Failures in communication and information transfer across the surgical care pathway: Interview study

BMJ Quality and Safety

Volumn 21, Issue 10, 2012, Pages 843-849

  Nagpal, Kamal ^a   Arora, Sonal ^a   Vats, Amit ^a   Wong, HelenW ^a   Sevdalis, Nick ^a   Vincent, Charles ^a   Moorthy, Krishna ^a  

^a ST MARY S HOSPITAL   (United Kingdom)

Author keywords

[No Author keywords available]

Indexed keywords

ANESTHESIST; ARTICLE; COMMUNICATION FAILURE; HEALTH CARE; HEALTH CARE QUALITY; HEALTH SERVICE; HUMAN; INFORMATION TRANSFER FAILURE; INTERPERSONAL COMMUNICATION; INTERVIEW; MORBIDITY; MORTALITY; NURSE; PATIENT SAFETY; QUALITATIVE ANALYSIS; SEMI STRUCTURED INTERVIEW; SURGEON; WORK ENVIRONMENT;

CRITICAL PATHWAYS; HUMANS; INFORMATION DISSEMINATION; INTERPROFESSIONAL RELATIONS; INTERVIEWS AS TOPIC;

EID: 84867722122     PISSN: 20445415     EISSN: None     Source Type: Journal    
DOI: 10.1136/bmjqs-2012-000886     Document Type: Article

References (30)

1. Undre S, Arora S, Sevdalis N. Surgical performance, human error and patient safety in urological surgery. Br J Med Surg Urol 2009;2:2-10.
2. Vincent C, Moorthy K, Sarker SK, et al. Systems approaches to surgical quality and safety: from concept to measurement. Ann Surg 2004;239:475-82. (Pubitemid 38372763)
3. Kohn L. To err is human: an interview with the Institute of Medicine's Linda Kohn. Jt Comm J Qual Improv 2000;26:227-34.
4. Leape LL, Brennan TA, Laird N, et al. The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II. N Engl J Med 1991;324:377-84.
5. Thomas EJ, Studdert DM, Burstin HR, et al. Incidence and types of adverse events and negligent care in Utah and Colorado. Med Care 2000;38:261-71.
6. Wilson RM, Runciman WB, Gibberd RW, et al. The quality in Australian Health Care Study. Med J Aust 1995;163:458-71.
7. Healey AN, Undre S, Vincent CA. Developing observational measures of performance in surgical teams. Qual Saf Health Care 2004;13(Suppl 1):i33-40. (Pubitemid 39389376)
8. Lingard L, Espin S, Whyte S, et al. Communication failures in the operating room: an observational classification of recurrent types and effects. Qual Saf Health Care 2004;13:330-4. (Pubitemid 39389393)
9. Sevdalis N, Forrest D, Undre S, et al. Annoyances, disruptions, and interruptions in surgery: the Disruptions in Surgery Index (DiSI). World J Surg 2008;32:1643-50.
10. Greenberg CC, Regenbogen SE, Studdert DM, et al. Patterns of communication breakdowns resulting in injury to surgical patients. J Am Coll Surg 2007;204:533-40. (Pubitemid 46428564)
11. Haynes AB, Weiser TG, Berry WR, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 2009;360:491-9.
12. Pronovost P, Berenholtz S, Dorman T, et al. Improving communication in the ICU using daily goals. J Crit Care 2003;18:71-5. (Pubitemid 36759157)
13. Marshall MN. Sampling for qualitative research. Fam Pract 1996;13:522-5. (Pubitemid 27060089)
14. Miles MB, Huberman AM. Qualitative Data Analysis. Thousand Oaks, California: Sage, 1994.
15. Kuper A, Lingard L, Levinson W. Critically appraising qualitative research. BMJ 2008;337:a1035.
16. Nagpal K, Vats A, Ahmed K, et al. A systematic quantitative assessment of risks associated with poor communication in surgical care. Arch Surg 2010;145:582-8.
17. Malterud K. Qualitative research: standards, challenges, and guidelines. Lancet 2001;358:483-8. (Pubitemid 32769861)
18. Hammersley M, Atkinson P. Ethnography: Principles in Practice. 2nd edn. London: Routledge, 1995.
19. Arora S, Sevdalis N, Nestel D, et al. Managing intra-operative stress: what surgeons want from a crisis training programme. Am J Surg 2009;197:537-43.
20. Flin R, O'Connor P, Crichton M. Safety at the Sharp Endda Guide to Non-technical Skills. Ashgate, 2007.
21. Vincent C. Understanding and responding to adverse events. N Engl J Med 2003;348:1051-6. (Pubitemid 36302252)
22. Christian CK, Gustafson ML, Roth EM, et al. A prospective study of patient safety in the operating room. Surgery 2006;139:159-73. (Pubitemid 43170315)
23. Catchpole KR, de Leval MR, McEwan A, et al. Patient handover from surgery to intensive care: using Formula 1 pit-stop and aviation models to improve safety and quality. Paediatr Anaesth 2007;17:470-8. (Pubitemid 46633402)
24. Lingard L, Regehr G, Orser B, et al. Evaluation of a preoperative checklist and team briefing among surgeons, nurses, and anesthesiologists to reduce failures in communication. Arch Surg 2008;143:12-17; discussion 18.
25. Van Eaton EG, Horvath KD, Lober WB, et al. A randomized, controlled trial evaluating the impact of a computerized rounding and sign-out system on continuity of care and resident work hours. J Am Coll Surg 2005;200:538-45. (Pubitemid 40432321)
26. Williams RG, Silverman R, Schwind C, et al. Surgeon information transfer and communication: factors affecting quality and efficiency of inpatient care. Ann Surg 2007;245:159-69. (Pubitemid 46148472)
27. Boorman D. Today's electronic checklists reduce likelihood of crew errors and help prevent mishaps. ICAO J 2001;1:17-36.
28. Nagpal K, Arora S, Abboudi M, et al. Postoperative handover: problems, pitfalls, and prevention of error. Ann Surg 2010;252:171-6.
29. Patterson ES, Roth EM, Woods DD, et al. Handoff strategies in settings with high consequences for failure: lessons for health care operations. Int J Qual Health Care 2004;16:125-32. (Pubitemid 38489473)
30. Aulbach RK, Brient K, Clark M, et al. Blood transfusions in critical care: improving safety through technology & process analysis. Crit Care Nurs Clin North Am 2010;22:179-90.