Communication failure during operating room turnover: a HFACS-informed qualitative case study of system-level...

To examine how communication failures develop across multiple system levels during operating room (OR) turnovers and to generate insights for system-level improvement using the Human Factors Analysis and Classification as an interpretive framework.

Operating room turnovers are high-risk transitional periods requiring rapid multidisciplinary coordination. Communication breakdowns during turnovers are a major contributor to perioperative adverse events. However, existing analyses often focus on individual communication errors, with limited attention to the latent organizational and contextual factors shaping frontline communication and coordination.

A qualitative single-case study was conducted in a tertiary hospital in China focusing on an information-rich OR turnover incident. Semi-structured interviews were conducted with five healthcare professionals involved in OR turnover coordination. Data were analysed using Colaizzi's seven-step method. HFACS was subsequently employed as a systems-oriented interpretive framework to support understanding of relationships among the identified themes across organizational, supervisory, environmental and frontline levels.

Six interrelated themes were identified: information transmission bias, absence of standardized communication protocols, fragmented interprofessional coordination, inconsistent institutional norms, inadequate alignment between skills and roles and insufficient information technology support. Together, these findings suggested a pattern of communication failure in which organizational constraints, supervisory limitations and operational pressures interacted to influence frontline communication and coordination during OR turnovers.

The findings highlight that communication failures during OR turnovers arise from interacting system-level factors rather than isolated individual errors. Understanding these mechanisms may support safer coordination processes, improve service reliability and reduce communication-related patient safety risks in high-intensity surgical settings.