Labeled surgical caps improve perioperative patient safety and interprofessional communication in the operating room: a scoping review

Abstract

Background

Effective communication is critical for patient safety and surgical outcomes inside the operating room (OR). Labeled surgical caps have been proposed as a strategy to improve intraoperative communication and teamwork by facilitating name and role recognition among surgical staff. However, concerns regarding potential surgical site infections (SSIs) have limited their widespread adoption and to this day hindered their use across Europe.

Methods

The MEDLINE/PubMed database was searched for peer-reviewed articles reporting on the use of labeled surgical caps and at least one outcome of interest (communication, teamwork, surgical site infections, costs, or environmental impact) from database inception to April 2025. Findings were synthesized qualitatively.

Results

Reusable labeled surgical caps improve interdisciplinary communication and name recognition in the operating room, thereby promoting effective teamwork. This effect is particularly relevant in robotic surgery, where the primary surgeon operates from a remote console. Current evidence does not indicate an increased risk of SSIs, with multiple studies reporting no significant difference in infection rates between reusable and disposable surgical headwear.

Conclusions

Reusable, labeled surgical caps should be implemented across the globe to improve communication and ultimately patient safety. They align with green hospital goals by reducing waste and long-term costs. Additionally, they also provide opportunity for stronger identification with the institution. Current regulations restricting their use are not supported by existing evidence and should be re-evaluated. Prospective studies also from European clinical settings may help to establish future policy updates and to further evaluate the microbiological safety of reusable surgical caps.

Background

Effective communication is crucial for best possible teamwork in the operating room (OR) and plays a major role for performance, outcomes and safety in health care [1–3]. Surgical personnel typically wear standardized attire, including masks, hats and surgical gowns, hindering identification and limiting opportunities for personal expression [4]. Additionally, frequent staff rotations and shift changes at major institutions can lead to further anonymity inside the OR and consequently to even worse interpersonal dynamics [5]. Consequently, names and roles are often forgotten, leading to generic references such as “anesthesia” for anesthesiologists and “nurse” for rotating nurses, instead of their respective names [6]. These significant communication barriers increase the risk of miscommunication, which may contribute to medical errors with potentially severe consequences for patient safety [2]. Moreover, they negatively impact teamwork and overall job satisfaction, as staff may feel unrecognized both as team members and as individuals [7].

Therefore, labeled surgical caps have recently been introduced and rapidly adopted across the United States to improve intraoperative communication and teamwork [5, 7–9]. Labeled surgical caps are reusable or disposable caps on which the wearer’s name and role are clearly displayed on the outside of the cap (Fig. 1). However, concerns regarding infection control and regulatory compliance have halted their broad adoption in Europe, where guidelines explicitly state that surgical textiles may only be laundered by certified facilities meeting hygiene standards for infection prevention (EN 14065) [10, 11]. Consequently, the goal of this review is to explore the feasibility, effectiveness, and safety of labeled surgical caps in the operating room, with the overarching aim of supporting their evidence-based implementation in clinical practice.

Fig. 1.

Preliminary project prototype and end result

Methods

A literature review was conducted to summarize current evidence on the use of labeled surgical caps in the operating room, focusing on their impact on communication, collaboration, infection control, and cost-effectiveness. The MEDLINE/PubMed database was searched from database inception to April 2025 using combined MeSH and free-text terms; the database was last accessed in April 2025. The core search string was: (“Operating Rooms”[MeSH] OR “operating room*” OR “surgical theatre*”) AND (“Head Protective Devices”[MeSH] OR cap* OR “scrub hat*” OR headwear OR headgear) AND (label* OR name* OR identification OR “team communication” OR teamwork). In addition, we performed targeted searches using the free-text terms “labeled surgical caps”, “labelled surgical caps”, “scrub hats names”, and “operating room communication”. No restrictions were placed on publication year or journal impact factor. The search was limited to articles published in English and conducted in humans. All titles and abstracts collected from the initial search were systematically scanned for relevance. The full texts of all relevant articles were then obtained and reviewed for suitability. Additional relevant studies were identified by secondary screening of the references cited in the selected articles. Original scientific articles were included if they reported on labeled surgical caps or other forms of displaying team members’ names and/or roles in the perioperative setting; and at least one predefined outcome of interest, such as communication, teamwork, speaking-up behavior, surgical site infections, microbiological contamination, costs, or environmental impact. Studies not related to labeled caps or lacking relevant outcomes were excluded. Data from selected studies were qualitatively synthesized to highlight key findings, trends, and existing gaps in the literature. Due to the narrative nature of this review, no formal quality assessment or meta-analysis was performed.

