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There are a number of tools available to improve communication in operating theatres. Following the Commission's proof of concept project the following communication tools were identified to roll out to DHBs.


A call-out is when someone vocalises or shouts out an important piece of information. These are most often used during emergency situations but can be useful in non-emergency situations too.

Information that all team members need to know or will be critical for subsequent actions are good topics for call-outs during theatre team briefings and the surgical safety checklist.

Closed-loop communication

When we communicate with others, we cannot be sure that they have heard us as intended unless they tell us what they heard.[1] This is the concept behind closed-loop communication. Closed-loop communication ensures the sender of information knows that the receiver of their information has heard and understood their instructions.

Misinterpreted communication has the potential to lead to adverse events. As such, it is always important to ensure a message/instruction has been transferred as intended. Repeating back instructions right away to clarify what has been said means the receiver knows they got the correct message.

Closed-loop communication is an important tool that can be applied to theatre team briefings, the checklist and debriefings.


Identify – Situation – Background – Assessment – Recommendation

ISBAR is a framework for communicating information in a clear, contextualised and collaborative way. When adopted by all members of the surgical team, patient information is more easily and clearly conveyed, with minimised risk of misinterpretation. ISBAR can be used in-person or over the phone, in hand-offs between units, and at shift changes.[2]

In particular, ISBAR is useful during theatre team briefings, completing the checklist and debriefings.  Each of these interventions requires patient information to be shared between team members in a collaborative way. Using ISBAR  will help ensure team members are operating with the same level of understanding and within the same context. Importantly, this tool allows staff to communicate assertively and effectively, reducing the need for repetition.[3]

Two challenge rule

It is human nature to say something only once, and also to often not listen to something the first time.[4] The two challenge rule supports the speaker to raise their concerns twice if they are not addressed the first time.

This rule highlights the responsibility of the listener to respond to the speaker, at least the second time the speaker asserts their concern. If the listener continues to be unresponsive, the two challenge rule empowers the concerned speaker to act and raise their concern to someone with the ability to effectively address the situation.[5]


  1. BC Patient Safety & Quality Council. 2013. Culture change toolboxURL: (accessed 30 June 2015).
  2. Ibid.
  3. NHS Institute for Innovation and Improvement. 2010. The Handbook of Quality and Service Improvement Tools. 
  4. BC Patient Safety & Quality Council. op. cit. 
  5. BC Patient Safety & Quality Council. op. cit. 
Last updated: 8th December 2021