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Communication failure during operating room turnover: a HFACS-informed qualitative case study of system-level
Xin Liao1,2, Yan Zeng1,2, Jun-Ying Zhou3,4
1Department of Operating Room, West China Second University Hospital, Sichuan University, Chengdu, 610000, China.
BMC Health Services Research
|June 26, 2026
Summary
Communication failures during operating room (OR) turnovers stem from systemic issues, not just individual errors. Addressing organizational and supervisory factors is key to improving patient safety in surgical settings.
Area of Science:
- Healthcare Management
- Patient Safety
- Human Factors Engineering
Background:
- Operating room (OR) turnovers are critical, high-risk transitions demanding efficient multidisciplinary collaboration.
- Communication breakdowns during OR turnovers are significant contributors to perioperative adverse events.
- Previous research often overlooks systemic factors, focusing instead on individual communication errors.
Purpose of the Study:
- To investigate the development of communication failures across multiple system levels during OR turnovers.
- To identify system-level factors contributing to communication breakdowns in OR transitions.
- To provide insights for enhancing communication and coordination in OR turnovers.
Main Methods:
- A qualitative single-case study design was employed in a tertiary hospital in China.
- Semi-structured interviews were conducted with five healthcare professionals involved in OR turnover coordination.
- Data analysis utilized Colaizzi's seven-step method, with the Human Factors Analysis and Classification System (HFACS) applied as an interpretive framework.
Main Results:
- Six themes emerged: information transmission bias, lack of standardized protocols, fragmented interprofessional coordination, inconsistent norms, role-skill misalignment, and inadequate IT support.
- Findings indicated a pattern where organizational, supervisory, and operational factors interacted to impede frontline communication.
- Communication failures were linked to systemic constraints influencing coordination during high-intensity OR turnovers.
Conclusions:
- Communication failures in OR turnovers result from interconnected system-level factors, not isolated individual mistakes.
- Understanding these systemic mechanisms can enhance coordination processes and improve service reliability.
- Addressing these factors is crucial for reducing patient safety risks associated with communication in surgical environments.
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