作者
Caprice C Greenberg, Scott E Regenbogen, David M Studdert, Stuart R Lipsitz, Selwyn O Rogers, Michael J Zinner, Atul A Gawande
发表日期
2007/4/1
期刊
Journal of the American College of Surgeons
卷号
204
期号
4
页码范围
533-540
出版商
No longer published by Elsevier
简介
BACKGROUND
Communication breakdowns are a common threat to surgical safety, but there are little data to guide initiatives to improve communication.
STUDY DESIGN
In surgeon-review of 444 surgical malpractice claims from 4 liability insurers, we identified 60 cases involving communication breakdowns resulting in harm to patients. Two surgeon-reviewers analyzed these cases to identify common characteristics and associated factors. Based on identified patterns, potential interventions to prevent communication breakdowns were developed and their potential impact was assessed.
RESULTS
The 60 cases involved 81 communication breakdowns, occurring in the preoperative (38%), intraoperative (30%), and postoperative periods (32%). Seventy-two percent of cases involved one communication breakdown. The majority of breakdowns were verbal communications (92%) involving 1 transmitter and 1 …
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