Presentation
Characterizing Resilient and Unsafe Communication in Surgery: Insights from Cases With and Without Intraoperative Adverse Events
DescriptionBackground and Rationale
Unsafe communication practices (e.g., delayed information exchange) are the most common cause of adverse events among surgical patients, with as many as 70% of intraoperative adverse events (IAEs) attributed to these breakdowns. While previous research has focused on identifying and categorizing communication failures, little is known about how they unfold in practice, contribute to harm, or why some result in IAEs while others do not.
To address this gap, we differentiate between unsafe communication practices (UCPs; interactions that may contribute to risk or harm) and resilient communication practices (RCPs; interactions that enhance team coordination and help prevent harm). The focus on UCPs in existing literature neglects the role that RCPs can play in preventing adverse events. RCPs (e.g., speaking up, verbalizing concerns, clarifying plans, and adapting to evolving situations) support team resilience and can serve as safeguards against harm. These practices also facilitate shared mental models (i.e., common understanding of the situation, treatment plan, and individual roles) which are critical for high-performing surgical teams. Despite its recognized importance, communication in the operating room (OR) remains poorly understood, both in terms of what constitutes UCPs that contribute to harm, and RCPs that help prevent harm. We still lack a clear understanding of how these interactions unfold in practice, and how they function as contributors to risk or as safeguards to prevent adverse events.
A major limitation of previous studies investigating communication in the OR is their reliance on surveys, interviews, or in-person observations, which cannot fully capture the dynamic team-wide nature of communication as it occurs. Audio/visual data offers a powerful alternative, providing richer, more contextual insights. The Operating Room Black Box (ORBB) is a multichannel data capture platform that synchronizes multiple camera feeds (2 room views & an intracorporeal view), microphones, and digital data sources to comprehensively record surgical procedures. Using data collected by the ORBB, we can gain deeper insights into communication practices in the OR and gain a better understanding of how communication acts not just as a risk factor, but as a critical safeguard in preventing adverse events.
Study Objectives
The objectives of this study are to 1) Compare the frequency and type of unsafe communication practices (UCPs) and resilient communication practices (RCPs) between surgical cases with IAEs and those without, 2) Within IAE cases, examine how UCPs and RCPs change over time (i.e., before and after the occurrence of the IAE).
Methods
We describe an exploratory observational study involving analysis of audio/video recordings captured by the ORBB of multiple types of surgeries at two large academic hospitals, and one large community hospital.
Human factors specialists reviewed videos and manually transcribed events of interest into a Microsoft Excel spreadsheet. Communication events were identified and categorized as an RCP or UCP. Deductive and inductive coding was used to identify themes (e.g., RCP: positive leadership; UCP: poor leadership).
IAEs were identified by surgical analysts and classified using the SEVERE index, which identifies the type of event (e.g., bleeding, mechanical injury) and scores the severity of the IAE on a scale of 1 to 5, where 1 is the least severe (e.g., very low blood loss) and 5 is the most (e.g., very high amount of blood loss). IAEs with a severity of 1 or 2, which are unlikely to lead to complications, were excluded. If a case contained multiple IAEs, then UCPs and RCPs occurring prior to and following the IAE were calculated relative to the first IAE. The number of codes was then normalized by case count and duration to calculate the average number of communication-related UCPs and RCP codes per case per hour.
Results
Data collection is still in progress, however as of the submission date, 68 cases across 3 hospitals were recorded. Fifteen cases were recorded from hospital A, 26 cases were recorded from hospital B, and 27 cases from hospital C.
The incidence of IAEs varied slightly across hospitals:
• Hospital A: 0.33 IAEs/case (4 total IAEs) ,
• Hospital B: 0.46 IAEs/case (12 total IAEs)
• Hospital C: 0.30 IAEs/case (8 total IAEs)
1) Comparison of UCPs and RCPs Between Cases With and Without IAEs:
Across all three hospitals, both unsafe communication practices (UCPs) and resilient communication practices (RCPs) occurred more frequently in cases without IAEs. The difference in the number of RCPs between IAE and no-IAE cases was larger as compared to the difference in UCPs across all three institutions. At hospital A, cases without IAEs had, on average, 0.63 more RCPs per hour and 0.04 more UCPs per hour than cases with IAEs. At hospital B, cases without IAEs showed an average of 1.91 more RCPs and 0.34 more UCPs per hour. At hospital C, cases without IAEs had an average of 0.51 more RCPs and 0.21 fewer UCPs per hour compared to IAE cases.
