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J Surg Res. 2012 Sep;177(1):37-42. doi: 10.1016/j.jss.2012.04.029. Epub 2012 May 4.

Deconstructing intraoperative communication failures.

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1
Center for Surgery & Public Health, Brigham & Women's Hospital, Boston, Massachusetts, USA.

Abstract

BACKGROUND:

Communication failure is a common contributor to adverse events. We sought to characterize communication failures during complex operations.

METHODS:

We video recorded and transcribed six complex operations, representing 22 h of patient care. For each communication event, we determined the participants and the content discussed. Failures were classified into four types: audience (key individuals missing), purpose (issue nonresolution), content (insufficient/inaccurate information), and/or occasion (futile timing). We added a systems category to reflect communication occurring at the organizational level. The impact of each identified failure was described.

RESULTS:

We observed communication failures in every case (mean 29, median 28, range 13-48), at a rate of one every 8 min. Cross-disciplinary exchanges resulted in failure nearly twice as often as intradisciplinary ones. Discussions about or mandated by hospital policy (20%), personnel (18%), or other patient care (17%) were most error prone. Audience and purpose each accounted for >40% of failures. A substantial proportion (26%) reflected flawed systems for communication, particularly those for disseminating policy (29% of system failures), coordinating personnel (27%), and conveying the procedure planned (27%) or the equipment needed (24%). In 81% of failures, inefficiency (extraneous discussion and/or work) resulted. Resource waste (19%) and work-arounds (13%) also were frequently seen.

CONCLUSIONS:

During complex operations, communication failures occur frequently and lead to inefficiency. Prevention may be achieved by improving synchronous, cross-disciplinary communication. The rate of failure during discussions about/mandated by policy highlights the need for carefully designed standardized interventions. System-level support for asynchronous perioperative communication may streamline operating room coordination and preparation efforts.

PMID:
22591922
PMCID:
PMC4539247
DOI:
10.1016/j.jss.2012.04.029
[Indexed for MEDLINE]
Free PMC Article
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