What's in a Name? Enhancing Communication in the Operating Room with the Use of Names and Roles on Surgical Caps

Jt Comm J Qual Patient Saf. 2021 Apr;47(4):258-264. doi: 10.1016/j.jcjq.2020.11.012. Epub 2020 Nov 26.


Objective: A pilot study was conducted in a tertiary referral center to assess whether wearing caps labeled with providers' names and roles has an impact on communication in the operating room (OR).

Methods: Two obstetricians observed surgeries for name uses and missed communications. Following each case, all providers were given a short survey that queried their attitude about the use of labeled surgical caps, their ability to know the names and roles of other providers during a case, and the impact of scrub attire on identifying others. They were also asked to rate the ease of communication and their ability to recall name and roles of the personnel specific to the case. Patients were asked how they perceived the use of labeled caps by providers.

Results: Twenty scheduled cesarean deliveries were randomized to either labeled (10) or nonlabeled (10) surgical caps. A total of 129 providers participated in the study, with 117 providing responses to the survey. Providers reported knowing the names and roles of colleagues more often with labeled caps vs. nonlabeled caps (names: 77.8% vs. 55.0%, 95% confidence interval [CI] = 64.4%-88.0% vs. 41.6%-67.9%, p = 0.011; roles: 92.5% vs. 78.3%, 95% CI = 81.8%-98.0% vs. 65.8%-88.0%, p = 0.036). Name uses increased (43 vs. 34, p = 0.208), and missed communications decreased (16 vs. 20, p = 0.614) when labeled caps were worn. Providers and patients had an overwhelmingly positive response to labeled caps.

Conclusion: This pilot study demonstrated that wearing labeled caps in the OR led to more frequent name uses and less frequent missed communications. Providers and patients embraced the concept of labeled caps and perceived wearing labeled caps as improving communication in the OR.

Publication types

  • Randomized Controlled Trial
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Communication*
  • Humans
  • Operating Rooms*
  • Pilot Projects
  • Referral and Consultation
  • Surveys and Questionnaires