Patient Safety Tip of the Week
March 17, 2015
Distractions in the OR
Distractions and interruptions are frequent contributing factors to errors in all healthcare settings. In the OR they are especially prone to result in errors that impact patient outcomes. Even short interruptions, especially if they occur during critical parts of procedures or when novel or unexpected events have occurred, could profoundly increase the odds of errors and untoward patient outcomes.
We discussed many
aspects related to OR distractions and interruptions in our May 21, 2013
Patient Safety Tip of the Week “Perioperative
Distractions”. Interruptions increase the likelihood of errors
because we must refocus to resume where we had left off in our task prior to
the interruption. It turns out that even very brief interruptions can have a
marked impact on our ability to resume those tasks. Altmann and colleagues studied
the effect of short interruptions on performance of a task that required
participants to maintain their place in a sequence of
steps (Altmann
2013). Interruptions averaging just 2.8 s long doubled the rate of sequence
errors and interruptions averaging 4.4 s long tripled the rate of sequence
errors on post-interruption trials relative to baseline trials.
Another recent study has looked at distractions in the OR (Wheelock
2015). Not surprisingly,
distractions occurred in 98% of cases. They occurred at a rate of 10.94
distractions per case or one distraction every 10 minutes.
The most frequent
types of distraction were those initiated by external staff entering the
operating room. The researchers note that such distractions were unnecessary
in 81% of cases! While these researchers actually attributed less
significance to their major outcome variables (like teamwork, stress, etc.),
they do acknowledge the potential impact on surgical infection rates, which
they did not monitor. In several Patient Safety Tips of the Week (“HAI’s:
Looking in All the Wrong Places”, “Prolonged
Surgical Duration and Time Awareness”, “Operative
Duration and Infection”) we’ve noted the risk of infection increases each
time the OR door is opened and foot traffic in and out of the OR increases.
Wheelock and
colleagues also measured intensity of distractions. They found that the most
intense distractions were those that were equipment-related (eg. wrong or
missing equipment). Equipment-related distractions impacted all aspects
of teamwork and also stress levels for nurses. And such distractions occurred
about once every 90 minutes.
Distractions were
generally associated with a negative impact on teamwork. Irrelevant
conversations had negative influence on coordination and leadership scores
for surgeons and anesthesiologists. Such distractions tended to occur more
often during periods when workload was low.
Acoustic distractions were associated with higher stress levels for surgeons and higher
workload for anesthesiologists. While they did not find a big impact from
acoustic distractions, they did note the recent study demonstrating that
excessive noise in a pediatric OR was associated with greater levels of surgeon
stress and postoperative complications (Engelmann
2014). Also in our May 21, 2013
Patient Safety Tip of the Week “Perioperative
Distractions” we noted a study on how background noise in the OR
might interfere with surgical team communication (Way
2013). Those researchers found that the impact of noise is considerably
greater when the participant is tasked. Moreover, the performance was poorer
when the sentences were low in predictability. One can readily see from their
results how background noise could interfere with the surgeon’s ability to
understand communications during a critical task, particularly if the
communication is not a predictable one. The authors conclude that to avoid
possible miscommunication in the OR, attempts should be made to reduce ambient noise levels.
Note that the rate
of one distraction every 10 minutes seen in the Wheelock study is actually very
similar to the rates described in a variety of other healthcare venues and
affecting nurses (see our columns August 25, 2009 “Interruptions,
Distractions, Inattention…Oops!” and May 4, 2010 “More
on the Impact of Interruptions”), ER
physicians (March 8, 2011 “Yes,
Physicians Get Interrupted Too!”), and radiologists
(July 1, 2014 “Interruptions
and Radiologists”, November 2014 “More
Radiologist Interruptions”). Interestingly, in the Wheelock study
distractions had lower frequency in longer cases.
It’s also important to recognize that distractions don’t just apply to the surgical procedure per se. Michelle Feil (Feil 2014), in her excellent article on OR incidents related to distractions in the Pennsylvania PA-PSRS database, notes that almost 20% of the errors were related to laboratory test problems. These included specimen labeling errors, specimen quality problems, and specimen delivery problems.
So what are the strategies
that can be employed to minimize the risks due to distractions?
Sterile cockpit
Of course, one way
to help ensure that interruptions and distractions do not occur at critical
junctures in procedures is use of the “sterile cockpit” concept. In aviation,
all extraneous conversations are ceased during preparation for and undertaking
takeoffs and landings. That helps ensure all attention is directed to the
critical tasks at hand. Hence, the term “sterile cockpit”.
One important consideration, however, is that those critical junctures may differ for different OR team members (Feil 2014). Feil notes several examples of different critical junctures for surgeons, anesthesiologists, nurses, etc. A classic example is the surgical sponge and instrument “count” which requires undivided attention by the nurse(s) and surgical tech(s) who may be doing the count but may not reach the same level of attention by the surgeon and anesthesiologist (even though all should be focused on the count)..
