• Yue-Yung Hu, Alexander F Arriaga, Sarah E Peyre, Katherine A Corso, Emilie M Roth, and Caprice C Greenberg.
• Center for Surgery & Public Health, Brigham & Women's Hospital, Boston, Massachusetts, USA.
• J. Surg. Res. 2012 Sep 1; 177 (1): 37-42.

BackgroundCommunication failure is a common contributor to adverse events. We sought to characterize communication failures during complex operations.MethodsWe 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.ResultsWe 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.ConclusionsDuring 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.Copyright © 2012 Elsevier Inc. All rights reserved.

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