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A theory-based instrument to evaluate team communication in the operating room: balancing measurement authenticity and reliability
  1. Lorelei Lingard1,
  2. Glenn Regehr1,
  3. Sherry Espin2,
  4. Sarah Whyte1
  1. 1Wilson Centre for Research in Education, University of Toronto, Eaton South, Toronto, Ontario, Canada
  2. 2Faculty of Nursing, Ryerson University, Toronto, Canada
  1. Correspondence to:
 Dr Lorelei Lingard
 Wilson Centre for Research in Education at University Health Network, University of Toronto, 200 Elizabeth Street, Eaton South 1–604, Toronto, Ontario, Canada M5G 2C4; lorelei.lingard{at}


Background: Breakdown in communication among members of the healthcare team threatens the effective delivery of health services, and raises the risk of errors and adverse events.

Aim: To describe the process of developing an authentic, theory-based evaluation instrument that measures communication among members of the operating room team by documenting communication failures.

Methods: 25 procedures were viewed by 3 observers observing in pairs, and records of events on each communication failure observed were independently completed by each observer. Each record included the type and outcome of the failure (both selected from a checklist of options), as well as the time of occurrence and a description of the event. For each observer, records of events were compiled to create a profile for the procedure.

Results: At the level of identifying events in the procedure, mean inter-rater agreement was low (mean agreement across pairs 47.3%). However, inter-rater reliability regarding the total number of communication failures per procedure was reasonable (mean ICC across pairs 0.72). When observers recorded the same event, a strong concordance about the type of communication failure represented by the event was found.

Discussion: Reasonable inter-rater reliability was shown by the instrument in assessing the relative rate of communication failures displayed per procedure. The difficulties in identifying and interpreting individual communication events reflect the delicate balance between increased subtlety and increased error. Complex team communication does not readily reduce to mere observation of events; some level of interpretation is required to meaningfully account for communicative exchanges. Although such observer interpretation improves the subtlety and validity of the instrument, it necessarily introduces error, reducing reliability. Although we continue to work towards increasing the instrument’s sensitivity at the level of individual categories, this study suggests that the instrument could be used to measure the effect of team communication intervention on overall failure rates at the level of procedure.

  • SEM, standard error of measurement

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  • i Recognising the relatively small sample size and the potential effect of a single outlier on the stability of the reliability estimates, the analyses were repeated with the 15-failure procedure removed. As the second rater, identified only nine failures for this procedure, the error variance was more inflated for this reason than the procedure variance. Therefore, the reliability estimates actually improved with the exclusion of this procedure (to 0.83 with an absolute SEM of 0.91). For completeness, the more conservative analyses with this procedure included are presented.

  • Funding: This research was funded by the Canadian Institutes of Health Research (CIHR) and by the doctors of Ontario through the PSI Foundation. LL is supported by a CIHR New Investigator Award and as the BMO Financial Group Professor in Health Professions Education Research. GR is supported as the Richard and Elizabeth Currie Chair in Health Professions Education Research.

  • Competing interests: None declared.