Unsafe communication practices (UCPs) included to poor communication practices (e.g., delayed or absent communication), poor leadership (e.g., providing feedback that is not constructive), and lack of team coordination and psychological safety (e.g., blaming team members). Resilient communication practices (RCPs) included clear communication practices (e.g., closed loop communication), positive leadership (e.g., providing feedback or support), and positive team coordination and psychological safety (e.g., team huddles and team updates). In the presentation, we will expand on differences in types of UCPs and RCPs.
2) Temporal Patterns of Communication Practices within IAE cases:
Within cases with an IAE, we compared the frequency of UCPs and RCPs before and after the event. For RCPs, Hospitals A and C showed higher frequencies prior to the IAE, with Hospital A averaging 0.02 more RCPs per hour before the event and Hospital C showing a larger difference of 1.85 more RCPs per hour. In contrast, Hospital B demonstrated an increase in RCPs per hour after the IAE, with an average of 0.97 RCPs per hour after the IAE occurred. For UCPs, Hospitals B and C had more frequencies before the IAE, with post-event decreases of 0.12 and 0.26 UCPs per hour, respectively. However, Hospital A showed the opposite pattern, with an average 0.46 more UCPs per hour occurring after the IAE.
Discussion
In hospitals A, B, and C, RCPs were more frequent in cases without IAEs, suggesting that resilient communication practices may be more protective and contribute to safer outcomes. The higher frequency of RCPs in non-IAE cases, especially compared to the relatively stable rate of UCPs, supports the idea that resilient communication practices are more strongly associated with surgical safety than the mere presence of UCPs. This aligns with safety II, which emphasizes resilience to be a stronger predictor of outcomes than safety threats.
Hospital A saw no change in RCPs prior to and after the IAE, and hospital C had more RCPs prior to the IAE occurrence. In contrast, hospital B saw an increase in RCPs after the IAE. In contrast, hospital B saw an increase in RCPs after the IAE. This suggests that RCPs at Hospital B may be more of a reactive response to adverse events. Moreover, hospital B has the largest rate of IAEs per case compared to hospital A and hospital C. Therefore, these findings suggest that communication-related resilience, not just presence of communication-related safety threats, are predictive of surgical outcomes.
Unsafe communication practices (e.g., delayed information exchange) are the most common cause of adverse events among surgical patients, with as many as 70% of intraoperative adverse events (IAEs) attributed to these breakdowns. While previous research has focused on identifying and categorizing communication failures, little is known about how they unfold in practice, contribute to harm, or why some result in IAEs while others do not.
To address this gap, we differentiate between unsafe communication practices (UCPs; interactions that may contribute to risk or harm) and resilient communication practices (RCPs; interactions that enhance team coordination and help prevent harm). The focus on UCPs in existing literature neglects the role that RCPs can play in preventing adverse events. RCPs (e.g., speaking up, verbalizing concerns, clarifying plans, and adapting to evolving situations) support team resilience and can serve as safeguards against harm. These practices also facilitate shared mental models (i.e., common understanding of the situation, treatment plan, and individual roles) which are critical for high-performing surgical teams. Despite its recognized importance, communication in the operating room (OR) remains poorly understood, both in terms of what constitutes UCPs that contribute to harm, and RCPs that help prevent harm. We still lack a clear understanding of how these interactions unfold in practice, and how they function as contributors to risk or as safeguards to prevent adverse events.
A major limitation of previous studies investigating communication in the OR is their reliance on surveys, interviews, or in-person observations, which cannot fully capture the dynamic team-wide nature of communication as it occurs. Audio/visual data offers a powerful alternative, providing richer, more contextual insights. The Operating Room Black Box (ORBB) is a multichannel data capture platform that synchronizes multiple camera feeds (2 room views & an intracorporeal view), microphones, and digital data sources to comprehensively record surgical procedures. Using data collected by the ORBB, we can gain deeper insights into communication practices in the OR and gain a better understanding of how communication acts not just as a risk factor, but as a critical safeguard in preventing adverse events.
Study Objectives
The objectives of this study are to 1) Compare the frequency and type of unsafe communication practices (UCPs) and resilient communication practices (RCPs) between surgical cases with IAEs and those without, 2) Within IAE cases, examine how UCPs and RCPs change over time (i.e., before and after the occurrence of the IAE).
Methods
We describe an exploratory observational study involving analysis of audio/video recordings captured by the ORBB of multiple types of surgeries at two large academic hospitals, and one large community hospital.
