April 20, 2016

Culture change: The best defense against communication failures

By: OR Manager
Sheila Rilee, MSM, MSN, BSN, RN, CNOR, CASC, operating room communication, culture

Sheila Rilee, MSM, MSN, BSN, RN, CNOR, CASC

Although most OR clinicians would agree poor team communication puts patients at risk, misunderstandings are not uncommon in the perioperative setting. Understanding how communication failures occur and how to correct course takes time and effort, but using the right tools and educating staff can ultimately make patients safer.

“The biggest impact on communication is culture,” says Sheila Rilee, MSM, MSN, BSN, RN, CNOR, CASC. While Rilee was systems director at Riverside Health System (RHS) in Newport News, Virginia, she helped implement a safety training program to reduce errors.

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Rilee and several other perioperative services leaders shared their perspectives with OR Manager and offered some tactics to improve communication and enhance the quality of care.


An alarming pattern

Amy Halverson, MD, operating room communication, operating room culture

Amy Halverson, MD

“Failures in communication have been correlated with increased surgical errors and flow disruptions,” says Amy Halverson, MD, associate professor of surgery and chief of colon rectal surgery at Northwestern Memorial Hospital in Chicago. Dr Halverson has studied communication patterns in the OR.

The Joint Commission consistently ranks communication as one of the top three contributing factors for sentinel events, and the literature finds communication failures common in the OR:

• In one article, Landers identified ineffective team communication and human error as the primary causes of adverse events in the OR.

• A study by Hu and colleagues reported that out of six complex operations, videotaping revealed communication failures in each case, at a rate of 1 every 8 minutes. In all, 88.7% of the failures affected flow or safety of the operation.

• In a review of observational studies related to communication in the OR, Weldon and colleagues found that communication affected OR practice in all 26 articles reviewed.

Estimates of wrong-patient, wrong-procedure, wrong-site, and wrong-side surgeries are as high as 40 times per week, according to the Joint Commission, and wrong-site surgery is estimated to occur in 1 of every 100,000 procedures, a 2015 JAMA Surgery article finds.

Communication failure can even affect patients postoperatively. A Patient Safety Primer from the Agency for Healthcare Research and Quality, for example, reports that poor communication has been directly linked to surgical complications.

“We need to be able to put in systems to decrease adverse events just like the airline industry has done,” says Nina Radcliff, MD, an attending anesthesiologist at AtlantiCare Regional Medical Center in Pomona, New Jersey, who has written on the challenge of effective communication during handoffs.


Absence of presence

Nina Radcliff, MD, operating room communication, operating room culture

Nina Radcliff, MD

Distractions or interruptions were contributing factors in 304 events occurring in the OR from January 2010 through May 2013, according to the Pennsylvania Patient Safety Reporting System. Adverse effects related to distraction that have been reported include wrong-side surgery and transfusing the wrong blood to the wrong patient. Noise is a concern; everything from equipment alarms to phone calls to music interfere with concentration.

Team members contribute to communication failures by misinterpreting information. “The most likely reason for communication errors is that people aren’t as precise in their communication as they should be,” says Dr Halverson. “We tend to make assumptions about other people’s knowledge and make cognitive leaps.” Team members come to the table with different perspectives. “If I say ‘Woodstock,’ some people will think of the concert and others will think of a yellow bird [from the Peanuts cartoon strip],” she says. “We often don’t consider the other person’s frame of reference.”

Rilee notes that team members are taught to communicate differently as part of their educational backgrounds. “Doctors tend not to be as open in their communication; they just want to get the case done,” she says. “Nurses are taught to be an advocate for patients, so they want to stop and do the time-out.”

Robin Chard, PhD, RN, CNOR, operating room communication, operating room culture

Robin Chard, PhD, RN, CNOR

Different levels of practitioners are another factor in communication failures. “Unfortunately, there is still that hierarchy where some members feel superior to others and don’t work as a team,” says Robin Chard, PhD, RN, CNOR, an associate professor at the Nova Southeastern University College of Nursing, Nova Southeastern University, in Fort Lauderdale, Florida, who has written on best practices for transfer of care.

One person who gets left out of the team communication discussion is the patient, says Patricia Seifert, MSN, RN, CNOR, FAAN, an independent cardiac consultant in Falls Church, Virginia. “We need to expand the team to include patients, even if they are anesthetized,” she says. “They are part of the team because it’s their presence that makes us able to provide our skills, talents, experience, and knowledge.”

Focusing on the patient helps identify communication points that might get missed. “If a patient who has been on aspirin for months comes in for surgery, we can anticipate that the patient may need platelets and discuss it with the surgeon and anesthesiologist,” she says.

Identifying which stages of the perioperative process are most vulnerable to communication breakdowns can help prevent them from happening. Some are intuitive, such as induction of anesthesia. Others, such as errors during scheduling, may not be.

In a 2015 review article, Kim and colleagues recommend that schedulers should not accept verbal requests and should verify key documents, such as the consent, history and physical, and orders about which surgery is scheduled.

Understanding the “mental workload” of each team member throughout the case is important. For example, the task complexity and responsibilities for a nurse anesthetist are high at the start of an open-heart procedure, but less so during bypass, compared to the perfusionist, whose task complexity and responsibilities are high during bypass and lower at the start of the procedure.

“Knowing this variation can help identify where the real dangers are,” Seifert says.

Type of communication plays a role in vulnerability to error as well. Dr Halverson and her research team found that communication failures most often are related to OR equipment and instruments as well as informing team members about the progress of the operation.


Culture shift

Improving team communication depends on creating a safety culture, and that requires leaders to be engaged.

