title: A systematic quantitative assessment of risks associated with poor communication in surgical care.
abstract: OBJECTIVE
  Health care failure mode and effect analysis identifies critical processes prone to information transfer and communication failures and suggests interventions to improve these failures.
  
  
  METHODS
  Failure mode and effect analysis.
  
  
  METHODS
  Academic research.
  
  
  METHODS
  A multidisciplinary team consisting of surgeons, anesthetists, nurses, and a psychologist involved in various phases of surgical care was assembled.
  
  
  METHODS
  A flowchart of the whole process was developed. Potential failure modes were identified and evaluated using a hazard matrix score. Recommendations were determined for certain critical failure modes using a decision tree.
  
  
  RESULTS
  The process of surgical care was divided into the following 4 main phases: preoperative assessment and optimization, preprocedural teamwork, postoperative handover, and daily ward care. Most failure modes were identified in the preoperative assessment and optimization phase. Forty-one of 132 failures were classified as critical, 26 of which were sufficiently covered by current protocols. Recommendations were made for the remaining 15 failure modes.
  
  
  CONCLUSIONS
  Modified health care failure mode and effect analysis proved to be a practical approach and has been well received by clinicians. Systematic analysis by a multidisciplinary team is a useful method for detecting failure modes.
authors.affiliation: Clinical Safety Research Unit, Department of Biosurgery and Surgical Technology, Imperial College London, 10th Floor, Queen Elizabeth the Queen Mother Building, St Mary's Hospital, South Wharf Road, London W2 1NY, United Kingdom. k.nagpal@imperial.ac.uk
authors.forename: Kamal
authors.initials: K
authors.lastname: Nagpal
authors.forename: Amit
authors.initials: A
authors.lastname: Vats
authors.forename: Kamran
authors.initials: K
authors.lastname: Ahmed
authors.forename: Andrea B
authors.initials: AB
authors.lastname: Smith
authors.forename: Nick
authors.initials: N
authors.lastname: Sevdalis
authors.forename: Helgi
authors.initials: H
authors.lastname: Jonannsson
authors.forename: Charles
authors.initials: C
authors.lastname: Vincent
authors.forename: Krishna
authors.initials: K
authors.lastname: Moorthy
mesh_terms: D003266:Continuity of Patient Care / Q000592:standards / Q000639:trends; D005069:Evaluation Studies as Topic; D005260:Female; D006801:Humans; D033183:Interdisciplinary Communication; D007400:Interprofessional Relations; D008297:Male; D019300:Medical Errors / Q000517:prevention & control*; D010348:Patient Care Team / Q000458:organization & administration*; D011182:Postoperative Care / Q000592:standards / Q000639:trends; D011300:Preoperative Care / Q000592:standards / Q000639:trends; D018570:Risk Assessment; D017751:Safety Management; D013503:Surgery Department, Hospital; D013514:Surgical Procedures, Operative / Q000009:adverse effects / Q000379:methods*; D013597:Systems Analysis; D017749:Total Quality Management; D016896:Treatment Outcome