R E V I E W S & A N A LY S E S Distractions in the Operating Room Michelle Feil, MSN, RN INTRODUCTION Senior Patient Safety Analyst Pennsylvania Patient Safety Authority Distraction is defined as having one's attention drawn or directed “to a different object or in different directions at the same time.”1 The impact of distraction is influenced by multiple variables, including the characteristics of the primary task, the distractions themselves, and the environment.2 In fact, distraction is to be expected in an environ- ment, such as healthcare, that requires constant communication and coordination. ABSTRACT Rivera-Rodriguez and Karsh concluded that distraction due to interruptions that are Distraction is a threat to patient safety purposeful and share important information may actually improve care by appropriately in the operating room (OR). Analysis of refocusing attention and improving problem identification, collaboration, and commu- events reported through the Pennsylvania nication3 (e.g., clinical alarms, a request to “stop the line” when a member of the staff Patient Safety Reporting System from identifies a patient safety concern). Of greater concern is distraction due to nonpurpose- January 2010 through May 2013 re- ful interruptions or operational failures that impair performance and contribute to error. vealed 304 reports of events occurring Distraction is particularly detrimental to performance of complex tasks that require in the OR in which distractions and/or high levels of cognitive processing.4 Such tasks are encountered often in the operating interruptions were indicated as contribut- room (OR) due to the complex nature of each work system factor: the physical envi- ing factors. Attention is warranted to all ronment, teamwork and communication, tools and technology, tasks and workload, events impacted by distraction in the and organizational processes.5 Even minor distractions in the OR can have a cascade OR regardless of frequency, due to effect that ultimately results in major events and patient harm.6 Healthcare facilities their high potential to result in serious can reduce both the occurrence of distractions in the OR and their potential negative patient harm. Distraction is particularly impact on patient safety by identifying the sources of distraction currently present and detrimental to performance of complex addressing them through application of strategies and tools such as those developed by tasks that require higher levels of cogni- perioperative professional associations and patient safety agencies. tive processing, such as those frequently encountered in the OR. Studies examin- BACKGROUND ing the impact of distraction in the OR Distractions occur frequently in the OR setting, both due to intrinsic sources (e.g., setting, along with guidelines and tools surgical equipment alarms, surgical team communication relevant to the procedure) developed by perioperative professional and extrinsic sources (e.g., beepers, phone calls, communication from staff outside the associations and patient safety agencies OR).7 Distractions can affect all members of the surgical team: anesthesiologists and to limit and/or ameliorate the nega- nurse anesthetists, nurses, perfusionists, surgeons, surgical technicians, and other team tive impact of distraction are discussed members. Cognitive workloads are demanding for each of these professionals, with high (e.g., application of the “sterile cockpit” levels of cognitive processing required of different members of the team at different concept from aviation, reducing distrac- times, resulting in multiple high-risk points in the course of an operative procedure.8 tions from technology and noise, use of OR team members can serve as both the source and the recipient of distracting com- surgical safety checklists and briefings, munication. An observational study of distracting communications in the OR by teamwork training). Engagement of Sevdalis, Healey, and Vincent identified many case-irrelevant communications (CICs), surgeons and multidisciplinary teams defined as communication not relevant to the surgical procedure in progress. Half of is necessary to address the problem of all CICs consisted of “small talk.” Although surgeons initiated and received the great- distractions in the OR. (Pa Patient Saf est number of CICs, visitors to the OR (defined as external staff not belonging to the Advis 2014 Jun;11[2]:45-52.) OR team involved in the current surgical procedure) initiated CICs with the highest levels of observable distraction (i.e., causing team members to pause, disrupting work- flow).* Communications directed to nurses and anesthesia providers resulted in higher levels of distraction than communications directed to surgeons.9 *At the time of this writing, new research was published by Sevdalis et al. that identified com- munication from external visitors directed to the surgeon or the entire OR team as statistically the most distracting (p < 0.05). Lack of coordination between hospital departments was identified as the most disruptive problem. A statistically significant correlation (p < 0.05) was found between more frequent and/or severe communication distractions and failure to complete intraoperative patient safety checks, even with experienced teams. (Sevdalis N, Undre S, McDermott J, et. al. Impact of intraoperative distractions on patient safety: a prospective descriptive study using vali- dated instruments. World J Surg 2014 Apr;38[4]:751-8.) Vol. 