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Patient safety

Patient Safety

Fewer mistakes are made when communication is enhanced.


Staff are clearly able to identify their co-workers which increases their confidence.

1. Surgical errors: miscommunication between surgical team members can lead to surgical errors such as wrong-site surgery, wrong-patient surgery, or the wrong procedure. These errors can have serious consequences for patients, including the need for additional surgeries, prolonged recovery times, and even permanent injury or death.

2. Delayed or inadequate responses to changes in patients' condition: miscommunication among the surgical team can result in delayed or inadequate responses to changes in the patient's condition during surgery. For example, failure to communicate vital signs or concerns about the patient's well-being can lead to delays in necessary interventions, potentially resulting in harm to the patient.  Some staff in operating theatres do not know the names of the people they are working with, so this can delay the communication amongst the team.


Reducing patient’s anxiety. To see a name is very reassuring to the patient.

3. Team coordination issues: miscommunication can lead to coordination problems among surgical team members, potentially causing inefficiencies, misunderstandings or conflicts that can compromise the overall quality of patient care and surgical outcomes. Hierarchical barriers are one of the many reasons for these inefficiencies and having names and roles on theatre hats has been proven to break these barriers down and allow staff members to speak up about their concerns.


Staff & patients feel reassured because human factors are enhanced when names and roles are clearly visible.

Medical errors

“Medical errors in hospitals are the third leading cause of death in the United States, just behind heart disease and cancer. Globally it is believed that medical errors kill more people than HIV, Malaria, and Tuberculosis, combined”.  (Patient safety network, 2020).

Miscommunication in operating theatres can lead to a variety of adverse events, some of which may have serious consequences for patients. Here are some examples of adverse events that can result from miscommunication in operating theatres:

Many Healthcare organisations have noticed the enormous results in improving communication and teamwork within operating theatres through strategies such as implementing easy to read named theatre hats. 

Incidences of misidentification

​A consultant paediatric surgeon believing his assistant to be a surgical fellow asked a leading question – ‘You’re okay to finish this operation aren’t you’. Perhaps assuming that he was supposed to be the medical student completing the case. The medical student was later reprimanded for not speaking up.

A gynaecologist made a hole in the patient’s bowel, so the colorectal surgeon was called. On arrival they were asked to scrub in. After spending 15 minutes trying to find the hole the gynaecologist asked his colleague what they should do to which his colleague replied, ‘I’m not sure – you do realise I’m a medical student’.

An anaesthetist believed that a staff member (who was a porter) was a qualified nurse in checking blood, allowed blood to be given. Unfortunately, due to the staff member being a theatre porter and not trained in checking blood products, the wrong blood was given, and the patient died. Staff misidentification was felt to be a major contributory factor.

  • As a nurse practitioner working with female obstetrics-gynaecology residents, I hear complaints about mistaken identity all the time. (see here)

  • As a junior hospital doctor, it was an almost daily occurrence that patients would mistake me for a nurse, student, or anything other than a doctor. (see here)

  • Unfortunately, I have heard countless stories of them (doctors) being mistaken for transport staff, technicians, and cooks. (see here)

Royal Liverpool feedback on implementing their named theatre hats:

Surgeon with reusable embroidered hat by Eco Ninjas
Surgeons with reusable embroidered hat by Eco Ninjas
  • “The theatre environment is a complex one where we interact with different team members all the time, all of whom work towards one goal: “Patient safety and the provision of safe patient care”.


  • “The use of reusable named theatre caps with roles on, enables better communication to provide this and since our Anaesthetists have been wearing their own caps, they have noticed an improvement in this”.

  • “Patients also know who they are interacting with, which allays their anxiety and improves their experience. There is better team engagement, and it allows team members to work together, which will improve even more once we get the fabric name and role hats across the board”.


  • “The biggest difference I noticed was on Monday when people addressed me by my name a lot more than usual”.

  • “The team huddle is all well and good in the morning, but I don’t remember everyone’s names and if we had named caps for everyone that would be great”.

  • “It’s a good idea and helps to identify who is who”.

  • “Double thumbs up, comfortable and environmentally friendly and in scenarios where we may be working with different teams i.e., in resus, on arrests on the ward etc, it improves communication”.

  • “They are definitely a good thing; we immediately know who is who”.

  • “They look smart as part of our uniform on top of our otherwise casual suit. The caps create a feeling of a unified workforce, representing the roles within the department.

  • ​“It enables clear communication, especially in emergencies where timing is key to communicate with specific individuals and calling by name is important”.

Over the years, there have been many adverse events caused by miscommunication in operating theatres around the world and here in the UK – many of which do not get reported!! 


“There is growing evidence that communication failures among team members are a common cause of medical errors and adverse events. The Joint Commission reported that in the United States communication was a root cause of nearly 70% of the thousands of adverse events reported to the organization between 1995 and 2005”.

Joint Commission. Sentinel event statistics. Dec 31, 2006. [5 May 2007]

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