Teamwork and communication failures in post-operative care

Abstract

Introduction Communication failures in surgery are a recognised source of error, however research in this area has primarily focussed on the operating room. We aimed to conduct a detailed examination of failures in post-operative care after elective surgery. Methods We conducted a prospective, ethnographic study of the post-operative care of patients following major elective gastrointestinal surgery. We observed 50 patients from the point of surgery to discharge, representing 659 days of post-operative care. An independent observer attended ward rounds, examined notes and charts and conducted interviews with clinical staff. Ethnographic field notes of any unexpected incident were analysed by two independent assessors, based on the methodologies employed by the Harvard Medical Practice Study, to identify failures in the process of care (reliability: intra-class correlation 0.755, p Results We observed 256 process failures (median 4.5 per patient, range 0-16), of which 74 (29%) were associated with patient harm, 23 (9%) met adverse event criteria and 85% were preventable. Process failures included problems with lines, tubes and drains, medications, blood transfusion and blood and radiological investigations. Poor communication was the cause of these failures in 105/256 (41%) cases, of which 104/105 (99%) were preventable. Communication breakdowns were due to poor written communication in 58/105 (55%) and poor verbal communication in 47/105 (45%) cases. Communication failed primarily between surgeons and nurses (46/105) and within the surgical team (19/105). Conclusions Communication breakdown is a common cause of process failures following surgery. Improving communication has the potential to decrease such failures and therefore enhance both outcomes and patient safety.