- communication
the process of people engaging in the exchange of knowledge, information, feelings and meanings. Communication can encompass spoken and written language, bodily gestures and meanings invested in things outside of the human body such as visual displays and architectural designs.
- preoperative care
care in the time before a patient enters the operating room.
- postoperative care
care in the time that the patient leaves the post-anaesthetic care unit and is directed to the surgical ward for recovery from surgery.
Communication failure can happen in any one of these situations, potentially leading to adverse outcomes. The chapter considers how communication failure can occur, and the strategies that can be implemented to improve communication. Some of these strategies focus on ensuring appropriate planning and preparation of surgical care before patients enter the operating room, including utilising a surgical checklist before the surgery starts, anticipating and avoiding complex communication situations right along the whole perioperative pathway, and conducting relevant and accurate handovers at strategic points.
- checklist
a list such as a ‘to-do list’ containing critical steps or items that need to be taken into account before initiating work processes. The checklist counteracts the shortcomings of human memory and inadequate attention to detail.
- perioperative pathway
the patients’ care immediately before, during and immediately following surgery by a group consisting of the surgeons, anaesthetists, nurses, operating room technicians, and other health professionals.
Introduction
Communicating well in and around surgery is crucial for patient safety. The settings where communication takes place involve more than just the operating room or theatre. They comprise the preoperative environment, prior to when patients enter the operating room, the intraoperative environment, including the holding bay, operating room and post-anaesthetic care unit, and the postoperative environment, involving the surgical ward. Collectively, these settings are called the perioperative pathway (Braaf et al., 2012). To comprehensively address communication that supports surgery, it is necessary to consider patient care activities that occur across the whole perioperative pathway and not just those activities that take place within the operating room. The necessity of focusing on the whole perioperative pathway has also been acknowledged by the World Health Organization, through its Surgical Safety Checklist (World Health Organization, 2009a) and its ‘Safe Surgery Saves Lives’ initiative (World Health Organization, 2009b).
- Surgical Safety Checklist
a list of activities devised by the World Health Organization; the checklist should be completed three times: before induction of anaesthesia, before skin incision by the surgeon, and before the patient leaves the operating room.
Approximately 234 million major surgeries are performed worldwide each year (Elder, 2014; Weiser et al., 2008). If surgery is not carried out safely, the potential for catastrophic consequences is high. Sentinel events, which are serious situations that occur independently of a patient’s condition, are not uncommon in Australian hospitals. Recent figures for 2012–13 show that retaining of instruments or other materials left in the body following surgery, leading to repeated procedures, was the second most common type of sentinel event. Surgical procedures involving the wrong patient or the wrong body part, causing death or permanent loss in function, was the fifth most common type of sentinel event (Department of Health, 2014). Common contributing factors associated with sentinel events relate to procedures and guidelines, human resource and staffing issues, and communication problems (Department of Health, 2014).
Due to the potentially serious nature of adverse events associated with surgery, key bodies have devised many initiatives to assist policy-makers, hospital managers and health professionals to improve surgical care to patients. These initiatives include the Surgical Safety Checklist devised by the World Health Organization (World Health Organization, 2009a) (Figure 8.1). The intent of the checklist is to help health professionals consider safety as pertaining to the whole perioperative pathway, and to create improved communication among the various healthcare disciplines involved. This checklist is not intended to be a regulatory tool, but rather a tool to identify areas where communication may fail, causing serious surgical incidents, including deaths and complications.
Figure 8.1 Implementation Manual: Surgical Safety Checklist of the World Health Organization
In recognising the value and importance of the Surgical Safety Checklist, a number of professional associations in Australia, such as the Royal Australasian College of Surgeons, in consultation with the Australian and New Zealand College of Anaesthetists and the Australian College of Operating Room Nurses, have modified the checklist to suit the Australian and New Zealand context (Royal Australasian College of Surgeons et al., 2009) (Figure 8.2). Checklists such as these act as supportive tools for health professionals and are not regulatory documents.
