Practice of Medicine


Miscommunication with Patients in the Surgery Setting

Executive Summary

Miscommunication in the surgery setting commonly leads to adverse outcomes. Often communication errors begin well before the surgery with early patient-physician encounters and phone call miscommunications, or during a patient’s journey through the hospital. Perioperative time-outs are vital for reducing adverse surgical outcomes.

Recommended Actions
  • Conduct preoperative briefings to confirm the correct patient, site, operation, medicine, labs and equipment needed for a successful surgery.
  • Consistently implement the WHO Surgical Safety Checklist before each surgery.
  • Ensure that the scheduling team is involved in the perioperative team and in communication with the practicing surgeon.

Along with technical and systems issues in the surgical setting, communication breakdown is another area that may lead to adverse outcomes. The book Surgical Patient Safety: A Case-Based Approach, edited by Philip Stahel, MD, and director of the Department of Orthopedics at Denver Health Medical Center, uses cases studies to draw awareness to the factors and situations that contribute to medical errors.

The following is an excerpt adapted from the book that focuses on the issue of wrong site surgery.

Case Description

Dr. A is a well-trained orthopedist who limits his practice to joint replacements. He has a great reputation and performs 450-500 arthroplasties per year.

The patient is a 78-year-old woman with a history of multiple joint replacements for rheumatoid arthritis. Both artificial hips, implanted 23 (right) and 25 (left) years ago, need revision. After discussing his plan with the patient and her husband, Dr. A sends them to his surgery scheduler with a surgical form that includes the following:

  • Operation: bilateral revision, staged. R/L
  • Time: 5 hours
  • Equipment: cement remover, revision set
  • Rep to be present. Call and Template.

On the day of surgery, Dr. A confirms with the patient that he will be revising the older, left hip. She and her husband agree. As is his custom, Dr. A uses an indelible marker to outline the posterior incision and sign his initials. As is his routine, he adds a smiley face at the end of the surgical site.

Following induction of anesthesia and lateral positioning of the patient, the operation proceeds smoothly. The prosthetic stem and cup are removed. Dr. A begins preparing the femoral canal and asks for the revision broach. The operating room nurse hands him a broach for a right stem and reports that all stems and trial components are for a right femur. Dr. A calls the manufacturing representative, but per hospital policy, the representative is not allowed in the operating room. The following conversation transpired:

Doctor: “Do you have a left revision set?”

Rep: “I was told it was a right revision.”

Doctor: “Back to my question. Do you have a left revision set?”

Rep: “Yes. Unfortunately, it will take at least three hours to get it here.”

Patient Outcome

Dr. A washed out the wound and closed the hip without prosthesis. Later that day he apologized to the patient, explained the error and informed her of his plan to return her to the operating room to complete the operation within two to three days. Unfortunately, she developed postoperative atelectasis, which delayed the second surgery. She then experienced a deep venous thrombosis that required six weeks of anti-coagulation therapy. Because of her inability to walk with a walker, she required a three-month nursing home stay. She and her husband sought the services of another orthopedist who told them that Dr. A committed malpractice. The patient filed a lawsuit, and Dr. A subsequently settled out of court based on pain, suffering and the need for ongoing medical and nursing home care.


A number of factors led to this event. To start, the scheduling form was ambiguous. the patient needed both hips revised, and the scheduler assumed that the right side would be performed first because it was written first. The scheduler never discussed the surgery with Dr. A. Since she believed the right hip would be revised first, this is what was communicated to the manufacturing representative.

The manufacturer’s representative made templates from the x-rays. Since both hips were to be revised, the rep marked both the right and left side, sizing the prosthesis for each side accordingly.

Dr. A never spoke directly to the representative, but placed the marked x-rays on the operating room view box. Hospital protocol did not allow the representative to be in the surgical suite, so he was not allowed to view the revision set of hip instruments as the operating room was opened. Finally, preoperatively, the surgical technician was counting and organizing the hundreds of pieces of equipment needed for a revision hip surgery. The scrub nurse never knew she had the wrong equipment until she was asked for the femoral broach.