Results

Communication errors impact surgical outcomes and patient safety

Effective communication is a critical determinant of patient safety and surgical outcomes [12]. Notably, hearing one’s name is a powerful activator of human attention and cognitive engagement [13]. In recognition, the preoperative surgical safety checklist, also known as team time-out, has been implemented across the globe, with a brief introduction of names and roles of surgical team members to enhance team coordination and reduce errors [14]. However, remembering names is inherently challenging, particularly as the surgical team time-out is often conducted in a distracting environment and under time constraints [15, 16]. At the same time, the surgical team (nurses, anesthesia, etc.) rotate in longer surgeries. To quantify the impact of communication errors, Hu et al. video-recorded six surgeries at a total of 22 h and observed communication errors at an alarming rate of one every 7–8 min, frequently leading to inefficiencies in surgical workflow [17]. Notably, communication errors were nearly twice as frequent between different disciplines (e.g. between a surgeon and a nurse), compared to intra-disciplinary communication (e.g. between two surgeons) [17]. Similarly, Bodor et al. demonstrated that nearly all surgeons were unable to accurately name lower-level anesthesia trainees, with misidentification of names and roles being particularly common across disciplines [6]. This challenge is further provoked by the fact that surgical teams often remain consistent, while perioperative personnel rotate more frequently through long procedures. These findings are further supported by Birnbach et al., who noted that most OR personnel failed to recall the names of their team members by the end of the surgical procedure, despite participating in a preoperative surgical team time-out [18]. Such evidence suggests that substantial communication weaknesses are largely driven by unfamiliarity and a lack of team integration, especially due to insufficient knowledge of colleague’s names and roles [17, 19]. Interestingly, name tags are widely used across various professional settings and are effective for rapid visualization of a person’s name and role. However, traditional name tags are often hidden beneath sterile gowns. As such, they fail to support communication in the OR.

Labeled surgical caps improve communication and teamwork

In a pilot study conducted at Stanford, Brodzinsky et al. examined 20 cesarean deliveries, randomly assigning surgical teams to either labeled or non-labeled surgical caps. Albeit not statistically significant, the introduction of labeled caps was associated with more frequent name use (p = 0.208) and a reduction in missed communication events (p = 0.614), defined as requests that were ignored or were repeated before being completed [7]. Moreover, missed communications were three times more likely to be corrected by use of the recipient’s name in teams wearing labeled surgical caps [7]. Similarly, Dougherty et al. and Douglas et al. reported a significant increase in OR staff knowledge of the team member names after displaying their name and role on their surgical cap [8, 20]. Finally, in a large-scaled quality improvement study with almost 1’000 participants, Wong et al. uncovered that the odds of being called by the correct name increased more than 13-fold after 6 months of implementing labeled surgical caps. Additionally, role recognition, teamwork and connection with teammates significantly improved after implementation [5]. Together, these findings indicate that visible names and roles make it easier to address colleagues directly, increase the use of names during critical exchanges, and reduce ambiguity about responsibilities, particularly in large or frequently rotating teams. Moreover, several academic institutions have deliberately chosen to display first names without academic titles on the caps to lower hierarchical barriers and to encourage junior team members to speak up when they notice a problem [9, 21]. In summary, introducing labeled surgical caps (such as in Fig. 1) may improve effective communication in the perioperative setting by strengthening name and role visibility and thereby reinforcing team integration and collaboration. The potential benefit of labeled headwear may be particularly noteworthy in robotic surgery. When the primary surgeon is seated at the console, they are physically separated from the sterile field and have a restricted view of the OR. Consequently, clearly visible names and roles on scrub hats provide an immediate visual anchor for all team members, enabling the staff to address each other directly by name without interrupting the procedure.

Impact on surgical site infection risk

Surgical site infections (SSIs) are significant complications associated with increased patient morbidity, hospital stay, and costs [22, 23]. Approximately 70% to 95% of SSIs are caused by the patient’s own endogenous flora [24, 25]. Therefore, only a minority are caused by external (e.g. team members) bacteria. Nevertheless, correct protection is very important for preventing SSIs, with bacterial shedding of team members being the primary concern of correct sterility [22, 23]. Adequate hair covering is important to mitigate this risk, as hair can easily fall into the surgical field. The use of correct surgical attire has been a topic of hot discussion ever since the Association of Perioperative Registered Nurses (AORN) recommended complete hair coverage with bouffant caps, instead of surgical caps, to prevent surgical site infections [26, 27]. Regarding the form of hair coverage (surgical versus bouffant cap), Shallwani et al. analyzed over 15’000 surgical cases over a 26-month period and found not a decrease, but rather a slight increase in the overall infection rate after the mandatory use of bouffant caps, challenging the rationale behind the policy change and suggesting that the choice of headwear does not significantly influence SSI rates [28]. Similarly, Farach et al. found an increase in SSI rates after strict implementation of bouffant caps [29]. Various other studies also found no association between choice of surgical headwear and the incidence of postoperative SSIs [30–32]. Finally, Wills et al. analyzed 34’042 surgeries over a 22-month period and found no significant difference in the risk of SSI, mortality, postoperative sepsis, or wound dehiscence, indicating that bouffant hats are neither beneficial nor cost-effective in preventing SSIs [33]. In summary, the form of hair coverage does not influence SSI rates.

