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Original Article
June 2010

A Systematic Quantitative Assessment of Risks Associated With Poor Communication in Surgical Care

Author Affiliations

Author Affiliations: Clinical Safety Research Unit, Department of Biosurgery and Surgical Technology, Imperial College London, United Kingdom.

Arch Surg. 2010;145(6):582-588. 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.