Table 4

Definitions of effect types with illustrative examples and notes

Effect and definition	Illustrative example and analytical note (in italics)
Inefficiency:
Communication failure requires team members to redo or undo a procedural step; step requires more actions or discourse than usual	The staff surgeon asks for a “wishbone”. The one available is not the one he wants. The scrub nurse explains the difficulty of changing the standing equipment order, referencing previous conversations they have had. The staff surgeon exclaims: “Well this is stupid, we’re ordering new stuff and getting old stuff.” The scrub nurse asks: “Anyone want to call CPD (the central processing department) AGAIN?”
	This particular equipment problem is not new to the team and yet it is not predicted prior to the case; rather, the communication arises at the moment of need, creating inefficiency of discourse and actions.
Tension:
Emotional responses to a communication failure;may ripple to other members/environments	In the instance regarding the wishbone (above), the circulating nurse, who is new to the division, responds that she will call CPD. The scrub nurse coaches her on what to say while the surgeon adds pointed suggestions. The circulating nurse is visibly anxious when she makes the call. When she hangs up the surgeon says “Well??”
	The surgeon is irritated in response to a recurring resource problem that has not been addressed proactively. The frustration spreads to nursing and CPD.
Delay:
Communication failure results in a delay in the surgical procedure	In instances in which the surgical staff or resident has not been present for discussions of positioning or draping, these activities occasionally need to be redone to accommodate the particular needs of the surgical team.
	Such rework efforts delay the commencement of a procedure, in addition to creating the effect of inefficiency in work practices.
Workaround:
Communication failure provokes a culturally accepted violation of an institutional regulation in order to maintain efficient workflow	After the patient has been anesthetized, the nurse tells the surgeon that the consent form used an abbreviation instead of the full procedure name, and adds that this is against regulations. The surgeon responds: “The key is, do you think he knew what he was coming for this morning?” The nurse assures: “Well, we didn’t delay the case because of it…”.
	Members make a tacit agreement to work around the hospital regulation by assuming informed consent to ensure the OR stays on schedule.
Resource waste:
Communication failure results in the use of equipment or personnel that is not required	A cell saver, a critical and limited equipment resource, was ordered and set up. When the circulating nurse asked the surgical team when they would be using this equipment, the surgical fellow responded that they wouldn’t be using it at all. Later the perfusionist enters and asks: “You don’t need this cell saver?” to which the staff surgeon responds apologetically, “No, it’s a cancer case. I should’ve told them that.”
	Had this information been transferred earlier, the equipment could have been dismantled and available if needed for another operating room theatre.
Patient inconvenience:
Communication failure creates undue strain or imposition on patient	A patient has arrived to the operating room and is having IV lines inserted when the anesthesiologist communicates to the nurse that the patient’s blood type information is “missing”. The case preparation must be halted while the patient waits on the operating table for blood to be taken.
	While “delay” is also a relevant effect, “patient inconvenience” acknowledges the added discomfort to the patient of delay in the OR environment rather than the holding area.
Procedural error:
Communication failure contributes to mistakes in decision making or failures of technique	The anesthesia fellow inserts a triple lumen in the patient. The staff surgeon arrives and says: “I want a [Swan-Ganz line].” Pointing, he says: “That IV is not appropriate for a transplant.” The anesthesia fellow, joined by the staff anesthesiologist, removes the triple lumen and replaces it with a Swan-Ganz line, a process that takes over 30 minutes.
	This example illustrates the procedural error of the insertion of an inappropriate line necessitating removal and reinsertion, each step of which raises the risk to the patient. This error may be influenced by variables other than information transfer, such as the knowledge and supervision of the anesthesia fellow; however, the failure of the team to communicate about key procedural steps such as major lines allows other system weaknesses to perpetuate until an obvious threat to safety arises.