Human factors specialists reviewed videos and manually transcribed events of interest into a Microsoft Excel spreadsheet. Communication events were identified and categorized as an RCP or UCP. Deductive and inductive coding was used to identify themes (e.g., RCP: positive leadership; UCP: poor leadership).
IAEs were identified by surgical analysts and classified using the SEVERE index, which identifies the type of event (e.g., bleeding, mechanical injury) and scores the severity of the IAE on a scale of 1 to 5, where 1 is the least severe (e.g., very low blood loss) and 5 is the most (e.g., very high amount of blood loss). IAEs with a severity of 1 or 2, which are unlikely to lead to complications, were excluded. If a case contained multiple IAEs, then UCPs and RCPs occurring prior to and following the IAE were calculated relative to the first IAE. The number of codes was then normalized by case count and duration to calculate the average number of communication-related UCPs and RCP codes per case per hour.
Results
Data collection is still in progress, however as of the submission date, 68 cases across 3 hospitals were recorded. Fifteen cases were recorded from hospital A, 26 cases were recorded from hospital B, and 27 cases from hospital C.
The incidence of IAEs varied slightly across hospitals:
• Hospital A: 0.33 IAEs/case (4 total IAEs) ,
• Hospital B: 0.46 IAEs/case (12 total IAEs)
• Hospital C: 0.30 IAEs/case (8 total IAEs)
1) Comparison of UCPs and RCPs Between Cases With and Without IAEs:
Across all three hospitals, both unsafe communication practices (UCPs) and resilient communication practices (RCPs) occurred more frequently in cases without IAEs. The difference in the number of RCPs between IAE and no-IAE cases was larger as compared to the difference in UCPs across all three institutions. At hospital A, cases without IAEs had, on average, 0.63 more RCPs per hour and 0.04 more UCPs per hour than cases with IAEs. At hospital B, cases without IAEs showed an average of 1.91 more RCPs and 0.34 more UCPs per hour. At hospital C, cases without IAEs had an average of 0.51 more RCPs and 0.21 fewer UCPs per hour compared to IAE cases.
Unsafe communication practices (UCPs) included to poor communication practices (e.g., delayed or absent communication), poor leadership (e.g., providing feedback that is not constructive), and lack of team coordination and psychological safety (e.g., blaming team members). Resilient communication practices (RCPs) included clear communication practices (e.g., closed loop communication), positive leadership (e.g., providing feedback or support), and positive team coordination and psychological safety (e.g., team huddles and team updates). In the presentation, we will expand on differences in types of UCPs and RCPs.
2) Temporal Patterns of Communication Practices within IAE cases:
Within cases with an IAE, we compared the frequency of UCPs and RCPs before and after the event. For RCPs, Hospitals A and C showed higher frequencies prior to the IAE, with Hospital A averaging 0.02 more RCPs per hour before the event and Hospital C showing a larger difference of 1.85 more RCPs per hour. In contrast, Hospital B demonstrated an increase in RCPs per hour after the IAE, with an average of 0.97 RCPs per hour after the IAE occurred. For UCPs, Hospitals B and C had more frequencies before the IAE, with post-event decreases of 0.12 and 0.26 UCPs per hour, respectively. However, Hospital A showed the opposite pattern, with an average 0.46 more UCPs per hour occurring after the IAE.
Discussion
In hospitals A, B, and C, RCPs were more frequent in cases without IAEs, suggesting that resilient communication practices may be more protective and contribute to safer outcomes. The higher frequency of RCPs in non-IAE cases, especially compared to the relatively stable rate of UCPs, supports the idea that resilient communication practices are more strongly associated with surgical safety than the mere presence of UCPs. This aligns with safety II, which emphasizes resilience to be a stronger predictor of outcomes than safety threats.
Hospital A saw no change in RCPs prior to and after the IAE, and hospital C had more RCPs prior to the IAE occurrence. In contrast, hospital B saw an increase in RCPs after the IAE. In contrast, hospital B saw an increase in RCPs after the IAE. This suggests that RCPs at Hospital B may be more of a reactive response to adverse events. Moreover, hospital B has the largest rate of IAEs per case compared to hospital A and hospital C. Therefore, these findings suggest that communication-related resilience, not just presence of communication-related safety threats, are predictive of surgical outcomes.
Event Type
Oral Presentations
TimeTuesday, March 241:30pm - 2:00pm EDT
LocationMurray Hill East
Patient Safety Research and Initiatives