Statement on Distractions in the Operating Room

This statement was developed by the American College of Surgeons (ACS) Committee on Perioperative Care and approved by the ACS Board of Regents at its June 2016 meeting.

There are many opportunities for distraction in the operating room (OR). Some can be attributed to the introduction of new technology, such as smartphone and mobile technology, and some are a function of noise levels, unnecessary conversation, and other variables that dilute the focus of perioperative team members because their attention is drawn “to…different object[s] or different directions at the same time.”^1,2 Because of the deleterious effects of distraction on cognitive processing and the performance of complex tasks and because of the potential impact of distraction on patient safety, it is important to recognize and mitigate the risks of distraction in the OR.

Distraction can result from both intrinsic sources, including alarms, noise from surgical devices, shift changes, and necessary communications, as well as extrinsic sources such as cell phones, beepers, computers and personal electronic devices, calls from outside the OR, communication that is not relevant to the case, visitors, and traffic in and throughout the OR. All members of the surgical team may be affected.

The surgical checklist was developed as an analogy to flight crew checklists, which is a series of procedures performed preliminary to takeoff that are intended to ensure safety during flight operations. By extension, the concept of the “sterile cockpit” has been introduced to describe protocols intended to limit distraction during critical periods in the OR. The sterile cockpit protocol is designed to limit activities that might “distract any flight crew member from the performance of his or her duties or which could interfere in any way with the proper conduct of those duties.”^3,4 One important difference between the OR and the cockpit, however, lies in the timing of critical events. They are much more tightly concentrated during flight. In the OR, critical events can and do occur throughout the operation.

When the timing of critical events, such as the clipping of an intracranial aneurysm or the initiation of a cardiopulmonary bypass, can be predicted, a structured communication protocol should be implemented to reduce the risk of distraction and miscommunication. The identification of critical phases of surgery has been shown not only to reduce miscommunication and distraction, but also operating time and costs.⁵

Distractions Arising from Technology

Newer technologies, including smartphones and other handheld electronic devices, have become ubiquitous. In many hospitals, they have been integrated into routine hospital communications and serve as access points to patient data and images. As useful and as important as they may be when used correctly, the undisciplined use of these devices may enhance distractions such as social media, e-mail, and other forms of electronic communication for health care personnel.

As a practical matter, many surgeons have come to rely on digital devices, including smartphones, for voice and data communication outside the office. Some institutions have established restrictive policies regarding the use of digital devices whereas others have not.

Therefore the ACS recommends that the use of smartphones in the OR be guided by the following considerations:

• The undisciplined use of smartphones in the OR—whether for voice, e-mail, or data communication, and whether by the surgeon or by other members of the surgical team—may pose a distraction and may compromise patient care.
• Surgeons should be considerate of the duties of personnel in the OR suite and refrain from engaging them unnecessarily in activities, including assistance in cellular communication, that might divert attention from the patient or the conduct of the procedure.
• Smartphones must not interfere with patient monitoring devices or with other technologies required for patient care.
• Whenever possible, members of the OR team, including the operating surgeon, should only engage in urgent or emergent outside communication during an operation. Personal and routine calls should be minimized. All phone calls should be kept as brief as possible.
• Whenever possible, incoming calls should be forwarded to the OR desk or to the hardwired telephone in the OR to minimize the potential distraction of smartphones.
• Whenever possible, incoming calls and data transmissions should be forwarded to voice mail or to memory. The ring tone should be silenced. An inaudible signal may be employed.
• Whenever possible, a distinct signal for urgent or emergent calls should be enabled. This signal may be implemented via a “page” option in most smartphones. Callers should be advised to use this function only for urgent and emergent calls if the phone is unanswered.
• The use of electronic and mobile devices or their accessories (such as earphones or keyboards) must not compromise the integrity of the sterile field. Special care should be taken to avoid sensitive communication within the hearing of awake or sedated patients.
• Communication using hardwired phones in the OR is subject to the same discipline as communication using electronic device technology.
• The use of electronic mobile devices to take and transmit photographs should be governed by hospital policy on photography of patients and by government regulations pertaining to patient privacy and confidentiality.