“You need leadership champions—administrators and leaders of departments,” Seifert says. “You can’t do it without physicians and administrators on board.” She encourages involvement of champions from all levels of the organization.

OR staff must be encouraged to speak up to their peers, to physicians, and other healthcare colleagues without fear of being blamed.

Dr Halverson says scripts can help staff speak up. “People want to know they can question a colleague without seeming to challenge or raise doubt about the other individual’s knowledge or ability,” she says. Staff are taught to say, “I want to clarify…” or “I want to confirm…” Chard says another good phrase is, “I’m concerned that…”

To foster speaking up behavior at RHS, Rilee says, each staff and leadership meeting started with a safety story about near misses or errors. “We publically talked about our mistakes within organizational meetings and with team members.” Staff became willing to share their safety stories and to recognize one another for making a good catch.

In addition, patients who had experienced errors were invited to speak to the leadership team. “That was very powerful,” Rilee says.

“There needs to be a tolerance for candor,” Seifert says. “We have to be able to share our concerns.” However, she adds, “There is no excuse for rudeness. You sometimes have to skip [communication] steps, but you can always be respectful.”

When errors occur, often times it’s the system rather than an individual who is at fault, Dr Radcliff notes. Someone needs to take responsibility for implementing communication tools and training, and that often falls to anesthesia providers or nurse leaders.

Furthermore, OR leaders play an important role in modeling desired communication behaviors, Seifert notes. “What we know is the ideal behavior and what we do are not always the same thing,” she says. “We need to do what we say we’re going to do.”


Training for success

Patricia Seifert, MSN, RN, CNOR, FAAN, operating room communication, operating room culture

Patricia Seifert, MSN, RN, CNOR, FAAN

Team training significantly reduced errors—from 56 errors observed over 76 hours to 20 errors observed over 74 hours—in a study Dr Halverson conducted with her colleagues.

Elements of a successful training program include taking an interprofessional approach and tailoring training and processes to each organization. For example, what works for a freestanding ambulatory surgery center might not work as well in an academic medical center, Dr Radcliff says.

At RHS, which consists of several hospitals and three outpatient surgery centers, Rilee was involved in a train-the-trainer safety training program. Leaders at RHS completed train-the-trainer programs provided by a safety vendor and then taught other leaders who, in turn, educated the staff.

Discussion of real-life errors was the most powerful part of the program, Rilee says. Initially, RHS showed videos of stories about errors that occurred in the US, and later created videos about its own error stories.

“The videos became real for our staff and our doctors because these were stories within our organization,” Rilee says. “This really gets people’s attention.”

Training was mandatory for everyone, and surgeons who missed training could not schedule cases until they participated. Rilee and her colleagues at RHS also taught staff in physician offices. The hospital paid any staff who incurred overtime to attend the mandatory program, and programs were offered in the evenings and on weekends.

Rilee says it took about a year to train staff, revise policies, and develop tools for the safety culture.

Some facilities supplement didactic training with simulation. For example, Dr Halverson gives a lecture to medical students during orientation, followed by a simulation in the OR with team members that includes briefings, time-outs, and debriefings.

Training takes a time commitment and support from the top to require training across the board, leaders agree. Periodic retraining and practicing are also recommended.


Sustaining success

Improving communication is an ongoing task for OR leaders. “You need to revisit it on a regular basis and make corrections as needed,” Dr Radcliff says. “Remind people that ‘this is what we do, and we want to be better.’” ✥



Agency for Healthcare Research and Quality. Improving communication between clinicians. Patient Safety Primer. March 2015. https://psnet.ahrq.gov/primers/primer/26/improving-communication-between-clinicians.

Chard R, Makary M A. Transfer-of-care communication: Nursing best practices 2.1. AORN J. 2015;102:330-339.

Feil M. Distractions in the operating room. Pennsylvania Patient Safety Advisory. 2014;11(2):45-53.

Halverson A L, Casey J T, Andersson J, et al. Communication failure in the operating room. Surgery. 2011;149(3):305-310.

Hempel S, Maggard-Gibbons M, Nguyen D K, et al. Wrong-site surgery, retained surgical items, and surgical fires: A systematic review of surgical never events. JAMA Surg. 2015;150(8):796-805.

Hu Y-Y, Arriaga A F, Peyre S E, et al. Deconstructing intraoperative communication failures. J Surg Res. 2012;177(1):37-42.

Kim F J, Donalisio da Silva R, Gustafson D, et al. Current issues in patient safety in surgery: A review. Patient Safety in Surgery. 2015;9:26.

Landers R. Reducing surgical errors: Implementing a three-hinge approach to success. AORN J. 2015;101(6):657-665.

Manser T, Foster S, Flin R, et al. Team communication during patient handover from the operating room: More than facts and figures. Hum Factors. 2013;55(1):138-56.

Singh-Radcliff N. Best practices for handover communication. Monitor. 2013;77(3):20-21.

Wadhera R K, Henrickson Parker S, Burkhart H M, et al. Is the ‘‘sterile cockpit’’ concept applicable to cardiovascular surgery, critical intervals, or critical events? The impact of protocol-driven communication during cardiopulmonary bypass. J Thorac Cardiovasc Surg. 2010;139:312-319.

Wahr J A, Prager R L, Abernathy III J H, et al. AHA Scientific Statement: Patient safety in the cardiac operating room: Human factors and teamwork. Circulation. 2013;128:1139-1169.

Weldon S M, Korkiakangas T, Bezemer J, et al. Communication in the operating theatre. Br J Surg. 2013;100(13):1677-1688.

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