Aviation-style checklist might solve operating room miscommunication:
Researchers

Poor communications an organizational problem

Ineffective communication among members of operating room teams can lead
to medical error, so identifying the reasons for poor communication are
vital, says a University of Toronto researcher.

"The literature has suggested an association between team communication
and error but, until now, there was no empirical evidence about what
communications problems occurred regularly for the purpose of being able
to intervene and improve things," says Lorelei Lingard, a professor at
the U of T Wilson Centre for Research in Education and Department of
Pediatrics.

Lingard and fellow U of T researchers identified these problems in a
study published in the October issue of Quality & Safety in Health Care.
They studied 421 communications events, such as requests for antibiotic
administration and discussions about patient positioning.

Researchers found communications failures occurred in 30 per cent of
such exchanges. One-third of these failures, or 10 per cent of the total
number of events, resulted in circumstances that could jeopardize
patient safety by increasing memory load, by interrupting routine or by
increasing the tension in the operating room.

The communications problems are "strikingly straightforward," says
Lingard.

They fall into four categories:

Communications that take place later than they should

Failure to communicate with all the relevant people on the team

Inaccurate, incomplete communications

Communications whose purpose isn't achieved

Since failure to communicate effectively has the potential to put
patients at risk, the researchers suggest one possible solution is
adopting and tailoring the checklist system for team communications used
by the flight teams in the aviation industry. This would ensure that all
team members have accurate and explicit data and that they exchange
information proactively. It would also allow for cross-checking.

"Communication failure is rarely an issue of individual competence;
rather, it reflects systemic issues such as workflow," says Lingard.

Contact: Elaine Smith, U of T public affairs, 416-978-5949,
elaine.smith@utoronto.ca.