Patient Safety Tip of the Week
May 21, 2013 Perioperative Distractions
Distractions and
interruptions are frequent contributing factors to errors in all healthcare
settings. But in the perioperative setting they are especially prone to result
in errors that impact patient outcomes. Several recent papers have highlighted
the many issues involved in producing interruptions and distractions in the
perioperative setting.
Jacqueline Ross (Ross
2013) recently highlighted in an editorial those interruptions and
distractions that often take place in the preoperative holding area, the OR,
the PACU, and the several handoffs that take place among these areas. She
correctly points out that many of these are likely not preventable but others
are preventable. Two of the areas in which distractions might be prevented are
OR traffic and use of wireless devices in these areas. She appropriately
invokes the aviation concept of the “sterile cockpit” that we have used so
often. 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. She suggests limiting the number of people entering
or leaving the OR during those critical tasks.
She then reopens the
controversial debate about cellphones (or other mobile electronic devices) in
the OR (or other perioperative areas). That debate has been ongoing for quite
some time now and, unfortunately, has so many pros and cons that resolution has
been slow.
Shortly after the
incident where 2 airline pilots overflew their destination because they had
become so engrossed in their laptop computers, Dean raised the question
of the need to ban personal computer use in the OR (Dean
2010). He cited the statistics on how reaction times are considerably
longer while reading an e-mail or sending a text message than they would be if
legally drunk. In our April 16, 2013
Patient Safety Tip of the Week “Distracted
While Texting” we discussed the New York Times article on the potential
patient safety issues related to distractions from electronic devices in
hospitals (Richtel
2011). It describes things like a neurosurgeon making personal calls on a
cell phone via wireless headset during an operation, and a nurse in the OR
using an OR computer to check airline prices during an ongoing operation. It
quoted an article from the journal Perfusion (Smith 2011) which
found that 55 percent of technicians who monitor bypass machines acknowledged
to researchers that they had talked on cellphones during heart surgery. Half
said they had texted while in surgery. The NYT article also cites an article by
anesthesiologist Dr. Peter Papadakos (Papadakos
2011). In that article he quotes an abstract presented at the 2011
annual meeting of the American Society of Anesthesiologists that nurse
anesthetists and residents were distracted by something other than patient care
in 54% of cases—even when they knew they were being watched! Most of what took
their time were pleasure cruises on the Internet (abstract 1726).
Now a new study has looked at how background noise in the OR might interfere with surgical team communication (Way 2013). This study got quite a bit of press, probably because one of the background noises considered was music in the OR. In a simulated OR setting the investigators looked at the ability of 15 surgeons (who had normal hearing sensitivity) to understand and repeat words against a varying background of noises whether or not they were performing tasks. They 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. The authors plan on extending the study to include other members of the surgical team and to also assess the impact in surgeons who have some hearing impairment to start with.
Our July 31, 2012 Patient Safety Tip of the Week “Surgical Case Duration and Miscommunications” highlighted a study (Feuerbacher 2012) of surgical residents in an OR simulator environment that clearly demonstrated the impact of OR distractions and interruptions (ORDI’s) in producing surgical errors. Eight of eighteen participants committed significant surgical errors during simulated laparoscopic cholecystectomy when distracted or interrupted, compared to only one of eighteen who were not interrupted or distracted.
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 recently 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.
Think of all the interruptions that occur during a surgical procedure. Even those 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.
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 video/audio recording in the OR (or other perioperative setting) 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.
The other is to use the direct observational methodology that we mentioned recently in several columns. That method relies on having specially trained observers within the perioperative setting to observe and record all events taking place (and it usually requires more than one observer at a time). In our November 27, 2012 Patient Safety Tip of the Week “Dealing with Distractions” we noted a study that used direct observation of anesthetists and anesthesiologists as they cared for patients from the time the anesthetist and patient entered the anesthetic room until recovery (Campbell 2012). They found an average of 0.23 interruptions per minute overall but the interruption rate differed during various stages of the overall process. Interruptions came from a variety of sources (internal team members, external team members, equipment-related issues, workspace design issues, noise, teaching responsibilities, patient-related problems, and items such as pagers and mobile phones). The authors did note that not all interruptions have negative impact. In fact, 3.3% had a positive impact (i.e. the distraction or interruption facilitated either the procedure or the safety of the patient). They went on to discuss strategies used by the anesthesia personnel for coping with distractions and interruptions. We also noted the utility of the direct observational methodology in our October 23, 2012 Patient Safety Tip of the Week “Latent Factors Lurking in the OR”.
We’ve done a number
of columns on the deleterious effects of interruptions and distractions for
physicians, nurses, pharmacists and others:
- 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”
References:
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
Dean S. Distractions in the Operating Room: Should the Use of Personal Computers Be Banned during the Administration of Anesthesia? APSF Newletter 2010; 25(1): 19 Spring 2010
http://www.apsf.org/newsletters/html/2010/spring/14_distract.htm
Richtel M. As
Doctors Use More Devices, Potential for Distraction Grows.,New York Times,
December 14, 2011
Smith T, Darling E,
Searles B. 2010 Survey on cell phone use while performing cardiopulmonary
bypass. Perfusion 2011; 26(5):
375-380
http://prf.sagepub.com/content/26/5/375.abstract
Papadakos PJ.
Electronic Distraction: An Unmeasured Variable in Modern Medicine.
Anesthesiology News 2011; 37:11 November 2011
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
Feuerbacher RL, Funk KH, Spight DH, et al. Realistic Distractions and Interruptions That Impair Simulated Surgical Performance by Novice Surgeons. Arch Surg 2012; (): 1-5 published online first July 2012
http://archsurg.jamanetwork.com/article.aspx?articleid=1216543
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
Campbell G, Arfanis K, Smith AF. Distraction and interruption in anaesthetic practice.
Br. J. Anaesth 2012; 109(5): 707-715
http://bja.oxfordjournals.org/content/109/5/707.abstract
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