Hindsight evaluation of any wrong side or wrong site surgery is relatively easy to understand. Yet despite major efforts, these errors continue. The Joint Commission published the Universal Protocol designed to eliminate wrong patient/wrong site/wrong procedure surgery.  The protocol consisted of three parts:

  1. Patient verification of the procedure.
  2. Surgical site marking.
  3. A time-out before starting surgery.

Yet several authors have confirmed that surgeries on the wrong patient, wrong site and wrong procedure continue to occur despite the protocol. It must be remembered that such sentinel events are rare, occurring an estimated 1 in 113,000 surgeries for wrong site events.

Unfortunately, the persistence of such events despite 11+ years of using the Universal Protocol attests to the difficulty of eradicating such errors. Systems analysis shows that these events involve more than just a surgeon operating on the wrong body part or without the proper equipment. The patient experience begins well before the physician-patient encounter. A phone call to the office may trigger a problem list, and language barriers are magnified by phone conversations where nonverbal cues are masked.

Receptionists and office aides often help complete forms that might create an anchoring bias for diagnosis and treatment. The patient’s journey through the hospital and operating room is guided by the surgeon, who relies on his or her team to help throughout this journey. The team is large and involves receptionists, nursing assistants, surgical schedulers, physician assistants, perioperative personnel, manufacturers’ representatives, anesthesiologists, residents, radiologists, pathologists and others.

Strategies for Improvement

Had the team taken a surgical time-out, the outcome may have been different.

The surgical time-out represents the last check before starting the procedure. The immediate members of the surgical team, including the surgeon, anesthesiologist, circulating nurse and surgical technician, must participate in a standardized, controlled process.

Time-out Essentials

  • Correct patient, surgery and site
  • Perioperative antibiotic needs
  • Allergies
  • Availability of pertinent history, labs, images and medications
  • Necessary equipment needed to perform the operation

In 2009, the World Health Organization (WHO) used its experience to publish the WHO Surgical Safety Checklist and implement it in eight diverse institutions. Significant reductions in morbidity and mortality were noted. Despite such observations, utilization of the perioperative checklist remains inconsistent.

In a 2015 article, Walter Biffle, MD, explored inconsistencies surrounding use of these protocols in an observational study of 854 cases involving 10 Colorado hospitals that mandated use of the WHO checklist. Dr. Biffle observed significant suboptimal compliance with the checklist, and he suggested that a lack of surgeon leadership about the issue was a major contributor to non-compliance.

Surgeons need to be aware of the areas of high risk this case study exemplifies and pay special attention to communication in these areas:

  • Surgical schedulers, whether in the office or operating room, are part of the perioperative team. Accurate communication between surgeon and scheduler is imperative.
  • Complex operations involving equipment not routinely found in the hospital or surgery center require accurate communication between the supplier and the surgical team.
  • Preoperative briefings should confirm the correct patient, site, operation, medicine, labs and equipment needed for a successful surgery.
Lessons Learned
  • Consider training surgeons and surgical staff on the essentials of effective communication to prevent words, signals or ideas being lost in translation.
  • Confirm that the WHO Surgical Safety Checklist is being implemented consistently and optimally before each surgery.
  • Consider providing additional checklists for more complex surgeries that require additional equipment or staffing.
Potential Damages

Communication errors in surgery occur relatively frequently and can lead to costly litigation. The surgeon and hospital can be required to compensate the patient for any injuries, disfigurement or further medical treatment needed.  


1. Before each surgery, the following should be confirmed: patient, site, operation, medicine, labs, equipment needed.
2. Surgical schedulers do not need to be involved in the perioperative team.
3. Complex operations need supplemental review during the perioperative time-out.


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The information provided in this resource does not constitute legal, medical or any other professional advice, nor does it establish a standard of care. This resource has been created as an aid to you in your practice. The ultimate decision on how to use the information provided rests solely with you, the PolicyOwner.