A policy-based intervention for the reduction of communication breakdowns in inpatient surgical care: results from a Harvard surgical safety collaborative.
Approach to Improving Safety
- Legal and Policy Approaches
- Communication between Providers
- Residents and Fellows
- Policies and Operations
Setting of Care
Communication failures in the surgical setting are a known threat to patient safety and the second most common root cause of adverse events (following technical errors). This study implemented a set of tailored policy and education initiatives at 4 teaching hospitals in an effort to increase timely and consistent resident–attending communication and promote attending visits with surgical patients. Investigators analyzed more than 200 critical events and 1300 patient cases and noted significant improvements in communication between residents and attendings. The number of patients not visited by attendings on weekends decreased by half, and the improved communications resulted in attending-level changes in patient management a third of the time. An accompanying editorial [see link below] discusses the study's findings and emphasizes the importance of simply setting clear and explicit expectations for communication. A past AHRQ WebM&M perspective discusses surgical safety with this study's senior author, Dr. Atul Gawande.