As hospitals commonly offer various different hair coverage possibilities, quantitatively assessing the influence of scrub hat material on SSI rates remains challenging. Markel et al. performed mock surgeries to compare contamination rates between disposable headwear versus newly laundered cloth skull caps and, unexpectedly, found greater permeability, particulate contamination and passive microbial shed in the disposable headwear [34]. These findings suggest that both disposable and reusable surgical headwear can safely be used in the OR, provided that laundering is regularly and correctly performed. Following this recent evidence, the AORN withdrew their original statement and now, in their most recent publication, stated that “there are many kinds of head coverings that can be worn in the perioperative environment, including bouffant caps and skull caps, which can either be reusable or disposable.” [35, 36].

Nevertheless, the European Standard (EN 14065:2016) requires reusable surgical textiles from the healthcare sector to only be reprocessed by laundries that guarantee an operating procedure that meets the requirements of infection prevention and control and that are hygienically tested and monitored accordingly [9, 37, 38]. This criterion must not only be met by surgical gowns and towels, but also by surgical caps worn by the operating room personnel. As reusable surgical caps may not be washed at home under current regulations, their implementation has largely stalled in European centers. Consequently, European hospitals have adopted a creative approach by attaching color-coded name tags to disposable surgical headgear, reporting improvements in communication and teamwork [9]. However, this method carries the potential for unsterile stickers falling into and thus contaminating the surgical field. Furthermore, this approach does not address key factors such as wearing comfort, consistent legibility (often compromised by handwriting quality) or institutional branding. Importantly, there is no robust evidence demonstrating higher infection rates associated with self-laundered surgical headwear. While a recent study found significantly higher total bacteria count on home-laundered scrubs than hospital-laundered scrubs, their research mostly analyzed uniforms, lab coats, and operating room scrubs, which are in greater contact with infectious pathogens than surgical caps [39]. In contrast, a systematic review postulated that scrubs can be laundered safely at home, provided wash temperatures between 60 °C and 69 °C are met [40].

Reusable caps lower costs and reduce environmental burden

The health care sector itself is responsible for almost 5% of total greenhouse gas emissions, with operating rooms being significantly more energy-intense than the hospital as a whole, primarily due to the use of anesthetic gases and high energy consumption [41, 42]. Consequently, experts have recommended rethinking how surgery is performed to reduce waste and resource consumption associated with health care. Notably, surgical attire is something we take for granted and thus change multiple times per day. However, Agarwal et al. demonstrated that reusable cloth surgical caps are easily adoptable solutions that may significantly reduce long-term greenhouse emissions [43]. Despite being more water intensive than single-use surgical caps, other studies confirmed that the use of reusable cotton caps may reduce CO₂ emissions by almost 80% [44]. Therefore, implementing reusable cotton caps over disposable caps may minimize the environmental footprint of surgical procedures and simultaneously have a positive socioeconomic impact [43, 44]. In our university hospital, 306’000 disposable surgical caps are used annually, resulting in a total expenditure of over 50’000 CHF (approx. 60’000 USD). To address this, we are initiating a hospital-wide implementation of custom-designed, color-coded reusable caps with a front-facing plastic window that allows for the insertion of name tags.

Conclusions

Current evidence suggests labeled surgical caps to be a safe, environmentally friendly and cost-effective alternative to improve communication in the perioperative setting by improving name and role recognition, as well as more frequent use of names. This change is consistently perceived as valuable by both staff and patients. Although the current European Standard (EN 14065:2016) poses barriers to widespread implementation, growing evidence on safety and economic sustainability in healthcare supports a re-evaluation of existing policies. However, further research is needed to determine the long-term safety of reusable caps under different laundering protocols and to quantify any potential impact on contamination and SSI risk. As the evidence base grows, adoption of labeled caps is likely to expand, particularly in minimally invasive and robotic surgery, where effective communication is essential for surgical success.

Abbreviations

AORN

Association of Perioperative Registered Nurses

OR

Operating room

SSI

Surgical site infection

Author contributions

The study was conceptualized by all authors. LPK and AF performed the primary literature search. AF wrote the original draft. Project administration and supervision was performed by EAK. All authors read, reviewed and approved the final manuscript.

Funding

Not applicable.

Data availability

Not applicable.

Declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.