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:
- Don’t initiate activities
other than your own responsibilities without knowing if help is needed (eg. starting to open up supplies might be distracting
to others).
- Each perioperative team
should have regular discussions about strategies to minimize interruptions
and distractions. (We recommend that also be part of each post-op
debriefing section as noted in our multiple columns on briefings and
debriefings listed below).
- Each facility or
organization must implement a policy for using communication devices (cell
phones, pagers, etc.) and routinely assess compliance with that policy. Battié notes that such devices are muted during key times such as
briefings and counting activities in her facilities.
- Devise hand signals or
other means of telling other staff they are in the midst of handoff
activities and cannot be interrupted.
- Make sure staff know how
to find instruments without interrupting other staff unnecessarily. For
example, OR staff should know how to use the instrument tracking system
rather than always calling the sterile processing department to look it
up.
- Facilities should have
music policies that clarify not only how loud music may be but also when
it is appropriate and when it is inappropriate.
- Avoid clustering around the
unit desk in the OR or postanesthesia
care unit for chit-chats and devise signals that may be used to get staff
to move to the lounge for such social conversations.
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:
- August
25, 2009 “Interruptions,
Distractions, Inattention…Oops!”
- November
3, 2009 “Medication
Safety: Frontline to the Rescue Again!”
- December
15, 2009 “The
Weekend Effect”
- May 4,
2010 “More
on the Impact of Interruptions”
- October 12, 2010 “Slowing
Down in the OR”
- March
8, 2011 “Yes,
Physicians Get Interrupted Too!”
- July 31, 2012 “Surgical
Case Duration and Miscommunications”
- August 28, 2012 “New
Care Model Copes with Interruptions Better”
- November 27, 2012 “Dealing
with Distractions”
- April 16, 2013 “Distracted
While Texting”
- May 21, 2013 “Perioperative
Distractions”
- July 1, 2014 “Interruptions
and Radiologists”
- November 2014 “More
Radiologist Interruptions”
- March 17, 2015 “Distractions
in the OR”
See our prior columns on huddles, briefings,
and debriefings:
- April 9, 2007 “Make
Your Surgical Timeouts More Useful”
- May 22, 2007 “More
on TeamSTEPPS™”
- December 9, 2008 “Huddles
in Healthcare”
- March 10, 2009 “Prolonged
Surgical Duration and Time Awareness”
- January 11, 2011 “NPSA
(UK) ‘How to Guide’: Five Steps to Safer Surgery”
- March 2009 “Surgical
Team Training”
- April 2012 “Operating
Room Briefings and Debriefings”
- July 31, 2012 “Surgical
Case Duration and Miscommunications”
- January 2014 “A
Tool to Assess Pre-op Briefings”
- July 22, 2014 “More
on Operating Room Briefings and Debriefings”
- March 17, 2015 “Distractions
in the OR”
References:
Battié RN. Thriving in the Midst
of Distractions. AORN Journal 2015; 102(1): 1-3
http://www.aornjournal.org/article/S0001-2092%2815%2900489-5/fulltext
American Association of Nurse Anesthetists (AANA). Mobile
Information Technology (Position
Statement). Updated 2015.
http://www.aana.com/resources2/professionalpractice/Pages/Mobile-Information-Technology.aspx
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
http://khn.org/news/do-cell-phones-belong-in-the-operating-room/
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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