Table 2

Information transfer and communication failures across all phases of care

Phase of care	Classification of failure type with examples and verbatim quotes	No. of subjects who said this	No. of times
Preoperative assessment and optimisation phase	Source failures Information at different places Consent/notes/investigations missing Documentation inadequate	11 (S=6, A=2, N=3)	13
	Transmission failures Lack of communication between anaesthetic and surgical teams Information not relayed from pre-assessment to theatre	15 (S=7, A=3, N=5)	24
	Receiver failures Investigations/specialists' opinion not checked	6 (S=3, A=3)	6
Preprocedure phase	Source failures List changed multiple times Incorrect/incomplete name on the list	12 (S=4, A=3, N=5)	17
	Transmission failures No collaborative network among theatre team Lack of communication between ward and theatre staff	8 (S=3, A=2, N=3)	8
	Receiver failures Equipment/cross match/HDU and ITU bed availability not checked Preoperative checklists not followed	8 (S=4, A=3, N=1)	8
Postoperative phase	Source failures Postoperative handover not done/incomplete Poor/illegible written handover Too much information, difficult to differentiate important from unimportant	15 (S=6, A=4, N=5)	24
	Transmission failures Debriefing does not happen Operation notes not transferred	3 (S=1, A=1, N=1)	3
	Receiver failures Nurse multitasking, not receiving complete information	2 (A=1, N=1)	2
Daily ward care	Source failures Information not available from the nurse (not on the rounds) Notes/observation, fluid charts missing Decisions from person leading round unclear	12 (S=6, A=4, N=2)	20
	Transmission failures Poor communication within and across teams Lack of organised process of handing over information	8 (S=4, A=3, N=1)	12
	Receiver failures Care pathways not followed	3 (S=3)	3

A, anaesthetists; HDU, high-dependency unit; ITU, intensive treatment unit; N, nurses; S, surgeons.