Deconstructing intraoperative communication failures

Yue Yung Hu, Alexander F. Arriaga, Sarah E. Peyre, Katherine A. Corso, Emilie M. Roth, Caprice C. Greenberg*

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

82 Scopus citations


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.

Original languageEnglish (US)
Pages (from-to)37-42
Number of pages6
JournalJournal of Surgical Research
Issue number1
StatePublished - Sep 1 2012


  • Communication failures
  • Intraoperative video
  • System communication
  • Team communication

ASJC Scopus subject areas

  • Surgery


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