Distractions Due to Noise

There are many sources of noise in the OR. Some, like music, may be relaxing or distracting, depending on the circumstances.

Critical alarms are distracting but crucial. They are meant to focus attention, rather than to distract attention, even though they do both. False alarms are problematic.⁶ The reduction of harm associated with clinical alarms was identified as a 2014 National Patient Safety Goal by The Joint Commission.⁷ The introduction of “smart alarms,” which are individualized to each patient’s needs, has been recommended as one solution.⁸

Surgical equipment noise, noise from visitors entering the OR from corridors, and noise transmitted into the OR from other areas may be more difficult to control. The problem of transmitted noise is an architecture-based issue and must be addressed when ORs are designed and maintained. Surgical equipment noise cannot be controlled easily once a piece of equipment has been installed but should be a consideration when equipment is selected.

Therefore the ACS recommends the following protocols to reduce noise:

• Surgeons should be sensitive to all members of the OR team when selecting the music played during an operation (volume, genre, lyrics).
• Tools to assist in establishing alarm safety protocols are widely available and should be implemented institution-wide, not just in the OR or perioperative areas.⁹
• Traffic in and out of the OR should be controlled both because of the potential for distraction and for purposes of infection control.
• Reduced surgical equipment noise should be conveyed as a critical design factor to surgical instrument and device manufacturers.

Conclusion

The risks of distraction in the OR and the tools to overcome distraction should be incorporated in training programs for surgeons and for perioperative personnel. The importance of designing health care facilities to reduce transmitted noise into the OR should be emphasized when facilities are being conceived and maintained. Noise levels should be considered when surgical and anesthetic devices and instrumentation are selected.

Disclaimer

The ACS offers this statement for consideration by surgeons, their hospitals, and health care organizations. This statement is provided as general guidance. It does not constitute a standard of care and is not intended to replace the professional judgment of the surgeon or health care administrator. The statement may be reviewed and modified as necessary to conform with the laws of the applicable jurisdiction, the circumstances of the individual hospital and health care organization, and requirements of other allied health care organizations.

References

1. Feil M. Distractions in the operating room. Patient Safety Advisory. June 2014. Available at: patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2014/jun;11(2)/Pages/45.aspx. Accessed August 15, 2016.
2. Magrabi F, Li SY, Dunn AG, et al. Challenges in measuring the impact of interruption on patient safety and workflow outcomes. Methods Inf Med. 2011;50(5):447-453.
3. Sumwalt R. Sterile cockpit rules: FAR 121.542/FAR 135.100. National Aeronautics and Space Administration. ASRS Directline. Available at: asrs.arc.nasa.gov/publications/directline/dl4_sterile.htm#anchor524636. Accessed August 15, 2016.
4. U.S. Department of Transportation. Federal Aviation Administration. Cockpit distractions. April 26, 2010. Available at: www.faa.gov/other_visit/aviation_industry/airline_operators/airline_safety/info/all_infos/media/2010/InFO10003.pdf. Accessed August 15, 2016.
5. Lee BT, Tobias AM, Yeuh JH, et al. Design and impact of an intraoperative pathway: A new operating room model for team-based practice. J Am Coll Surg. 2008;207(6):865-873.
6. Wyatt RM. The Joint Commission. The alarming world. The Leadership Blog. July 17, 2013. Available at: www.jointcommission.org/jc_physician_blog/the_alarming_world/. Accessed August 15, 2016.
7. The Joint Commission. The R3 report: Requirement, rational, reference: Alarm system safety. December 11, 2013. Available at: www.jointcommission.org/r3_report_issue5/. Accessed August 15, 2016.
8. Agency for Healthcare Research and Quality. Alarm safety resource site. Available at: innovations.ahrq.gov/qualitytools/alarm-safety-resource-site. Accessed August 15, 2016.
9. The Joint Commission. Sound the alarm: Managing physiologic monitoring systems. The Joint Commission Perspectives on Patient Safety. December 2011. Available at: www.jointcommission.org/assets/1/6/perspectives_alarm.pdf. Accessed August 15, 2016.