11, No. 2—June 2014 Pennsylvania Patient Safety Advisory Page 45 ©2014 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S Distraction from computers and personal Table 1. Surgery or Invasive Procedure Problems Attributed to Distractions in the electronic devices (PEDs) is also a growing Operating Room, as Reported to the Pennsylvania Patient Safety Authority, concern for OR teams. The widespread January 2010 through May 2013 use of computers in clinical settings, EVENT SUBTYPE NO. OF REPORTS % along with the recent rapid growth in the Count incorrect—equipment 39 23.1 use of cell phones and smartphones, has Count incorrect—needles 27 16.0 contributed to a heightened focus on the Preparation inadequate/wrong 19 11.3 potential for error and harm caused by Break in sterile technique 12 7.1 distractions that result from the use of Count incomplete/not performed 11 6.5 these devices, particularly within the OR environment. “Distracted doctoring” is a Other (specify) 11 6.5 term coined by the media to describe this Procedure delayed 10 5.9 phenomenon.10-12 Furthermore, distrac- Foreign body in patient 9 5.3 tion from smartphones and other mobile Wrong side (left versus right) 9 5.3 devices was identified for the first time as Count incorrect—sponges 7 4.1 one of the top 10 health technology haz- Wrong procedure 4 2.4 ards for 2013 by ECRI Institute.13 Wrong patient 3 1.8 In a 2011 study of perioperative nurses’ Identification missing/incorrect 2 1.2 perceptions of near-miss patient safety Procedure canceled/not performed 2 1.2 events (defined as deviations in care with clearly significant potential conse- Wrong site 2 1.2 quences), distractions and interruptions Procedure not completed 1 0.6 were listed as one of the most common Unintended laceration/puncture 1 0.6 causal factors, second only to communica- Total 169 100.1* tion between team members.14 Also in * Total percentage is greater than 100 due to rounding. 2011, the Association of periOperative Registered Nurses (AORN) surveyed its members to determine what they con- were indicated as contributing factors. The specimens (n = 10), incomplete or missing sidered the highest-priority patient safety majority of these events were reported as specimen labels (n = 10), specimen quality issues.15 As a follow-up, in 2013, AORN errors related to procedures, treatments, problems (n = 7), and specimen delivery published a set of recommendations that or tests (73.7%, n = 224). Within this problems (n = 7). highlighted preventing distractions and event type, surgery or invasive procedure Attention is warranted to all events interruptions as key strategies to address problems were reported most frequently impacted by distraction in the OR regard- 3 of the top 10 patient safety issues iden- (75.4%, n = 169), followed by laboratory less of the frequency with which they are tified in the survey: wrong-site surgery, test problems (19.2%, n = 43). reported, due to their high potential to retained surgical items, and specimen mis- Of the surgery or invasive procedure prob- result in serious harm. The following are management errors.16 These three event lems (see Table 1), the subtypes reported examples of Serious Events (i.e., events types are supported as priority focus areas with greatest frequency were incorrect involving patient harm) reported through in analysis of reports to the Pennsylvania counts of equipment (n = 39) and incorrect PA-PSRS associated with distraction in Patient Safety Authority for events occur- needle counts (n = 27). Of note, within the OR: ring in the OR related to distractions. the subtype labeled “Other,” three events —— Wrong-side surgery involved specimen mishandling during the OR DISTRACTIONS IN —— Wrong-site surgery procedure and three events involved the PENNSYLVANIA use of expired products or implanted mate- —— Transfusion of the wrong blood to rials that were discovered after having been the wrong patient Analysis of events reported through the Authority’s Pennsylvania Patient used as part of the procedures. —— Failure to remove a piece of resected Safety Reporting System (PA-PSRS) from bowel, requiring a return to the OR Of the 43 laboratory test problems January 2010 through May 2013 revealed (see Table 2), the event subtypes most —— Injection of a patient using an unla- 304 reports of events occurring in the OR frequently reported were mislabeled beled syringe and needle previously in which distractions and/or interruptions used on another patient Page 46 Pennsylvania Patient Safety Advisory Vol. 11, No. 2—June 2014 ©2014 Pennsylvania Patient Safety Authority Table 2. Laboratory Test Problems Attributed to Distractions in the Operating Room, as lower levels of mental workload at differ- Reported to the Pennsylvania Patient Safety Authority, January 2010 through May 2013 ent times.8 For instance, anesthesiologists EVENT SUBTYPE NO. OF REPORTS % have designated induction and emergence Mislabeled specimen 10 23.3 as critical phases in the administration of Specimen label incomplete/missing 10 23.3 anesthesia that are analogous to takeoff and landing.20 Specimen quality problem 7 16.3 But for surgeons, critical phases of an Specimen delivery problem 7 16.3 operative procedure may occur at various Result missing or delayed 4 9.3 points during the procedure depending Other (specify) 2 4.7 on the steps involved8 (e.g., creation of Test ordered, not performed 2 4.7 an anastomosis, nerve dissection). And Wrong test performed 1 2.3 for nurses, surgical