Presentation
HE14 - Speech Communication Interference in the Operating Room
DescriptionTopic: Understanding Causes of Miscommunication in the Operating Room
Background, Importance, and Objective:
Six to 10% of US patients sustain a surgical complication (1) costing between $1.5-$5.9 billion annually, (2) of which half may be preventable. Miscommunication in the Operating room (OR) has been implicated in 68% of preventable surgical errors, (3) with communication failures occurring 7-8 times per hour during a surgery. (4) There is evidence that improving communication and teamwork reduces complications such as hemorrhage, (5) desaturation/hypoxia, (6) and surgical site infection, (7) and decreases overall patient mortality. (3) Although the linear relationships in these studies may represent an oversimplification from a complex systems perspective, communication and teamwork are clearly a crucial part of safety and performance in the OR.
Patient safety depends on unobstructed and accurate communication among various teams, yet today’s OR sound environment hinders communication and distracts from monitoring patient safety. While much of the of noise in the OR can be from technology essential for vital communications and tasks, not all noises are essential, and some can be mitigated. For example, human-caused sound distractions, such as case non-relevant conversations occur as often as every three minutes, (8) and OR team members can also be distracted by case-relevant tasks. Each of these factors has been shown to interfere with team communication and the team’s ability to monitor patient safety. (9) In our initial work, OR staff, including surgeons, anesthesia providers, and nursing staff, confirmed that the loud OR sound environment interfered with job performance and team communication. (10)
Over the past 20 years medical and human factors research has extensively studied how the OR sound environment contributes to miscommunication in the OR. However, wide variation in the methods and rigor of this research has meant that progress in improving communication and reducing patient injuries has been limited. We propose a methodologically rigorous approach to the measurement of Speech Communication Interference (SCI) that also advances our conceptual understanding of OR miscommunication. By focusing on how the OR environment interferes with speech communication, (10) SCI captures when and how critical messages between OR team members are blocked. Over three successful studies we have refined our theoretical framework so we can properly measure OR communication. Our practical data collection methods have allowed us to build a repeatable and falsifiable empirical model of miscommunication in the OR that will move the understanding OR miscommunication forward.
Objective:
In this work, our objective was to observe first-hand episodes of speech communication interference in the OR and to describe and classify the potential noises and their context within the surgical environment. If we can better understand the context of SCI, then we can make recommendations and changes to improve the OR system that better supports team communication.
Presentation:
We will present results from a prospective study in which we observed 40 surgeries, primarily general surgery, to measure the frequency of SCI, defined as “group discourse disrupted according to the participants, the goals, or the physical and situational context of the exchange.” We observed all phases of surgery, including the critical moment of the surgery, defined as when patient safety is most in jeopardy. For example, the critical moment of a laparoscopic cholecystectomy is the dissection of the triangle of calot, when the bile duct is at risk for injury and team communication is essential. We performed supplemental observations focused on conducting post-surgery interviews with SCI event participants to identify contextual factors. We thematically analyzed notes and interviews.
Results:
The observed 103 SCI events in 40 surgeries (mean 2.58) mostly involved the attending surgeon (50.5%), circulating nurse (44.6%), resident surgeon (44.6%), or scrub tech (42.7%). 17.5% occurred during the critical moment. The majority (82.1%) of SCI events occurred during another patient related task. Examples of tasks being performed by the receiver during a SCI event included the circulating nurse using a computer to update the patient’s chart, the surgical attending or resident inserting a trocar, the scrub tech opening a package, or someone talking on the phone. Concurrent loud noise or an overlapping conversation contributed to 38.4% of SCI events. Bedside suction was the most common loud noise during SCI events. Observations and postop interviews revealed that loud noises such as packaging, the suction device, and alarms interfered with hearing a request, and were exacerbated when the sender used a quiet voice. Similarly, conversations in the room, whether case-relevant or case-irrelevant served as both a loud noise preventing the receiver from hearing the request and as a distractor, diverting attention from the sender.
In the 40 surgeries, 27.2% of SCI events were not acknowledged or repeated and the message was lost. 97.0% of SCI events caused a delay (mean 5 seconds). Inter rater reliability, calculated by Gwet’s AC1 was 0.87 – 0.98. Post-surgery interviews confirmed miscommunication and distractions. Attention was most commonly diverted by loud noises (e.g. suction), conversations, or multitasking (e.g. using the Electronic Health Record). Successful strategies included repetition or deferment of the request until competing tasks were complete.
We will present a detailed visual timeline of a miscommunication involving a surgeon’s request not being heard by the scrub tech due to the anesthesia provider talking on the phone and the noise from a gown being balled up to be thrown in the trash.
Conclusions:
Influenced by environmental noises, including machines and other conversations in the room, communication interference impacts the entire surgical team and can potentially compromise patient safety. Studies on the loudness of the OR (11) suggest our primary findings are generalizable. Through reorganization of workflow, team member tasks and communication behaviors, we can reduce miscommunication and improve surgical safety, efficiency, and patient care.
References
1. Zeeshan, Patient Saf Surg. 2014
2. Van Den Bos, Health Aff (Millwood). Apr 2011
3. Hughes, J Appl Psychol. Sep 2016
4. Hu, J Surg Res. Sep 2012
5. Dillon, Am J Obstet Gynecol. Oct 2021
6. El-Shafy, J Surg Educ. Jan-Feb 2018
7. Dellinger, Surg Infect (Larchmt). Apr 2016
8. Zheng, Surg Endosc. Oct 2008
9. Sevdalis, World J Surg. Apr 2014
10. Brommelsiek, World J Surg. Jun 2022
11. Arabaci, J Perianesth Nurs. Feb 2021
Background, Importance, and Objective:
Six to 10% of US patients sustain a surgical complication (1) costing between $1.5-$5.9 billion annually, (2) of which half may be preventable. Miscommunication in the Operating room (OR) has been implicated in 68% of preventable surgical errors, (3) with communication failures occurring 7-8 times per hour during a surgery. (4) There is evidence that improving communication and teamwork reduces complications such as hemorrhage, (5) desaturation/hypoxia, (6) and surgical site infection, (7) and decreases overall patient mortality. (3) Although the linear relationships in these studies may represent an oversimplification from a complex systems perspective, communication and teamwork are clearly a crucial part of safety and performance in the OR.
