Communication failure during operating room turnover: a HFACS-informed qualitative case study of system-level coordination
Xin Liao, Yan Zeng, Jun-Ying Zhou, Yu-Qing Song · 2026
Read Communication failure during operating room turnover: a HFACS-informed qualitative case study of system-level coordination by Xin Liao, Yan Zeng, Jun-Ying Zhou, Yu-Qing Song (2026) in the Tower of Babel, a free online library of public-domain works preserved in clean, searchable text. No sign-up. The full text is served as a plain-text file at a predictable URL, where text is present: https://antarctic-labs.com/tower-of-babel/PMC13576318.txt.
Description
Xin Liao and three colleagues examine a breakdown in staff talk during an operating room handover, in a 2026 case study from a large Chinese hospital. Turnover between operations demands fast, tight coordination across many roles, and breakdowns there feed surgical harm. Rather than blame individuals, the team read the incident through a human factors framework.
Interviews with five staff involved in turnover coordination produced six linked themes. Information got distorted in transit, no standard talk protocol existed, and professions worked in fragments. Wider problems included clashing hospital norms, staff skills mismatched to roles, and weak tech support. Together the themes showed system layers stacking pressure onto frontline talk. The authors argue fixes must target that system stack, not single speakers, to make surgical teamwork safer.
Catalog record
| CREATOR | Xin Liao, Yan Zeng, Jun-Ying Zhou, Yu-Qing Song |
|---|---|
| YEAR | 2026 |
| COLLECTION | PAPERS |
| FORMAT | TXT |
| FILE SIZE | 39012 |
| LICENSE | https://creativecommons.org/licenses/by/4.0 |
| RIGHTS | CC BY |
| SOURCE | Europe PMC |