In our May 21, 2013
Patient Safety Tip of the Week “Perioperative
Distractions” we noted an editorial by Jacqueline Ross (Ross
2013) pointing out that many distractions and interruptions are likely not
preventable but others are preventable. During crucial portions of a procedure
(eg. pre-op huddle, surgical timeout, induction, surgical incision, closure,
debriefing, anesthesia emergence, etc.) there should be no extraneous
conversations and all should focus on the task at hand (Ross
2013). She suggests limiting the number of people entering or leaving the
OR during those critical tasks.
Restricting OR traffic
As above, each time
the door to the OR opens it introduces an opportunity for not only
interruptions and distractions but also increases the potential for a surgical
site infection. Restricting OR traffic was one of the two types of
interventions Ross had noted as potentially useful in reducing interruptions (Ross
2013). Ross had suggested restricting OR traffic during critical periods
that merit a sterile cockpit atmosphere. One might envision setting the OR up
like a recording studio with its “On the Air” sign lighting up to restrict
entry into the OR during such critical periods. But it makes sense to restrict
unnecessary OR traffic whenever possible, not just during critical periods. In
the Wheelock study (Wheelock
2015) the most frequent types of
distractions were those initiated by external staff entering the operating room
and such distractions were unnecessary in 81% of cases! Anecdotally, simply
having everyone attempting to enter the OR fill out a log entry with the reason
for entering substantially reduces the number of people entering.
Preoperative huddles/briefings
The value of preoperative huddles/briefings in avoiding delays and preventing unnecessary interruptions and distractions is immeasurable. The typical preoperative huddle/briefing is done before each case. However, some have used a variant “the daily preoperative huddle” (Jain 2015). In the latter, the team convenes and does the huddle at the start of the day and looks at the entire day’s cases. This gives the team a chance to identify potential problems, set expectations, and develop a shared mental model prior to beginning the day’s cases. Such a huddle works best when the entire team will be present for all the day’s cases. Thus, it really is intended for teams operating within specialty settings. In the Jain study all participants were orthopedic surgeons and the orthopedic teams.
In the pilot study by Jain and colleagues (Jain 2015) the daily huddle resulted in improvement of the surgeons’ perception of the “day’s flow”. The number of unexpected delays dropped from 23% per case to 6.45% per case (and from 79% per day to 21% per day). It also impacted on interruptions, particularly those related to equipment issues, antibiotics, and issues regarding planned procedure. Overall, the number of total interruptions/questions decreased by 77% (from 2.51 per case before implementation of the daily huddle to 0.57 per case after).
As we’ve recommended in our numerous columns on preoperative huddles/briefings Jain and colleagues utilized a structured tool to help identify items to be discussed during the daily preoperative huddle.
Note, however, we suspect the daily huddle concept might be vulnerable to last minute changes in the OR schedule or changes in the schedule that occur after the morning huddle. We’ve seen too many disasters take place when patients are “taken out of turn” in the OR schedule. The “immediate” pre-op huddle is better timed to deal with such contingencies than is the “daily” pre-op huddle. So we would hope that some mechanism would be built in to systems using a daily huddle to add an “immediate” huddle any time an unanticipated change in schedule occurs.
Nevertheless, the concept of the “daily” preoperative huddle is one worth further exploring. We’ve actually advocated for the daily morning huddle in several other venues: the office or clinic, hospitalist rounds, bed coordination rounds, etc. (see our December 9, 2008 Patient Safety Tip of the Week “Huddles in Healthcare”).
Post-operative debriefings
Post-operative debriefings are also very helpful at reducing interruptions and delays. Obviously
they won’t prevent an interruption in the case just finished but the issues
identified can definitely help prevent interruptions in future cases. This is
especially likely to be helpful in preventing equipment-related or
supply-related issues. Think about how many times you’ve heard after an
equipment malfunction “Oh, that happened the last time we used it, too!”. Issues raised in debriefings need to be systematically
addressed to provide fixes before they recur (see our July 22, 2014 Patient
Safety Tip of the Week “More
on Operating Room Briefings and Debriefings”).
Policies on cellphone and other device use
The second area noted by Ross in which distractions might be prevented is use of wireless devices in these areas (Ross 2013). Cellphone use has become ubiquitous. There are many great advantages they provide us. But they also have a downside when used in the OR. Our May 21, 2013 Patient Safety Tip of the Week “Perioperative Distractions” discussed multiple examples of distractions related to cell phones in the OR. There are a multitude of issues related to cell phones in the OR including not only interruptions but also infection control issues, security and confidentiality issues, and detrimental effects on communication in the OR (Byrne 2013). Our recommendation is for all the OR team to leave their cellphones at the main OR desk where someone can triage incoming phone calls (we used to say the same thing for pagers but we haven’t seen a pager in a long time!).
