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Cognition, Technology & Work

, Volume 13, Issue 1, pp 1–10 | Cite as

Engineering the system of communication for safer surgery

  • Andrew N. HealeyEmail author
  • Kamal Nagpal
  • Krishna Moorthy
  • Charles A. Vincent
Original Article

Abstract

Communication failures are a leading cause of error in surgery. Researchers and practitioners have therefore developed different interventions to improve communications, such as team briefing and pre-operative patient checklists. These different methods have clear merit. However, they have only dealt with portions of a complex system. Consequently, disparate interventions of varying kinds may not integrate and build an effective system of communication. We argue that a new view of communication is needed to improve safety in surgery; the view that communication is more fundamentally as a property of the whole system of work rather than confined to interpersonal exchanges. Rather than simply add an intervention to the system, interventions should integrate into the system. To achieve this, we propose a practical strategy to re-engineer the system of communication for surgery. This demands an analysis of the immediate informational needs within the system of interest, and an account of the wider system and those ergonomic and human factors shaping the performance of communicators. We illustrate the application of the method and refer to potential improvements in safety.

Keywords

Operating room Surgery System Communications Safety 

Notes

Acknowledgments

The Clinical Safety Research Unit is affiliated with the Centre for Patient Safety and Service Quality at Imperial College Healthcare NHS Trust, which is funded by the National Institute of Health Research. The Engineering and Physical Sciences Research Council (http://www.epsrc.ac.uk/default.htm) supported Dr A N Healey.

