Dr M Gomes Dr R Padmore
-Possible serious Consequences of comm breakdown!
Nejm 91 - adverse events fiest paper on consequences
N Zealand -comm errors are a result of systemic problems. Comm problems involv both transmission and reception (as in communication theory)
Deconstruction of comm
-what is the specific process?
-when it starts and finishes?
-which are the comm steps?
- where are possible flaws?
-how to improve it and make it safe?
-Com failures in OR:observation classf recurrent types and effects
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1743897/pdf/v013p00330.pdf
-occasion fail-situation or context of comm-wrong moment
-content fail-lack or inaccuracy of info
-purpose-why the comm happenrd if nothing was done?purpose is unclear
-audience fail-gaps in composition of group engaged in the comm
-eval of preop checklist 2008 Lingard
Improved results of communication?
How to improve: Briefing?Checklist? Debriefing? Three diff tactics
-2/3 of com failure did not cause Immediate result-but encourages migration from a safety zone to a dangerous zone in which BAD results are very probable
Model-trapezium at the circus - four points to close the loop safelly(both hands of two artists)
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