Figure 8.2 Surgical Safety Checklist adapted for Australia and New Zealand (Royal Australian College of Surgeons; adapted from World Health Organization, 2009b)1
Other resources pertinent to communication in surgery include ones made available by the Australian Commission on Safety and Quality in Health Care (2012), in its National Safety and Quality Health Service Standards. These standards need to be used by all Australian healthcare organisations for them to be formally accredited for their various healthcare activities. The standards of particular relevance to communicating in surgery include Standard 2, Partnering with Consumers; Standard 5, Patient Identification and Procedure Matching; and Standard 6, Clinical Handover. The challenge for health professionals is to reflect critically on how these standards apply to their own practice and how these standards can be actively used to improve communication with other healthcare disciplines and with patients, with the ultimate aim of facilitating patient safety. Patient identification ensures that the correct person is undergoing the surgical procedure to be performed. Correct identification is also associated with making sure the right surgical site is used and surgical procedure is carried out. Procedure matching is the process by which the surgical team identifies the correct procedure to be performed on a particular patient. This process involves identifying the correct operation site and side.
It is important to consider what is good and what is ineffective communication in surgery to be able to propose improvements in practice. Communication failure is defined as a problem in the content of the communication encounter, in the audience involved in the communication encounter, in the occasion of the communication encounter, or in the purpose of the communication encounter (Lingard et al., 2004). Extensive work has been undertaken on the prevalence of communication failures in the perioperative environment. Lingard et al. (2004) found a communication failure rate of 30% in the operating room. Halverson et al. (2011) reported 56 communication failures in 76 hours occurring in the operating room before the conduct of a team training curriculum, whereas, following training, 20 communication failures over 74 hours were observed. Nagpal et al. (2010a) identified information transfer failure rates of 62% for pre-procedural teamwork and 53% for postoperative handover. Furthermore, in an Australian study, Gillespie, Chaboyer & Fairweather (2012) reported a communication failure rate of 57% in surgical procedures observed in the operating room. In another Australian study, Braaf et al. (2012) identified a failure rate of 28% across the perioperative pathway.
Research has also been undertaken into the types of communication failures identified. Knowledge of this information can help in developing strategies and policies aimed at addressing particular areas of concern. According to Lingard et al.’s (2004) work in the operating room, communication failure types comprised problems such as poor timing (45.7% of instances), problems with content where information was missing or inaccurate (35.7%), problems with purpose where disagreements were not resolved (24.0%) and problems with audience where key people were not included (20.9%). In the observational work across the perioperative pathway conducted by Braaf et al. (2012), the following communication types were found: purpose (41%), content (40.9%), occasion (9.9%) and audience (8.1%). While there appears to be marked variation in the proportions of failure types per operating room, it is clear that each type – purpose, content, occasion and audience – plays an important role in how communication occurs in practice.
Aside from considering the prevalence and types of communication failures, it is vital to explore outcomes associated with communication failures. Knowledge of these outcomes can be used in educating health professionals to develop understandings of how good communication influences safe surgical care. By identifying outcomes over time, it would be possible to track how changes in strategies and policies can lead to improved outcomes. In the observational work undertaken by Braaf et al. (2012), communication failure led to health professionals engaging in more frequent communication encounters, working with missing information, enduring an increased workload and experiencing confusion in clinical practice.
Other outcomes included tensions between health professionals of similar or different healthcare disciplines, inefficiencies in surgical and anaesthetic practices, delays in work processes, documentation errors, rushed clinical tasks, procedural errors, and wasted resources. Specific patient outcomes that were attributed to communication failures involved delays or cancellation of surgery, near miss events, adverse events, and longer operation times. Specific staff outcomes attributed to communication failures related to health professionals having to work overtime and increased harm to staff members, such as needle stick injuries and back injuries. Communication failures were also examined in terms of outcomes of care in Gillespie and colleagues’ (2012) work. They found the number of communication failures contributed to increasing the expected length of the operation.
