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Patient Safety Tip of the Week

January 11, 2022

Documenting Distractions in the OR



We’ve done numerous columns on the occurrence and impact of distractions in the OR and other healthcare venues (see the full list below). And we’ve also done a number of columns on the use of video recording in the OR as a mechanism to identify various patient safety risks, among which distractions play a prominent role.


A recent pilot study used Operating Room Black Box (ORBB) technology to observe 25 patients undergoing total laparoscopic hysterectomy between May 2019 and February 2020 at a Canadian tertiary care academic hospital (Nensi 2021). 


“Cognitive” distractions included time pressure and device absence or malfunction, each in 48% of the cases, and non-case-related conversations in 64% of cases. But perhaps the most striking finding was a median of 262 “auditory” distractions per case. “Auditory” distractions included :


Put in perspective, door opening occurred once every 1.8 minutes and a noise-related auditory distraction occurred on average once every 60 seconds.


Overall, there was a median of 3 safety threats identified per case and at least one error was identified in 11/25 cases (44%), even though only 2 actual adverse events occurred. A total of 23 errors were noted, with at least one error was identified in 11 (44%) cases. The majority of errors were related to unexpected bleeding, either during the ligation of the uterine arteries or during the colpotomy. All of these instances were rectified with no resultant adverse events. Only two intraoperative adverse events were noted among the 25 cases (both instances were injuries to the bladder with a sharp instrument secondary to inadequate visualization). But there was a median of 3 threats identified per case, with inadequate visualization noted 34 times in 18 different cases, loss of pneumoperitoneum identified nine times in nine different cases, tool failure identified 18 times in 12 cases, and technical threats (i.e., risk of injury or adverse event due to actions of the surgeon) identified 14 times in 12 cases.


The researchers also observed non-technical skills for surgeons, nurses, and anesthetists.  The vast majority of observations for all three groups were positive. The most positive observations were for situational awareness and leadership among the surgical team and communication and teamwork among the nursing/scrub technician and anesthesia teams. The most common negative observation for the surgical team was in setting/providing and maintaining standards, and all 13 negative observations were related to a lack of maintaining sterile technique. There were no negative observations noted for the nursing/scrub technician or anesthesia teams.


The researchers were also able to determine valuable details about total procedure duration and duration of each procedure step from the ORBB. The authors note that these details allow for the identification of steps that have the potential to cause the most time delay.


We are struck by the number of door openings per case (median 89 per case, averaging once every 1.8 minutes). We’ve actually done multiple columns on door opening in the OR (see full list below). While our focus has mostly been on the impact of door opening and OR foot traffic on infection control issues, the distractions caused by such can obviously also impact team performance during surgery. Our prior columns discuss ways to reduce unnecessary door opening and OR foot traffic. But most facilities have no idea how often such events occur or why they occur. The only way to begin addressing that issue is to collect actual data on the frequency of and reasons for such door opening. Use of video and audio recordings such as those in the ORBB setup is a good way to capture at least some of that data. It may not always capture the reasons for the door opening, so you may need an additional way to capture the reasons. If you find staff are opening the door to obtain additional equipment or supplies, that becomes an important part of planning either for individual cases or for stocking frequently needed items in the OR itself.


One way to reduce distractions due to absent or malfunctioning equipment is to make better use of both pre-op “huddles” and post-op debriefings. The pre-op huddles help ensure that necessary equipment will be available for the case. Post-op debriefings should discuss, among other things, problems that occurred with a particular piece of equipment. We continue to see instances where an instrument or piece of equipment did not function properly, only to hear that it had also malfunctioned during a prior case.


Conversations not related to the case are more difficult to eliminate. However, simply making staff aware of how often they are participating in such conversations might have an impact. Bergstrom et al. (Bergström 2018) found that audio-video recording during laparoscopic surgery in a Swedish study reduced irrelevant conversations in the OR. Irrelevant conversation time fell from 4.2% of surgical time to 1.4% when both audio and video recordings were made.


Cellphones in the OR have been a frequent cause of distractions. It’s not just cellphones ringing with incoming calls. More often, it is the alert that sounds when a text message is received on the phone. And it is not just the sound that is a distraction. The surgeon (or other healthcare worker) receiving that text message is often distracted by concerns about what the content of the text message might be. Our February 23, 2021 Patient Safety Tip of the Week “Cellphones and the OR” discusses the pros and cons of allowing cellphones in the OR. Our personal recommendation is not to allow cellphones in the OR. They can either be “parked” with OR clerical or management staff, or the healthcare workers simply need to ensure that paging systems know they are in the OR and deliver any absolutely necessary messages via the OR clerical staff. At any rate, every facility should have a policy on cellphone use in the OR.


