Aviation-style Checklist Might Solve Operating Room Miscommunications

“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.