Coordination breakdown management in surgical units

Communication and coordination breakdowns represent the leading cause of adverse events in healthcare. This is especially true in the operating room environment - the wrong patient may be operated on, the wrong procedure may be performed, or consideration of specific patient information may be missed in surgery planning, preparation and execution. This book presents an in-depth study of the impact of breakdowns on surgical work in two large urban hospitals. The focus of analysis is set beyond teamwork dynamics to include system level communication and coordination processes. The book presents a breakdown detection method as a first step in the management of breakdowns. The knowledge acquired through a series of hospital studies is also translated into system design guidelines tailored to the requirements of the surgical setting.