A systematic quantitative assessment of risks associated with poor communication in surgical care

Arch Surg. 2010 Jun;145(6):582-8. doi: 10.1001/archsurg.2010.105.


Hypothesis: Health care failure mode and effect analysis identifies critical processes prone to information transfer and communication failures and suggests interventions to improve these failures.

Design: Failure mode and effect analysis.

Setting: Academic research.

Participants: A multidisciplinary team consisting of surgeons, anesthetists, nurses, and a psychologist involved in various phases of surgical care was assembled.

Main outcome measures: A flowchart of the whole process was developed. Potential failure modes were identified and evaluated using a hazard matrix score. Recommendations were determined for certain critical failure modes using a decision tree.

Results: The process of surgical care was divided into the following 4 main phases: preoperative assessment and optimization, preprocedural teamwork, postoperative handover, and daily ward care. Most failure modes were identified in the preoperative assessment and optimization phase. Forty-one of 132 failures were classified as critical, 26 of which were sufficiently covered by current protocols. Recommendations were made for the remaining 15 failure modes.

Conclusions: Modified health care failure mode and effect analysis proved to be a practical approach and has been well received by clinicians. Systematic analysis by a multidisciplinary team is a useful method for detecting failure modes.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Continuity of Patient Care / standards
  • Continuity of Patient Care / trends
  • Evaluation Studies as Topic
  • Female
  • Humans
  • Interdisciplinary Communication*
  • Interprofessional Relations
  • Male
  • Medical Errors / prevention & control*
  • Patient Care Team / organization & administration*
  • Postoperative Care / standards
  • Postoperative Care / trends
  • Preoperative Care / standards
  • Preoperative Care / trends
  • Risk Assessment
  • Safety Management*
  • Surgery Department, Hospital
  • Surgical Procedures, Operative / adverse effects
  • Surgical Procedures, Operative / methods*
  • Systems Analysis
  • Total Quality Management
  • Treatment Outcome