References

  1. Awad SS, Fagan SP, Bellows C, Albo D, Green-Rashad B, De la GM et al (2005) Bridging the communication gap in the operating room with medical team training. Am J Surg 190(5):770–774CrossRefGoogle Scholar
  2. Benn J, Healey AN, Hollnagel E (2008) Improving performance reliability in surgical systems. Cogn Technol Work Spec Issue Enhanc Surg Sys 10:323–333Google Scholar
  3. Brennan TA, Leape LL, Laird NM, Hebert L, Localio AR, Lawthers AG et al (1991) Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. N Engl J Med 324(6):370–376CrossRefGoogle Scholar
  4. Carthey J, de Leval MR, Wright DJ, Farewell VT, Reason JT (2003) Behavioural markers of surgical excellence. Saf Sci 41:409–425Google Scholar
  5. Catchpole KR, Giddings AE, de Leval MR, Peek GJ, Godden PJ, Utley M, Gallivan S, Hirst G, Dale T (2006) Identification of systems failures in successful paediatric cardiac surgery. Ergonomics 49(5–6):567–588Google Scholar
  6. Coiera E, Tombs V (1998) Communication behaviours in a hospital setting: an observational study. BMJ 316(7132):673–676Google Scholar
  7. DeFontes J, Surbida S (2004) Preoperative safety briefing project. Permaente Journal 8:21–27Google Scholar
  8. Degani A, Wiener EL (1997) Procedures in complex systems: the airline cockpit. IEEE Transactions on Systems, Man, and Cybernetics, SMC 27(3):302–312Google Scholar
  9. Eisenberg EM, Murphy AG, Sutcliffe KM, Wears RL, Schenkel S et al (2005) Communication in emergency medicine: implications for patient safety. Communications Monographs 72(4):390–413CrossRefGoogle Scholar
  10. Fairbanks RJ, Bisantz AM, Sunm M (2007) Emergency department communication links and patterns. Ann Emerg Med 50(4):396–406CrossRefGoogle Scholar
  11. Greenberg CC, Regenbogen SE, Studdert DM, Lipsitz SR, Rogers SO, Zinner MJ et al (2007) Patterns of communication breakdowns resulting in injury to surgical patients. J Am Coll Surg 204(4):533–540CrossRefGoogle Scholar
  12. Grote G, Zala-Mezo E, Grommes P (2004) The effects of different forms of coordination on coping with workload. Group Interaction in high-risk environments. Ashgate, Germany, pp 39–55Google Scholar
  13. Healey AN, Undre S, Vincent CA (2004) Developing observational measures of performance in surgical teams. Qual Saf Health Care 13(Suppl. 1):i33–i40Google Scholar
  14. Healey AN, Sevdalis N, Vincent CA (2006) Measuring intra-operative interference from distraction and interruption observed in the operating theatre. Ergonomics 49(5–6):589–604CrossRefGoogle Scholar
  15. Henriksen K, Dayton E (2006) Organizational silence and hidden threats to patient safety. Health Serv Res 41(4p2):1539–1554CrossRefGoogle Scholar
  16. Kwaan MR, Studdert DM, Zinner MJ, Gawande AA (2006) Incidence, patterns, and prevention of wrong-site surgery. Arch Surg 141(4):353–357CrossRefGoogle Scholar
  17. Lilford RJ, Brown CA, Nicholl J (2007) Use of process measures to monitor the quality of clinical practice. BMJ 335(7621):648–650CrossRefGoogle Scholar
  18. Lingard L, Espin S, Whyte S, Regehr G, Baker GR, Reznick R et al (2004) Communication failures in the operating room: an observational classification of recurrent types and effects. Qual Saf Health Care 13(5):330–334CrossRefGoogle Scholar
  19. Lingard L, Espin S, Rubin B, Whyte S, Colmenares M, Baker GR et al (2005) Getting teams to talk: development and pilot implementation of a checklist to promote interprofessional communication in the OR. Qual Saf Health Care 14(5):340–346CrossRefGoogle Scholar
  20. Lingard L, Regehr G, Orser B, Reznick R, Baker GR, Doran D et al (2008) Evaluation of a preoperative checklist and team briefing among surgeons, nurses, and anesthesiologists to reduce failures in communication. Arch Surg 143(1):12–17CrossRefGoogle Scholar
  21. Ludbrook GL, Webb RK, Fox MA, Singleton RJ (1993) The Australian incident monitoring study. Problems before induction of anaesthesia: an analysis of 2000 incident reports. Anaesth Intensive Care 21(5):593–595Google Scholar
  22. Makary MA, Holzmueller CG, Thompson D, Rowen L, Heitmiller ES, Maley WR et al (2006) Operating room briefings: working on the same page. Jt Comm J Qual Patient Saf 32(6):351–355Google Scholar
  23. Makary MA, Mukherjee A, Sexton JB, Syin D, Goodrich E, Hartmann E et al (2007) Operating room briefings and wrong-site surgery. J Am Coll Surg 204(2):236–243CrossRefGoogle Scholar
  24. Martin JA, Regehr G, Reznick R et al. (1997) Objective structured assessment of technical skill (OSATS) for surgical residents. Br J Surg 84:273–278Google Scholar
  25. Mishra A, Catchpole K, Dale T, McCulloch P (2008) The influence of non-technical performance on technical outcome in laparoscopic cholecystectomy. Surg Endosc 22(1):68–73CrossRefGoogle Scholar
  26. Moorthy K, Munz Y, Adams S, Pandey V, Darzi A (2005) A human factors analysis of technical and team skills among surgical trainees during procedural simulations in a simulated operating theatre. Ann Surg 242(5):631–639CrossRefGoogle Scholar
  27. Murphy AG, Wears RL (2009) The medium is the message: communication and power in sign-outs. Ann Emerg Med 54(3):379–380CrossRefGoogle Scholar
  28. Nemeth CP (ed) (2008) Improving healthcare team communication: building on lessons from aviation and aerospace. Ashgate, Aldershot, UK 280Google Scholar
  29. Ovretveit J, Gustafson D (2002) Evaluation of quality improvement programmes. Qual Saf Health Care 11(3):270–275CrossRefGoogle Scholar
  30. Patterson ES, Wears RL (2009) Beyond “communication failure”. Ann Emerg Med 53(6):711–712CrossRefGoogle Scholar
  31. Rasmussen J (1997) Risk management in a dynamic society: a modelling problem. Saf Sci 27(2/3):183–213CrossRefGoogle Scholar
  32. Rogers SO Jr, Gawande AA, Kwaan M, Puopolo AL, Yoon C, Brennan TA et al (2006) Analysis of surgical errors in closed malpractice claims at 4 liability insurers. Surgery 140(1):25–33CrossRefGoogle Scholar
  33. Rubin HR, Pronovost P, Diette GB (2001) The advantages and disadvantages of process-based measures of health care quality. Int J Qual Health Care 13(6):469–474CrossRefGoogle Scholar
  34. Schwaitzberg SD (2006) The emergence of radiofrequency identification tags: applications in surgery. Surg Endosc 20(8):1315–1319CrossRefGoogle Scholar
  35. Undre S, Healey AN, Darzi A, Vincent CA (2006) Observational assessment of surgical teamwork: a feasibility study. World J Surg 30(10):1774–1783CrossRefGoogle Scholar
  36. Vincent CA, Wears RL (2002) Communication in the emergency department: separating the signal from the noise. Med J Aust 176(9):409–410Google Scholar
  37. Vincent C, Taylor-Adams S, Stanhope N (1998) Framework for analysing risk and safety in clinical medicine. British Medical Journal 316(7138):1154–1157Google Scholar
  38. Vincent C, Neale G, Woloshynowych M (2001) Adverse events in British hospitals: preliminary retrospective record review. BMJ 322(7285):517–519CrossRefGoogle Scholar
  39. Williams RG, Silverman R, Schwind C, Fortune JB, Sutyak J, Horvath KD et al (2007) Surgeon information transfer and communication: factors affecting quality and efficiency of inpatient care. Ann Surg 245(2):159–169CrossRefGoogle Scholar
  40. World Alliance for Patient Safety (2008) Safe surgery save lives. http://www.who.int/patientsafety/safesurgery. 10-10-2008
  41. Xiao Y (2005) Artifacts and technical work in health care: methodological, theoretical, and technological implications of the tangible. J Biomed Inform 38(1):26–33CrossRefGoogle Scholar
  42. Xiao Y, Schenkel S, Faraj S, Mackenzie CF, Moss J (2007) What whiteboards in a trauma center operating suite can teach us about emergency department communication. Ann Emerg Med 50(4):387–395CrossRefGoogle Scholar
  43. Yule S, Flin R, Paterson-Brown S, Maran N, Rowley D (2006) Development of a rating system for surgeons’ non-technical skills. Med Educ 40(11):1098–1104CrossRefGoogle Scholar

Copyright information

© Springer-Verlag London Limited 2010

Authors and Affiliations

  • Andrew N. Healey
    • 1
    Email author
  • Kamal Nagpal
    • 2
  • Krishna Moorthy
    • 2
  • Charles A. Vincent
    • 2
  1. 1.Clinical Safety Research UnitImperial College LondonBerkshireUK
  2. 2.Clinical Safety Research Unit, Department of SurgeryImperial College LondonLondonUK

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