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

Background: Ineffective team communication is frequently at the root of medical error. The objective of this study was to describe the characteristics of communication failures in the operating room ( OR) and to classify their effects. This study was part of a larger project to develop a team checklist to improve communication in the OR. Methods: Trained observers recorded 90 hours of observation during 48 surgical procedures. Ninety four team members participated from anesthesia ( 16 staff, 6 fellows, 3 residents), surgery ( 14 staff, 8 fellows, 13 residents, 3 clerks), and nursing ( 31 staff). Field notes recording procedurally relevant communication events were analysed using a framework which considered the content, audience, purpose, and occasion of a communication exchange. A communication failure was defined as an event that was flawed in one or more of these dimensions. Results: 421 communication events were noted, of which 129 were categorized as communication failures. Failure types included "occasion'' (45.7% of instances) where timing was poor; "content'' (35.7%) where information was missing or inaccurate, "purpose'' (24.0%) where issues were not resolved, and "audience'' (20.9%) where key individuals were excluded. 36.4% of failures resulted in visible effects on system processes including inefficiency, team tension, resource waste, workaround, delay, patient inconvenience and procedural error. Conclusion: Communication failures in the OR exhibited a common set of problems. They occurred in approximately 30% of team exchanges and a third of these resulted in effects which jeopardized patient safety by increasing cognitive load, interrupting routine, and increasing tension in the OR.