Communication breakdowns can be a factor in patients’ adverse events, data show.

“Statistics from The Joint Commission identified that 70% of adverse events that are occurring in the surgical environment are caused by breakdowns in communication among healthcare providers,” says Lisa Spruce, DNP, RN, ACNP, director of evidence-based perioperative practice, Association of periOperative Registered Nurses (AORN). “The latest statistics show that wrong-site surgery and unintended retention of a foreign body continue to be the top events.”1

AORN developed new communication guidance to help perioperative professionals use communication tools to reduce the incidence of patient safety events. The guideline’s chief message is for surgery centers to focus on team communication, using tools to prevent communication breakdowns.

“It is estimated that between 180,000 and 400,000 patient deaths occur annually as a result of medical errors, making it the third leading cause of death,” Spruce says.2 “Every facility needs to focus on patient safety as this number is staggering.”

AORN offers several tools that help with team communication, as well as evidence-based protocols to improve patient safety.3 “Tools such as a handover process, a briefing process, a surgical safety checklist, and a debriefing process can help perioperative team members to improve patient safety by promoting optimal communication during every phase of the surgical process,” Spruce says.

Communication errors can occur through written or verbal means. They can be acts of omission. “Many factors can impact communication, including distractions, personal relationships, hierarchical cultures, language preferences, culture, and others,” Spruce says.

For example, Spruce recalls a case in which a biopsy was performed on the wrong surgical site. “The cause of that incident was a failure of the perioperative team to conduct a time out to confirm the site prior to proceeding with the procedure,” she explains.

The first step in avoiding a communication error and adverse event is to stop thinking that critical patient errors and adverse events will not happen at one’s own surgery center. “As humans, we are all vulnerable to human error and failures in communication,” Spruce notes. “Perioperative nurses must speak up when patient safety is in jeopardy.” Even if a surgery center uses communication tools, they will not be enough if nurses do not have the courage to speak up, advocate for their use, and stand firmly behind safety measures.

Spruce recommends nurses read The Silent Treatment, published in 2011 and authored by representatives from the American Association of Critical-Care Nurses, AORN, and VitalSmarts. “It examines an especially dangerous kind of communication breakdown: risks that are known, but not talked about.”4


  1. The Joint Commission. Sentinel Event statistics released for first 6 months of 2019 with new suicide categories, Aug. 14, 2019. Available at: Accessed Oct. 24, 2019.
  2. Makary MA, Daniel M. Medical error-the third leading cause of death in the US. BMJ 2016;353:i2139.
  3. Association of periOperative Registered Nurses. Guideline on team communication search results. Available at: Accessed Oct. 24, 2019.
  4. Patient Safety & Quality Healthcare. The Silent Treatment: Why Safety Tools and Checklists Aren’t Enough. Published September/October 2011. Available at: Accessed Oct. 24, 2019.