Caregiver distractions from smartphones and other mobile
devices even made ECRI Institute’s annual list of Top 10 Technology Hazards for
2013 (ECRI
2012). A recent article in the lay press (Hawryluk
2015) 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 Hawryluk article notes several high profile cases in the
press in which distractions occurred in the OR due to personal use of
smartphones.
You’ll, of course, get the argument “I use my cellphone to access important information pertinent to the case” (like 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.
Nurses, and perhaps anesthesiologists, are increasingly using mobile devices to improve efficiencies in documentation within the OR and ensuring compliance with guidelines (AORN 2015). But, again, such devices can be configured not to allow distracting features like texting and instant messaging.
Other strategies
Michelle Feil, in addition to her excellent article on OR incidents related to distractions (Feil 2014), had previously researched the PA-PSRS database for events related to distractions in multiple healthcare venues (Feil 2013). She noted that most reports did not note the specific nature of the distraction. Nevertheless, she was able to glean insight from the narrative portion of the reports to provide case examples of the impact of distractions on nursing, surgeons, radiology, laboratory, anesthesia, pharmacy and multiple examples of the impact of distractions on medication errors. She provides a nice description of the constructs involved in memory and the effect of distractions on them. She has a section on sources of distractions that emphasizes “small talk” and technological devices as important sources of distraction.
In both articles, Feil provides multiple strategies to ameliorate the impact of distractions. Those include use of the “sterile cockpit” concept and pre-op huddles/briefings as we’ve discussed above. Others are use of checklists and teamwork training (eg. CRM, TeamSTEPPS™). She emphasizes, however, that having a culture of safety is most important and surgeons must be engaged and take leadership roles in developing that culture in the OR. She goes on to provide a list of risk reduction strategies you should consider implementing. Both the articles by Feil are insightful and useful and we encourage you to read them.
Ironically, most of us don’t even recognize when and how
often we are being distracted. There are a couple ways to get a better handle
on that, though both are resource-intensive. One is to do the sort of direct
observation as done by Wheelock and colleagues. The other is to do 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 interfered with
their communications. It can also help assess how well the team adheres to protocols like the Universal
Protocol or surgical timeout procedures or the sponge/instrument “count”. But
it could be used to assess interruptions and distractions as well.
Unfortunately, too many surgeons and hospital attorneys are loathe to use video
taping even when it is clearly being done for quality improvement activities.
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”
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”
References:
Altmann EM, Trafton
JG, Hambrick DZ. Momentary Interruptions
Can Derail the Train of Thought. Journal of Experimental Psychology: General,
Jan 7, 2013
http://psycnet.apa.org/index.cfm?fa=buy.optionToBuy&id=2013-00033-001
Wheelock A, Suliman A, Wharton RBM, et al. The Impact of Operating Room Distractions on Stress, Workload, and Teamwork. Annals of Surgery 2015; published ahead of print January 23, 2015
Engelmann CR, Neis JP, Kirschbaum C, et al. A noise-reduction program in a pediatric operation theatre is associated with surgeon’s benefits and a reduced rate of complications: a prospective controlled clinical trial. Ann Surg 2014; 259(5): 1025-1033
Way TJ, Long A, Weihing J, et al. Effect of Noise on Auditory Processing in the Operating Room. J Am Coll Surg 2013; 216(5): 933-938
http://www.journalacs.org/article/S1072-7515%2813%2900044-6/abstract
Feil M. Distractions in the Operating Room. Pa Patient Saf Advis 2014; 11(2): 45-52
http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2014/Jun;11%282%29/Pages/45.aspx
Ross J. Distractions and Interruptions in the Perianesthesia Environment: A Real Threat to Patient Safety. J Perianesth Nursing 2013; 28(1): 38-39
http://www.jopan.org/article/S1089-9472%2812%2900531-X/fulltext
Jain AL, Jones KC, Simon J, Patterson MD. The impact of a daily pre-operative surgical huddle on interruptions, delays, and surgeon satisfaction in an orthopedic operating room: a prospective study. Patient Safety in Surgery 2015; 9: 8
http://www.pssjournal.com/content/9/1/8
Byrne MD. Mobile Devices in the Perianesthesia Environment. J Perianesth Nursing 2013; 28(1): 26-30
http://www.jopan.org/article/S1089-9472%2812%2900533-3/fulltext
ECRI Institiute. Top 10 Health Technology Hazards for 2013. Health Devices 41(11): November 2012
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
Association of
Perioperative Registered Nurses (AORN) Surgical Conference 2015. Presented
March 9, 2015. As reported by Frellick M. Operating Room Best Practices
Move to Handheld Devices. Medscape March 09, 2015
http://www.medscape.com/viewarticle/841106
Feil M. Distractions and their impact on patient safety. Pa Patient Saf Advis 2013; 10(1): 1-10
http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2013/Mar;10%281%29/Pages/01.aspx
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