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:








Ross J. Distractions and Interruptions in the Perianesthesia Environment: A Real Threat to Patient Safety. J Perianesth Nursing 2013; 28(1): 38-39



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



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



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



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



Altmann EM, Trafton JG, Hambrick DZ.  Momentary Interruptions Can Derail the Train of Thought. Journal of Experimental Psychology: General, Jan 7 , 2013



Campbell G, Arfanis K, Smith AF. Distraction and interruption in anaesthetic practice.

Br. J. Anaesth 2012; 109(5): 707-715







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