Unlocking the Power of Closed-Loop Communication: An Essential Skill for Your Patients’ Safety
By: Jill Graham, BSN, RN
Published: 4/17/2025
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Many of our habits and techniques in patient care stem from one intent: to prevent harm to our patients. We count to prevent retained surgical items. We maintain sterility to prevent infection. We perform a time out to prevent wrong-site, wrong-side, and wrong-patient surgeries. We apply proper positioning to prevent unintended injuries. We implement a multitude of safeguards to avoid harm.
We diligently strive to keep our patients safe. But there is one tool that you likely do not utilize to its fullest potential to optimize your patients’ safety. You always have it with you, and it costs nothing to use, but you may not realize its importance.
It’s Your Words
The way in which we use our words significantly impacts our patients’ risks for sentinel events. When analyzing root causes in the Sentinel Event Data 2023 Annual Review, The Joint Commission identified communication failures as a leading cause of reported sentinel events.1
How you communicate with your team and patients is a safety issue. Period. This should reframe our perspective on conversations in the OR. Communication between all team members should be effective and appropriate during all cases.
Closed-loop communication is hands down the best tool for effective and appropriate communication. Closed-loop communication is a three-step process:
- The first speaker offers information or an instruction.
- The second team member listens and repeats back what was understood.
- The first communicator then repeats the information a final time to close the loop. This ensures that the message was received accurately.
This can seem a bit clunky and daunting (not to mention time consuming), but we can simplify it. By simplifying our communication to an “echo, ask, and inform” technique, we apply the closed-loop communication concepts to our everyday workflows without having to awkwardly insist that everyone in the room repeat all the commands given in a day. This approach will also engage coworkers who may not see the value in textbook closed-loop communication.
Echo and Ask
When we receive information or a request, we echo it back and ask for confirmation. Echoing back tells the giver of information what we understood the information to be. Adding the request for confirmation to the end of our sentence effectively gives an easy and convenient way for our teammate to close the loop.
The following is an example of using the “echo and ask” technique:
- Scrub person: “We used 10 mL of local.”
- Nurse: “You used 10 mL of 0.25% bupivacaine. Correct?”
- Scrub person: “Yes. Correct.”
Echoing and asking for confirmation will eliminate many misunderstandings. Always echo clearly. Like the nurse in the example above, be specific and don’t use ambiguous language. The nurse didn’t echo back “local” but rather echoed back the specific drug that was given at the beginning of the case. This eliminates wrong assumptions. This also allows for correction. If the amount had been 11 mL but the nurse echoed back 7 mL, the scrub person could correct the nurse easily. If the nurse only offered a generic “okay,” the scrub person could not discern that there was a misunderstanding, let alone help correct it.
Inform
It may be a bit awkward to make announcements to a room, but when we inform our team of completed tasks, we are again closing the loop and avoiding misunderstandings. There are a lot of moving pieces in a case, and we have to inform others about the tasks that can’t be immediately echoed and confirmed. It may seem a bit redundant, but we cannot rely on “what usually happens” to keep our patients safe. We inform our team so that corrections can be made if needed.
The following are examples of passing along helpful information succinctly:
- Nurse: “0.2 mg Methergine given IM.”
- Nurse: “Cautery is set to 40/40.”
- Nurse: “Your specimen has been sent to radiology. They will call the room when imaging is complete.”
Be sensitive to what is happening in the case. Don’t interrupt a tense situation. Wait for a natural break in the case unless it is truly emergent. Then state the information as simply as possible. We don’t usually need to include all the backstory in the moment; just give the information that is needed to keep moving forward.
These techniques are invaluable during cases with our team, but they also should be used with our patients. When a patient verbalizes a concern to you, echo it back and ask for confirmation. This will let them know that you hear them and value their concerns. Also, inform them. Many patients are medically illiterate and have no understanding of what happens in a surgical suite. While every detail isn’t helpful, some details can help them battle uncertainty and anxiety of the unknown.
The following is an example of echoing a patient’s concern and asking for confirmation:
Nurse: “You have pain in your right shoulder, but it isn’t aggravated if we keep that shoulder close to your side, correct?”
The following is an example of informing a patient to help alleviate uncertainty and anxiety:
Nurse: “It will seem very busy and a little chaotic when we get to the operating room. This is normal for this type of procedure. Your comfort is my priority, so please speak up with any questions you have.”
Conclusion
Perioperative nurses take pride in speaking up for our patients in their most vulnerable moments, but speaking up shouldn’t only occur when we have to advocate for them. Speaking up for our patients impacts our entire workflow when we ensure that the whole team is communicating effectively and appropriately through every case, every day, every task. We close the loop by echoing, asking, and informing. This is a communication habit to prevent harm. This is patient safety.
Reference
1. Sentinel Event Data 2023 Annual Review. The Joint Commission. https://www.jointcommission.org/-/media/tjc/documents/resources/patient-safety-topics/sentinel-event/2024/2024_sentinel-event-_annual-review_published-2024.pdf. Accessed October 10, 2024.
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