Failures in communication through documents and documentation across the perioperative pathway

Area of Science:

• Healthcare Communication
• Patient Safety
• Perioperative Care

Background:

• Documents and documentation are critical for communicating patient information in perioperative settings.
• Communication failures are frequently reported in perioperative care.

Purpose of the Study:

• To explore the nature and causes of communication failures in perioperative documentation.
• To identify how these failures impact nurse, surgeon, and anaesthetist interactions.

Main Methods:

• Qualitative study conducted in three Melbourne hospitals.
• Data collected through 350 hours of observation, 2 focus groups, and 20 semi-structured interviews.
• Thematic analysis of data from 125 healthcare professionals.

Main Results:

• Failures stemmed from reliance on documents at transitions, poor document quality, and access issues.
• Institutional practices (efficiency, fiscal constraints) shaped communication, compromising safety.
• Information was often buried, insufficient, inaccurate, or lacked verbal reinforcement.

Conclusions:

• Communication breakdowns in perioperative documentation negatively affect patient safety, leading to treatment delays and inadequate care.
• Enhanced organizational support for documentation completion and access is needed.
• Implementing improved communication technologies can facilitate information exchange.