Qual Saf Health Care 13:330-334 doi:10.1136/qshc.2003.008425
  • Original Article

Communication failures in the operating room: an observational classification of recurrent types and effects

  1. L Lingard,
  2. S Espin,
  3. S Whyte,
  4. G Regehr,
  5. G R Baker,
  6. R Reznick,
  7. J Bohnen,
  8. B Orser,
  9. D Doran,
  10. E Grober
  1. University of Toronto, Toronto, Canada
  1. Correspondence to:
 L Lingard PhD
 Associate Professor, Department of Paediatrics, University of Toronto Faculty of Medicine, Donald R. Wilson Centre for Research in Education, University Health Network, 200 Elizabeth Street, Eaton South 1–604, Toronto, Ontario, Canada M5G 2C4;
  • Accepted 11 March 2004


Background: Ineffective team communication is frequently at the root of medical error. The objective of this study was to describe the characteristics of communication failures in the operating room (OR) and to classify their effects. This study was part of a larger project to develop a team checklist to improve communication in the OR.

Methods: Trained observers recorded 90 hours of observation during 48 surgical procedures. Ninety four team members participated from anesthesia (16 staff, 6 fellows, 3 residents), surgery (14 staff, 8 fellows, 13 residents, 3 clerks), and nursing (31 staff). Field notes recording procedurally relevant communication events were analysed using a framework which considered the content, audience, purpose, and occasion of a communication exchange. A communication failure was defined as an event that was flawed in one or more of these dimensions.

Results: 421 communication events were noted, of which 129 were categorized as communication failures. Failure types included “occasion” (45.7% of instances) where timing was poor; “content” (35.7%) where information was missing or inaccurate, “purpose” (24.0%) where issues were not resolved, and “audience” (20.9%) where key individuals were excluded. 36.4% of failures resulted in visible effects on system processes including inefficiency, team tension, resource waste, workaround, delay, patient inconvenience and procedural error.

Conclusion: Communication failures in the OR exhibited a common set of problems. They occurred in approximately 30% of team exchanges and a third of these resulted in effects which jeopardized patient safety by increasing cognitive load, interrupting routine, and increasing tension in the OR.


  • This research was funded by the Canadian Institutes of Health Research (CIHR) and the Physicians of Ontario through the PSI Foundation. L Lingard is supported by a CIHR New Investigator Award; G Regehr is supported as the Richard and Elizabeth Currie Chair in Health Professions Education; B Orser is supported by an Ontario Ministry of Health Career Award.