Communication failures in the operating room: an observational classification of recurrent types and effects

This studied communication in the operating room with the aim to classify the types of communication failures and their effects.

94 healthcare personnel were observed by trained observers; 09 hours of observations were collected. 421 communication events were noted.

Although it’s a niche area (operating room staff) and from 2004, the findings are still pretty interesting in my view.

Results

Overall they found:

·???????? Four types of communication failure were noted: 1) occasion (suboptimal timing), content (insufficiencies or inaccuracies) purpose (lack of resolution) and audience (gaps in group composition)

·???????? Communication failures accounted for about a third of all communication exchanges

·???????? The most frequently observed communication failures were “exchanges that happened too late to be maximally useful and exchanges that were incomplete because relevant information was missing”

·???????? A third of communication failures had immediate effects, like inefficiency or team tension

Occasion was the most commonly observed failure (45.7% instances) – all instances here included suboptimal timing of exchange, where info was requested or provided too late to be maximally useful.

Content category (35.7% of instances) had two types of exchange failures – missing relevant info (accounting for most of this category), and inaccurate info.

Purpose category (24%) had two types – one was the participants’ failure to achieve communicative objectives due to a lack of resolution of a raised issue, and less frequently where observers judged the objective from the communicator as inappropriate.

Audience category (20%) all involved instances where a key team member was absent during the communication event

Effects of communication failures

They analysed all of the communication failures and found that 36.4% of failures resulted in visible effects on system processes. These effects included inefficiency, team tension, resource waste, workarounds, delay, patient inconvenience and procedural error.

Discussing the findings, they note that “we found that these failures are based in strikingly simple factors: communication is too late to be effective, content is not consistently complete and accurate, key individuals are excluded, and issues are left unresolved until the point of urgency”.

They point out that while these results may be affected by potential sampling bias – the results may also be the tip of the iceberg in terms of communication failure. Moreover, intervening to strengthen communication may be challenging because communication in healthcare teams “is rooted in the distinct and often conflicting professional identities of team members and is bounded by a culture that has been traditionally and persistently hierarchical”.

They argue that these communication failures are important because they, in part, “can act as a signal of a problem originating elsewhere, in attitudinal or system processes”. For instance, in one of the procedural error exchanges they observed, the communication failures are not only directly connected to the procedural issue, but “also signals of other system issues such as trainee supervision”.

While a relatively small percentage of communication failures resulted in immediate effects (36.4%), this is likely a “conservative depiction”, due to the study design which couldn’t trace effects beyond the observation site.

Finally, they argue that “The invisibility of the effects of communication failure as well as the phenomenon of migration probably explain how the operating team has come to the status quo in which it is highly irregular for a surgeon, an anesthesiologist, and a nurse to meet and discuss a procedure before it commences”.

Link in comments.

Authors: Lingard, L., Espin, S., Whyte, S., Regehr, G., Baker, G. R., Reznick, R., ... & Grober, E. (2004). BMJ Quality & Safety, 13(5), 330-334.