Our March 17, 2020 Patient Safety Tip of the Week “Video Recording in the OR” highlighted how Northwell Health used video/audio recording to help improve OR teamwork and communication (Cheney 2020). They use it proactively to improve coordination in the OR. They have used it to identify distractions and interruptions and, especially, people entering and leaving the room. But it’s also used in their quality improvement and educational activities. Interestingly, Northwell has also used it to cover some of the aspects we discuss during post-procedure “debriefings”. For example, they might identify issues related to equipment availability or other problems with equipment or supplies.


One major impediment to more widespread use of video recording in the OR or elsewhere has been the fear that some surgeons and hospital attorneys have about “discoverability”. Northwell Health made it clear that the recordings were being used to improve quality and safety, but it did more to alleviate those concerns. First, everything is de-identified. The cameras even blur the faces of the OR team! And second, the focus is to look at system issues, not individual human issues. They also note that de-identifying the data also protects patient privacy.


In our March 17, 2015 Patient Safety Tip of the Week “Distractions in the OR” we recommended video/audio recording in the OR with subsequent playback for all parties in a constructive fashion so they can see how well (or not so well) they communicated and how distractions and interruptions interfered with their communications. Jung et al. reported their first-year analysis of the operating room black box study (Jung 2020). They conducted a prospective cohort study in 132 consecutive patients undergoing elective laparoscopic general surgery at an academic hospital during the first year after the definite implementation of a multiport data capture system called the OR Black Box to identify intraoperative errors, events, and distractions. They found that auditory distractions occurred a median of 138 times per case and that at least 1 cognitive distraction appeared in 64% of cases. Medians of 20 errors and 8 events were identified per case. Both errors and events occurred often in dissection and reconstruction phases of operation. Technical skills of residents were lower than those of the attending surgeon.


We’ve often recommended doing video/audio recording in the OR and then play it back for all parties in a constructive fashion so they can see how well (or not so well) they communicated and how distractions or interruptions interfered with their communications. Teodor Grantcharov, MD, creator of surgery's 'black box' and senior author on the Jung study, noted in an interview that they’ve shown that coaching surgical teams with black box data reduces the rate of surgical errors by 50%. (Grantcharov 2019). He notes that the black box captures video and audio recordings of everything that happens in the OR, including what steps were completed, how well the team communicated, and includes physiological information from patient monitors and the physical environment of the room, including ambient temperature, decibel levels and how many times the door is opened. He notes that it's designed to identify near misses, understand the risks involved and proactively mitigate those risks. But he notes this isn't just about targeting errors and near-misses. They use the data to study successes in great detail, so they can identify and reinforce positive behaviors. They use the information to coach surgical teams on ways to improve their performances, using the analogy of how sports teams study videos and stats to enhance how they play.


Video/audio recording in the OR is a good way to identify potential distractions and interruptions. But it clearly also provides a lot of information that can be used constructively to improve a variety of OR issues. We remained puzzled that more organizations have not adopted its use.



Prior Patient Safety Tips of the Week dealing with interruptions and distractions:


·       January 28, 2020         Dang Those Cell Phones!

·       September 2020          AORN on Distractions and Interruptions

·       February 23, 2021       Cellphones and the OR

·       November 2021          New Risk Factor for Patient Safety Events: Motor Vehicle Accidents


Our prior columns focusing on surgical OR foot traffic and door opening:


·       April 23, 2019             In and Out the Door and Other OR Flow Disruptions

·       June 8, 2021                Cut OR Traffic to Cut Surgical Site Infections


Some of our previous columns discussing video recording:


September 23, 2008 “Checklists and Wrong Site Surgery

December 6, 2010 “More Tips to Prevent Wrong-Site Surgery

November 2011 “Restricted Housestaff Work Hours and Patient Handoffs

March 2012 “Smile...You’re on Candid Camera!

August 27, 2013 “Lessons on Wrong-Site Surgery

March 17, 2015 “Distractions in the OR

November 24, 2015 “Door Opening and Foot Traffic in the OR

March 2019 “Another Use for Video Recording

March 17, 2020 “Video Recording in the OR







Nensi A, Palter V, Reed C, et al. Utilizing the Operating Room Black Box to Characterize Intraoperative Delays, Distractions, and Threats in the Gynecology Operating Room: A Pilot Study. Cureus 2021; 13(7): e16218



Bergström, H., Larsson, L. & Stenberg, E. Audio-video recording during laparoscopic surgery reduces irrelevant conversation between surgeons: a cohort study. BMC Surg 2018; 18: 92



Cheney C. Northwell Pioneers Black Boxes in Operating Rooms for Performance Improvement. HealthLeaders Media 2020; February 26, 2020



Jung JJ, Jüni P, Lebovic G, GrantcharovT. First-year Analysis of the Operating Room Black Box Study. Annals of Surgery 2020; 271(1): 122-127



Grantcharov T. Real-time OR Monitoring Leads to Better, Safer Surgery. QA with Teodor Grantcharov, MD, PhD, FACS, creator of surgery's 'black box' and believer that data doesn't lie. Outpatient Surgery Magazine 2019; April 3, 2019






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