Skip to main content
SpringerLink
Log in

Engineering the system of communication for safer surgery

  • Original Article
  • Published:
Cognition, Technology & Work Aims and scope Submit manuscript

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.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

  • 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):770–774

    Article  Google Scholar 

  • Benn J, Healey AN, Hollnagel E (2008) Improving performance reliability in surgical systems. Cogn Technol Work Spec Issue Enhanc Surg Sys 10:323–333

    Google Scholar 

  • 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):370–376

    Article  Google Scholar 

  • Carthey J, de Leval MR, Wright DJ, Farewell VT, Reason JT (2003) Behavioural markers of surgical excellence. Saf Sci 41:409–425

    Google Scholar 

  • 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):567–588

    Google Scholar 

  • Coiera E, Tombs V (1998) Communication behaviours in a hospital setting: an observational study. BMJ 316(7132):673–676

    Google Scholar 

  • DeFontes J, Surbida S (2004) Preoperative safety briefing project. Permaente Journal 8:21–27

    Google Scholar 

  • Degani A, Wiener EL (1997) Procedures in complex systems: the airline cockpit. IEEE Transactions on Systems, Man, and Cybernetics, SMC 27(3):302–312

    Google Scholar 

  • 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):390–413

    Article  Google Scholar 

  • Fairbanks RJ, Bisantz AM, Sunm M (2007) Emergency department communication links and patterns. Ann Emerg Med 50(4):396–406

    Article  Google Scholar 

  • 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):533–540

    Article  Google Scholar 

  • 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 39–55

    Google Scholar 

  • Healey AN, Undre S, Vincent CA (2004) Developing observational measures of performance in surgical teams. Qual Saf Health Care 13(Suppl. 1):i33–i40

    Google Scholar 

  • Healey AN, Sevdalis N, Vincent CA (2006) Measuring intra-operative interference from distraction and interruption observed in the operating theatre. Ergonomics 49(5–6):589–604

    Article  Google Scholar 

  • Henriksen K, Dayton E (2006) Organizational silence and hidden threats to patient safety. Health Serv Res 41(4p2):1539–1554

    Article  Google Scholar 

  • Kwaan MR, Studdert DM, Zinner MJ, Gawande AA (2006) Incidence, patterns, and prevention of wrong-site surgery. Arch Surg 141(4):353–357

    Article  Google Scholar 

  • Lilford RJ, Brown CA, Nicholl J (2007) Use of process measures to monitor the quality of clinical practice. BMJ 335(7621):648–650

    Article  Google Scholar 

  • 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):330–334

    Article  Google Scholar 

  • 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):340–346

    Article  Google Scholar 

  • 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):12–17

    Article  Google Scholar 

  • 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):593–595

    Google Scholar 

  • 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):351–355

    Google Scholar 

  • 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):236–243

    Article  Google Scholar 

  • Martin JA, Regehr G, Reznick R et al. (1997) Objective structured assessment of technical skill (OSATS) for surgical residents. Br J Surg 84:273–278

    Google Scholar 

  • 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):68–73

    Article  Google Scholar 

  • 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):631–639

    Article  Google Scholar 

  • Murphy AG, Wears RL (2009) The medium is the message: communication and power in sign-outs. Ann Emerg Med 54(3):379–380

    Article  Google Scholar 

  • Nemeth CP (ed) (2008) Improving healthcare team communication: building on lessons from aviation and aerospace. Ashgate, Aldershot, UK 280

    Google Scholar 

  • Ovretveit J, Gustafson D (2002) Evaluation of quality improvement programmes. Qual Saf Health Care 11(3):270–275

    Article  Google Scholar 

  • Patterson ES, Wears RL (2009) Beyond “communication failure”. Ann Emerg Med 53(6):711–712

    Article  Google Scholar 

  • Rasmussen J (1997) Risk management in a dynamic society: a modelling problem. Saf Sci 27(2/3):183–213

    Article  Google Scholar 

  • 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):25–33

    Article  Google Scholar 

  • 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):469–474

    Article  Google Scholar 

  • Schwaitzberg SD (2006) The emergence of radiofrequency identification tags: applications in surgery. Surg Endosc 20(8):1315–1319

    Article  Google Scholar 

  • Undre S, Healey AN, Darzi A, Vincent CA (2006) Observational assessment of surgical teamwork: a feasibility study. World J Surg 30(10):1774–1783

    Article  Google Scholar 

  • Vincent CA, Wears RL (2002) Communication in the emergency department: separating the signal from the noise. Med J Aust 176(9):409–410

    Google Scholar 

  • Vincent C, Taylor-Adams S, Stanhope N (1998) Framework for analysing risk and safety in clinical medicine. British Medical Journal 316(7138):1154–1157

    Google Scholar 

  • Vincent C, Neale G, Woloshynowych M (2001) Adverse events in British hospitals: preliminary retrospective record review. BMJ 322(7285):517–519

    Article  Google Scholar 

  • 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):159–169

    Article  Google Scholar 

  • World Alliance for Patient Safety (2008) Safe surgery save lives. http://www.who.int/patientsafety/safesurgery. 10-10-2008

  • Xiao Y (2005) Artifacts and technical work in health care: methodological, theoretical, and technological implications of the tangible. J Biomed Inform 38(1):26–33

    Article  Google Scholar 

  • 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):387–395

    Article  Google Scholar 

  • 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):1098–1104

    Article  Google Scholar 

Download references

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.

Author information

Authors and Affiliations

  1. Clinical Safety Research Unit, Imperial College London, Human Factors, AWE, Aldermaston, Reading, Berkshire, RG7 4PR, UK

    Andrew N. Healey

  2. Clinical Safety Research Unit, Department of Surgery, Imperial College London, 10th Floor, QEQM Building, St. Mary’s Hospital, Praed Street, London, W2 1NY, UK

    Kamal Nagpal, Krishna Moorthy & Charles A. Vincent

Authors
  1. Andrew N. Healey
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Kamal Nagpal
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Krishna Moorthy
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Charles A. Vincent
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Andrew N. Healey.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Healey, A.N., Nagpal, K., Moorthy, K. et al. Engineering the system of communication for safer surgery. Cogn Tech Work 13, 1–10 (2011). https://doi.org/10.1007/s10111-010-0152-5

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10111-010-0152-5

Keywords

Search

Navigation