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Failures in communication and information transfer across the surgical care pathway: interview study
  1. Kamal Nagpal,
  2. Sonal Arora,
  3. Amit Vats,
  4. Helen W Wong,
  5. Nick Sevdalis,
  6. Charles Vincent,
  7. Krishna Moorthy
  1. Centre for Patient Safety and Surgical Quality, Department of Biosurgery and Surgical Technology, Imperial College London, St Mary's Hospital, London, UK
  1. Correspondence to Sonal Arora, Department of Biosurgery and Surgical Technology, Imperial College London, 10th floor, QEQM, St Mary's Hospital, South Wharf Road, London W2 1NY, UK; sonal.arora06{at}


Background and Objectives Effective communication is imperative to safe surgical practice. Previous studies have typically focused upon the operating theatre. This study aimed to explore the communication and information transfer failures across the entire surgical care pathway.

Methods Using a qualitative approach, semi-structured interviews were conducted with 18 members of the multidisciplinary team (seven surgeons, five anaesthetists and six nurses) in an acute National Health Service trust. Participants' views regarding information transfer and communication failures at each phase of care, their causes, effects and potential interventions were explored. Interviews were recorded, transcribed verbatim, and submitted to emergent theme analysis. Sampling ceased when categorical and theoretical saturation was achieved.

Results Preoperatively, lack of communication between anaesthetists and surgeons was the most common problem (13/18 participants). Incomplete handover from the ward to theatre (12/18) and theatre to recovery (15/18) were other key problems. Work environment, lack of protocols and primitive forms of information transfer were reported as the most common cause of failures. Participants reported that these failures led to increased morbidity and mortality. Healthcare staff were strongly supportive of the view that standardisation and systematisation of communication processes was essential to improve patient safety.

Conclusions This study suggests communication failures occur across the entire continuum of care and the participants opined that it could have a potentially serious impact on patient safety. This data can be used to plan interventions targeted at the entire surgical pathway so as to improve the quality of care at all stages of the patient's journey.

  • Communication
  • information transfer
  • handover
  • interview
  • surgery
  • checklists
  • patient safety
  • root cause analysis
  • risk management

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  • Funding The research described here was supported by the National Institute of Health Research (NIHR) and the UK Engineering and Physical Sciences Research Council (EPSRC).

  • Competing interests None.

  • Ethics approval The project protocol was submitted to the National Research Ethics Service (Joint UCL/UCLH Committees on the Ethics of Human Research). They felt it was a ‘service evaluation’ study so did not require ethical approval. REC reference number: 08/H0715/112.

  • Provenance and peer review Not commissioned; externally peer reviewed.