The Institute of Medicine’s report in 1999 To Err is Human estimated that 44 000 to 98 000 deaths occur due to preventable medical errors every year in the USA. These startling numbers thrust patient safety and medical error into the spotlight of public discourse and professional debate.1 The field of surgery has responded by positioning to lead process and outcomes improvement in the operating theatre and critical care settings. In the US, the adoption of the National Surgery Quality Improvement Project from the Veterans Administration by the American College of Surgeons (ACS) has led to a reduction in 30-day mortality by nearly one-third and 30-day morbidity by nearly two-fifths in the initial cohort of participating hospitals.2 The Surgical Care Improvement Project, a collaboration between the US Centers for Medicare and Medicaid Services, the ACS, the American Hospital Association and others, has set its goal to reduce surgical complications by one-quarter by the year 2010.3

In spite of these initiatives, there remains a gap in safe and effective communication in the operating room and in the surgical intensive care unit. Communication failures frequently are engendered by status asymmetry and high-tension situations.45 In the face of communication failure, many staff members turn to process work-arounds, which may solve the immediate problem but fail to improve the system.6 Quick fixes should no longer be acceptable to staff …