Journal article

Patterns of communication breakdowns resulting in injury to surgical patients

Caprice C Greenberg, Scott E Regenbogen, David M Studdert, Stuart R Lipsitz, Selwyn O Rogers, Michael J Zinner, Atul A Gawande

JOURNAL OF THE AMERICAN COLLEGE OF SURGEONS | ELSEVIER SCIENCE INC | Published : 2007

Abstract

BACKGROUND: Communication breakdowns are a common threat to surgical safety, but there are little data to guide initiatives to improve communication. STUDY DESIGN: In surgeon-review of 444 surgical malpractice claims from 4 liability insurers, we identified 60 cases involving communication breakdowns resulting in harm to patients. Two surgeon-reviewers analyzed these cases to identify common characteristics and associated factors. Based on identified patterns, potential interventions to prevent communication breakdowns were developed and their potential impact was assessed. RESULTS: The 60 cases involved 81 communication breakdowns, occurring in the preoperative (38%), intraoperative (30%), ..

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