Patient Safety Tip of the Week

July 21, 2015    Avoiding Distractions in the OR



We’ve discussed in detail the problem of distractions and interruptions in the OR in our Patient Safety Tips of the Week for May 21, 2013 “Perioperative Distractions” and March 17, 2015 “Distractions in the OR”.


We thought we covered the most important aspects of distractions in the OR and perioperative environment in those previous columns. But Renae Battié, president of AORN, just offered some very practical recommendations for avoiding perioperative distractions in her President’s Message in the July issue of the AORN Journal (Battié 2015).


Battié reiterates three very important elements in maintaining a culture of safety: (1) discussing daily activities with all her staff, (2) recognizing normalization of deviance and (3) recognizing that many of the distractions are created by our own well-intended actions.


We’ve discussed “normalization of deviance” in several of our columns, most recently in our July 14, 2015 Patient Safety Tip of the Week “NPSF’s RCA2 Guidelines”. This is where the culture of the system has led to acceptance of a certain deviation from proper practice as being “normal” and allowed that deviation to be performed by many individuals. The deviation has been used so frequently without serious adverse consequences occurring that staff no longer consider it abnormal. Battié uses the analogy in which we all add a few MPH above the speed limit when driving because we’ve never gotten a speeding citation or had an accident.


Discussions with her staff serve multiple purposes regarding patient and staff safety. They reinforce that “most of what happens every day truly is high risk” and thus demands engagement in every step. But they also bring to light circumstances and actions that may reveal underlying safety vulnerabilities.


Some examples she gives of staff-created distractions are actions such as checking in on coworkers and asking “Do you need a break? or “Do you need any help?”. Such actions both cause unnecessary opening of OR doors (which may, for example, impact infection rates) or lead to distractions that interrupt important activities. Outside the OR these may result in interruptions during other critical activities such as preoperative assessments or medication administration.


Another common cause of distractions and interruptions is related to technology. She notes that her facilities use wireless hands-free communication devices. But sometimes a communication may go to more than just the staff who need to see that particular communication. It is important to recognize whether those alerts or requests for help should go to everyone or just a few key staff.


Battié discusses some techniques that may be useful in minimizing distractions and interruptions. She notes her facility uses red mats in medication dispensing units to signify “no interruption zone”. Her surgical scheduling unit has devised hand signals to signify when they want quiet or when they want assistance.


Here are some of her other recommendations:


Our Patient Safety Tips of the Week May 21, 2013 “Perioperative Distractions” and March 17, 2015 “Distractions in the OR” had detailed discussion about use of cell phones and other wireless devices in and around the OR with multiple examples of distractions related to such in the OR. There are a multitude of issues related to cell phones in the OR including not only interruptions and distractions but also infection control issues, security and confidentiality issues, and detrimental effects on communication in the OR. Our recommendation is for all the OR team to leave their cellphones at the main OR desk where someone can triage incoming phone calls and messages.


You’ll, of course, get the argument “I use my cellphone to access important information pertinent to the case” (like drug information, guidelines, images, reports, etc.). But most of that information can be obtained from devices that do not also send instant messages, texts and phone calls. And if the surgeon really wants to see an imaging study you want him or her looking at it on a large computer screen rather than a small smartphone screen.


Indeed there are legitimate advantages of advanced technology in the OR. The American Association of Nurse Anesthetists recently updated its position paper on use of mobile technology in the perioperative environment and nicely discusses both the pros and cons of such use, along with excellent references (AANA 2015).


Several articles in the lay press (Richtel 2011, Luthra 2015, Hawryluk 2015) have highlighted high profile cases in which distractions occurred in the OR due to personal use of smartphones. The Hawryluk article discussed in detail the issue of distractions from smartphones in the OR, highlighting some of the work by anesthesiologist Dr. Peter Papadakos (Papadakos 2011) that we discussed in our May 21, 2013 Patient Safety Tip of the Week “Perioperative Distractions”.


The logical comparison of cell phone use in the OR is texting while driving. We fully anticipate that subpoenaing cell phone records after OR incidents may become as common as it is done after vehicular accidents (automobile, airplane, railroad, etc.). Members of the Committee on Electronic Media and Information Technology of the American Society of Anesthesiologists recently addressed the issue (Klumpner 2015). To quote Klumpner and colleagues Anything You Say or Do (Electronically) May Be Used Against You …”. They note that traces of internet browsing, texts, Facebook posts, etc. can be found long after you’d think they would be gone and that deleting such may also be illegal or a criminal activity.


Our multiple columns on interruptions and distractions are listed below but we think you’ll find our Patient Safety Tips of the Week for May 21, 2013 “Perioperative Distractions” and March 17, 2015 Patient Safety Tip of the Week “Distractions in the OR” especially helpful.




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


See our prior columns on huddles, briefings, and debriefings:








Battié RN. Thriving in the Midst of Distractions. AORN Journal 2015; 102(1): 1-3



American Association of Nurse Anesthetists (AANA). Mobile Information Technology (Position Statement). Updated 2015.



Richtel M. As doctors use more devices, potential for distraction grows. New York Times. December 14, 2011



Luthra S. Do Cell Phones Belong in the Operating Room? Kaiser Health News 2015; July 14, 2015



Hawryluk M. Is your surgeon focused on you or his smartphone? The Bulletin (Bend, OR) 2015; Published Feb 1, 2015, Updated Feb 2, 2015



Papadakos PJ. Electronic Distraction: An Unmeasured Variable in Modern Medicine. Anesthesiology News 2011; 37:11 November 2011



Klumpner TT, Biggs DA, Gottlieb O. Technology: An Uninvited Guest in the O.R.? (American Society of Anesthesiologists Article). ASA Newsletter 2015; 79(4) April 1, 2015






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