical skills in surgery. Download pdf article (121kb)

Critical thinking: Non-technical skills in surgery. Download pdf article (98kb)

Scientific Meetings

NOTSS research has been presented at several conferences from 2003-2008, including HFES, ASME, AMEE, ASGBI, IAAP, IMMS, AAvP.



Royal College of Surgeons of Edinburgh
NHS Education Scotland (NES)


Prof Rhona Flin
Mr Simon Paterson-Brown
Dr Nikki Maran
Prof David Rowley
Prof George Youngson
Prof Stuart Macpherson
Dr Steven Yule


Prof Rhona Flin
School of Psychology
University of Aberdeen
Aberdeen AB24 2UB

: +44 1224 273210
fax: +44 1224 273211


Royal College of Surgeons of Edinburgh Patient Safety Board

ANTS: Anaesthetists' Non-Technical Skills

Scottish Clinical Skills Network

Imperial College Clinical Safety Research Unit