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PSNet: Patient Safety Network
Journal Article

Patterns of communication breakdowns resulting in injury to surgical patients.

Greenberg CC, Regenbogen SE, Studdert DM, et al. Journal of the American College of Surgeons. 2007;204:533-40.

The authors analyzed more than 80 communication breakdowns identified in a past review of surgical malpractice claims. The breakdowns took place with similar frequency in the preoperative, operative, and postoperative periods, and more than 70% involved a single communication failure. Attending surgeons were most commonly a part of the breakdowns, while ambiguity in the communicated roles and responsibilities contributed to more than half the events overall. Based on the findings, the authors developed a series of triggers that would prompt a direct communication with the attending surgeon. In addition, the authors advocate for greater use of structured protocols to address handoffs and transfers in care, times at which communication is critical and errors common.