Patterns of Communication Breakdowns Resulting in Injury to Surgical Patients
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Greenberg, Caprice C.
Regenbogen, Scott E.
Studdert, David M.
Lipsitz, Stuart R.
Rogers, Selwyn O.
Zinner, Michael J.
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CitationGreenberg, Caprice C., Scott E. Regenbogen, David M. Studdert, Stuart R. Lipsitz, Selwyn O. Rogers, Michael J. Zinner, and Atul A. Gawande. 2007. “Patterns of Communication Breakdowns Resulting in Injury to Surgical Patients.” Journal of the American College of Surgeons 204 (4): 533–40. https://doi.org/10.1016/j.jamcollsurg.2007.01.010.
AbstractBACKGROUND: Communication breakdowns are a common threat to surgical safety, but there are little data to guide initiatives to improve communication. STUDY DESIGN: In surgeon-review of 444 surgical malpractice claims from 4 liability insurers, we identified 60 cases involving communication breakdowns resulting in harm to patients. Two surgeon-reviewers analyzed these cases to identify common characteristics and associated factors. Based on identified patterns, potential interventions to prevent communication breakdowns were developed and their potential impact was assessed. RESULTS: The 60 cases involved 81 communication breakdowns, occurring in the preoperative (38%), intraoperative (30%), and postoperative periods (32%). Seventy-two percent of cases involved one communication breakdown. The majority of breakdowns were verbal communications (92%) involving 1 transmitter and 1 receiver (64%). Attending surgeons were the most common team member involved. Status asymmetry (74%) and ambiguity about responsibilities (73%) were commonly associated factors. Forty-three percent of communication breakdowns occurred with handoffs and 39% with transfers in the patient's location. The most common Communication breakdowns involved residents failing to notify the attending surgeon of critical events and a failure of attending-to-attending handoffs. Proposed interventions could prevent 45% to 73% of communication breakdowns in this cases series. CONCLUSIONS: Serious communication breakdowns occur across the continuum of care, typically result from a failure in verbal communication between a surgical attending and another caregiver, and often involve ambiguity about responsibilities. Interventions to prevent these breakdowns should involve: defined triggers that mandate communication with an attending surgeon; structured handoffs and transfer protocols; and standard use of read-backs.
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