Patterns of communication breakdowns resulting in injury to surgical patients

J Am Coll Surg. 2007 Apr;204(4):533-40. doi: 10.1016/j.jamcollsurg.2007.01.010.


Background: 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.

Publication types

  • Research Support, Non-U.S. Gov't
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Communication*
  • General Surgery*
  • Humans
  • Malpractice
  • Medical Errors* / mortality
  • Medical Errors* / prevention & control
  • Patient Transfer
  • Risk Factors