Below is an observational excerpt relating to a patient who was scheduled to have elective surgery in a public hospital. The patient had an allergy to an intravenous contrast dye that was to be used during her surgical procedure. To prevent possible adverse reactions relating to the dye, she was required to receive a premedication regimen over a course of several hours. Unfortunately, her anaesthetist never prescribed the premedication regimen due to increased busyness of the perioperative environment and problems with communication.
The 69-year-old female patient was booked for an elective repair of a thoracic aortic aneurysm. She arrived in the surgical ward of the hospital a couple of days before her pending surgery. The patient was allergic to intravenous contrast dye. This allergy was noted by the anaesthetist during his preoperative visit on the day prior to surgery. The vascular registrar had documented in the medical history that the patient should have a series of intravenous hydrocortisone injections and an intravenous diphenhydramine dose as a part of her premedication regimen. The purpose of this premedication regimen was to counter any allergic effects from the contrast dye that would be used during surgery. Unfortunately, these orders were not written down by the anaesthetist. According to hospital protocol, the following orders should have been documented as ‘premedication: 200 mg of hydrocortisone, to be administered intravenously 13 hours, 7 hours and 1 hour prior to the surgery, and 50 mg of diphenhydramine, to be administered intravenously 1 hour prior to the surgery’. The process of writing up the premedication orders was the responsibility of the anaesthetist. As the anaesthetist was speaking with the patient, however, he was interrupted by his pager. In answering his pager, the anaesthetist was called to the recovery room. Another patient was experiencing laboured breathing in the recovery room and the theatre staff needed assistance. Due to the interruption, the anaesthetist was trying to complete his session with the patient quickly, but he had forgotten to write up the hydrocortisone and diphenhydramine orders. The anaesthetist did, however, write up orders for diazepam and metoclopramide, which were routinely prescribed as premedication to patients.
The afternoon nurse noticed the comment made by the vascular registrar in the patient’s medical record, but she did not relay this information at handover to the night-time nursing staff. Similarly, the vascular registrar did not verbally communicate with medical staff during the medical handover about the premedications. As a result, none of the afternoon or night-time staff realised that the patient required premedication orders for hydrocortisone and diphenhydramine.
The patient was transferred to the operating room at 7 a.m. on the day of surgery. On arrival to the operating room, the patient was welcomed by the nurse in the holding bay who noticed that the patient was allergic to intravenous contrast dye. However, she did not check if any premedication had been prescribed or administered to prevent allergic reactions from the contrast dye. The patient was wheeled on a trolley into the operating room. The anaesthetist induced the patient with general anaesthesia, and proceeded to monitor her vital signs and conscious state.
A time out procedure was then conducted. The surgeon asked everyone to hurry up with the time out because he just wanted to get on with the procedure. During the time out, the scout nurse raised a concern about the patient’s allergy to intravenous contrast dye. The theatre team glanced at the anaesthetist for advice. The anaesthetist checked the premedication orders, and realised his mistake. No hydrocortisone and diphenhydramine had been administered prior to surgery. As it was important for the patient to have the hydrocortisone intravenous injections over several hours before surgery and to have the diphenhydramine one hour before surgery, the anaesthetist commented that the surgery could not continue and that it would need to be rescheduled. The surgeon sighed and, saying nothing, he walked out of the operating room with a look of disgust. After the anaesthetist administered the reversal agents for anaesthesia and removed the endotracheal tube, the patient was wheeled into the post-anaesthetic care unit. The anaesthetist was frustrated with himself for neglecting to document the premedication orders. As the patient began to wake up, the anaesthetist told her that there were some concerns with giving her the contrast dye, and the surgical team needed to wait till tomorrow where they could make the necessary adjustments to her medications and perform the surgery. He did not mention that two important medications were not prescribed and administered prior to her surgery. The patient returned to the surgical ward, feeling upset and confused.
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