Patient safety depends on unobstructed and accurate communication among various teams, yet today’s OR sound environment hinders communication and distracts from monitoring patient safety. While much of the of noise in the OR can be from technology essential for vital communications and tasks, not all noises are essential, and some can be mitigated. For example, human-caused sound distractions, such as case non-relevant conversations occur as often as every three minutes, (8) and OR team members can also be distracted by case-relevant tasks. Each of these factors has been shown to interfere with team communication and the team’s ability to monitor patient safety. (9) In our initial work, OR staff, including surgeons, anesthesia providers, and nursing staff, confirmed that the loud OR sound environment interfered with job performance and team communication. (10)
Over the past 20 years medical and human factors research has extensively studied how the OR sound environment contributes to miscommunication in the OR. However, wide variation in the methods and rigor of this research has meant that progress in improving communication and reducing patient injuries has been limited. We propose a methodologically rigorous approach to the measurement of Speech Communication Interference (SCI) that also advances our conceptual understanding of OR miscommunication. By focusing on how the OR environment interferes with speech communication, (10) SCI captures when and how critical messages between OR team members are blocked. Over three successful studies we have refined our theoretical framework so we can properly measure OR communication. Our practical data collection methods have allowed us to build a repeatable and falsifiable empirical model of miscommunication in the OR that will move the understanding OR miscommunication forward.
Objective:
In this work, our objective was to observe first-hand episodes of speech communication interference in the OR and to describe and classify the potential noises and their context within the surgical environment. If we can better understand the context of SCI, then we can make recommendations and changes to improve the OR system that better supports team communication.
Presentation:
We will present results from a prospective study in which we observed 40 surgeries, primarily general surgery, to measure the frequency of SCI, defined as “group discourse disrupted according to the participants, the goals, or the physical and situational context of the exchange.” We observed all phases of surgery, including the critical moment of the surgery, defined as when patient safety is most in jeopardy. For example, the critical moment of a laparoscopic cholecystectomy is the dissection of the triangle of calot, when the bile duct is at risk for injury and team communication is essential. We performed supplemental observations focused on conducting post-surgery interviews with SCI event participants to identify contextual factors. We thematically analyzed notes and interviews.
Results:
The observed 103 SCI events in 40 surgeries (mean 2.58) mostly involved the attending surgeon (50.5%), circulating nurse (44.6%), resident surgeon (44.6%), or scrub tech (42.7%). 17.5% occurred during the critical moment. The majority (82.1%) of SCI events occurred during another patient related task. Examples of tasks being performed by the receiver during a SCI event included the circulating nurse using a computer to update the patient’s chart, the surgical attending or resident inserting a trocar, the scrub tech opening a package, or someone talking on the phone. Concurrent loud noise or an overlapping conversation contributed to 38.4% of SCI events. Bedside suction was the most common loud noise during SCI events. Observations and postop interviews revealed that loud noises such as packaging, the suction device, and alarms interfered with hearing a request, and were exacerbated when the sender used a quiet voice. Similarly, conversations in the room, whether case-relevant or case-irrelevant served as both a loud noise preventing the receiver from hearing the request and as a distractor, diverting attention from the sender.
In the 40 surgeries, 27.2% of SCI events were not acknowledged or repeated and the message was lost. 97.0% of SCI events caused a delay (mean 5 seconds). Inter rater reliability, calculated by Gwet’s AC1 was 0.87 – 0.98. Post-surgery interviews confirmed miscommunication and distractions. Attention was most commonly diverted by loud noises (e.g. suction), conversations, or multitasking (e.g. using the Electronic Health Record). Successful strategies included repetition or deferment of the request until competing tasks were complete.
We will present a detailed visual timeline of a miscommunication involving a surgeon’s request not being heard by the scrub tech due to the anesthesia provider talking on the phone and the noise from a gown being balled up to be thrown in the trash.
Conclusions:
Influenced by environmental noises, including machines and other conversations in the room, communication interference impacts the entire surgical team and can potentially compromise patient safety. Studies on the loudness of the OR (11) suggest our primary findings are generalizable. Through reorganization of workflow, team member tasks and communication behaviors, we can reduce miscommunication and improve surgical safety, efficiency, and patient care.
References
1. Zeeshan, Patient Saf Surg. 2014
2. Van Den Bos, Health Aff (Millwood). Apr 2011
3. Hughes, J Appl Psychol. Sep 2016
4. Hu, J Surg Res. Sep 2012
5. Dillon, Am J Obstet Gynecol. Oct 2021
6. El-Shafy, J Surg Educ. Jan-Feb 2018
7. Dellinger, Surg Infect (Larchmt). Apr 2016
8. Zheng, Surg Endosc. Oct 2008
9. Sevdalis, World J Surg. Apr 2014
10. Brommelsiek, World J Surg. Jun 2022
11. Arabaci, J Perianesth Nurs. Feb 2021
Event Type
Poster Presentation
TimeMonday, March 254:45pm - 6:15pm CDT
LocationSalon C
Digital Health
Simulation and Education
Hospital Environments
Medical and Drug Delivery Devices
Patient Safety Research and Initiatives