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Simple budget-neutral tool to improve intraoperative communication
  1. James Dougherty,
  2. Charlie Slowey,
  3. Anne Hermon,
  4. Jed Wolpaw
  1. Anesthesiology and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA
  1. Correspondence to Dr Anne Hermon, Anesthesiology and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, MD 21287, USA; ahermon1{at}


Background Communication failure is a common cause of medical errors and adverse events. Within the operating room (OR), there are many barriers to good communication, which can adversely affect patient outcome.

Objective Implementing a simple, cost-neutral tool aimed at improving intraoperative communication and engagement.

Methods Three anaesthesiology residents collected data using a data sheet and tailored surveys distributed to OR staff. Data were collected over a 2-week period in 2019, with 1 week each of preintervention and postintervention data collection. The intervention consisted of wearing OR caps displaying the first name and role of the anaesthesia resident clearly on the front.

Results A total of 20 data sheets and 48 preintervention and postintervention surveys were collected for a response rate of 57%. There was a statistically significant increase in OR staff knowledge of the anaesthesia resident’s name (66% vs 100%, p=<0.001), an increase in the mean number of times the surgical providers addressed the anaesthesia residents (3.6 vs 7.8, p=0.0074) and an increase in the mean number of times the surgical providers addressed them by their first name (0.7 vs 4, p=0.0067). Comments received during the intervention were positive with overwhelming support.

Conclusions This study demonstrated that a simple, cost-effective intervention can result in dramatic improvement in intraoperative communication and engagement between teams.

  • adult anaesthesia
  • surgery
  • quality in health care

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  • Contributors JD proposed the idea for the study and performed the literature search. JD, AH and CS collected data and wrote the manuscript. CS performed data analysis. JW served as a project advisor and edited the manuscript. AH submitted the study and corresponded with the journal. JD is the guarantor of this study.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement All data relevant to the study are included in the article.

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