Deconstructing intraoperative communication failures

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.

Introduction

Communication is critical to the safe delivery of surgical care. The Joint Commission attributes 56% of operative or postoperative complications to faulty communication [1]. Problematic behavior lie at the root of 78% of surgical malpractice claims, and among these, the failure to communicate is the most common, accounting for 22% of complications [2].

In the operating room (OR), a high degree of coordination between individuals and teams is required. Such teamwork necessitates effective communication. Multiple studies have alluded to the importance of communication in the OR. One review of surgical malpractice claims found that nearly a third of communication breakdowns occurred in the OR [3]. Nationally, hospitals in which physician communication is rated highly by surgical staff members have demonstrated lower risk-adjusted morbidity [4]. In one field observation study, patients were observed to have an increased odds of complications or death when intraoperative information sharing was low [5].

Although progress in the study of intraoperative communication has been made, the specific characteristics that predispose it to or safeguard it from failure have yet to be completely described. Lingard et al. [6], [7] developed and validated an instrument for evaluating team communication in the OR, but because her team did not observe procedures in their entirety, her findings may not truly represent intraoperative communication as a whole. Halverson et al. [8] expanded this instrument to capture discussion content but used it to study failures alone, disregarding all other intraoperative communications. Indeed, although the instrument defines broad categories for describing communication in the OR, it has yet to be applied to determine how various failures and their sequelae are influenced by the participants, their discipline, the timing of the communication, and its content. This manuscript will attempt to address these gaps.

Finally, this instrument has thus far only been used during live observations, a methodology limited by the transient and complex nature of OR interactions. Because it relies on humans to observe and process multiple, often simultaneous, conversations and occurrences, its reproducibility is a concern. Thus, we sought to apply Lingard's instrument to characterize intraoperative communication in complex operations captured on video.