counts and specimen labeling are examples of critical phases.16 Total 43 100.2* * Total percentage is greater than 100 due to rounding. Identification of critical phases may also vary depending on the type of procedure. For example, in a study examining the —— Failure to notice a significant loss incidence of distractions. Specific strate- feasibility of applying the “sterile cockpit” of evoked potential from a patient’s gies supported in the literature include concept to cardiopulmonary bypass arm during spinal surgery implementing the “sterile cockpit” rule surgery, researchers found it was more —— Inflation of a tourniquet applied to a and reducing distractions from technology beneficial to define critical phases accord- patient’s leg for longer than intended, and noise. ing to procedure-specific events (e.g., resulting in neurovascular changes establishment of activated clotting time, “Sterile cockpit.” The concept of the initiation of cardiopulmonary bypass, “sterile cockpit” comes from aviation. It DISCUSSION administration of cardioplegia) rather describes a protocol that applies during than specific time intervals. A structured The Authority has published previously critical periods of high mental workload communication protocol was imple- on the topic of distraction, noting that and high risk, when all communication mented during these critical events, and hospitals can consider steps to reduce in the cockpit is restricted to informa- miscommunications during those times the impact of distraction by recogniz- tion necessary for handling the plane were reduced by half.8 In a similar study ing common sources of distraction and (i.e., during taxi, takeoff, landing, and evaluating the use of an intraoperative situations that are distraction-prone, iden- any flight operations below 10,000 feet). pathway for deep inferior epigastric per- tifying clinical tasks or procedures that This rule not only prohibits nonessential forator flap breast reconstruction surgery, are most likely to result in medical error conversation but also eating, reading nine critical stages were identified (e.g., and patient harm as a result of distrac- materials not relevant to operating induction, perforator dissection/flap tion, and applying specific risk reduction the plane, and any activity that “could harvest, recipient vessel harvest). The strategies.17 To support hospitals in these distract any flight crewmember from activities for each staff member were endeavors, the Authority sought to find the performance of his or her duties or defined for each stage, and checklists examples of best practices and specific which could interfere in any way with the and interphase transition briefings were tools currently in clinical use that could proper conduct of those duties.” 18 used to standardize processes, resulting in be shared with hospitals in Pennsylvania. In order to apply the “sterile cockpit” rule improved interdisciplinary communica- The perioperative area was identified as in the OR, it is necessary to first define the tion and statistically significant reductions the healthcare setting in which the most critical phases of operative procedures dur- in OR time and costs.21 concrete work has been done to iden- ing which the rule would apply. Critical tify such practices and develop tools to Reducing distractions from technology. phases for the OR team have been defined address the problem of distraction. Beyond distraction from cell phones as briefing, time-out, and debriefing. 16,19 and pagers, distraction from the use of Difficulty lies in further identifying critical Limiting Distraction in the OR newer technologies, such as smartphones phases common to the entire team, as the and other PEDs, is a growing concern in One approach to managing the problem tasks and their associated cognitive loads healthcare.10-12,22,23 In addition to phone of distractions in the OR is to employ pri- vary over the course of the procedure, calls and text messages, these devices mary prevention strategies to decrease the with different roles experiencing higher or Vol. 11, No. 2—June 2014 Pennsylvania Patient Safety Advisory Page 47 ©2014 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S introduce distractions from social media, communication to urgent or emergent noise and distraction that disrupt patient e-mail, and other forms of electronic conversations.28 care and impair clinician performance. communication. The compulsion to con- While cell phones, pagers, and smart- Aside from this direct effect, frequent stantly check PEDs is being recognized phones have introduced new distractions false alarms can distract clinicians, causing as an addiction that is impacting users in the healthcare setting, these technologies them to fail to recognize “real” events.34 of these devices, not least among them may also hold the key to better handling In a review of the literature, Konkani et al. healthcare providers.24 As of this writing, interruptions to workflow. Clinicians concluded that individualizing alarm AORN is updating its position statement prefer synchronous communication settings for each patient’s condition is the on noise in the perioperative setting to (e.g., face-to-face or telephone conversa- most direct method for decreasing false include new suggestions for preventing tions) and engage in more of this type alarms. Promoting a hospital culture that distractions from PEDs during critical of communication over asynchronous emphasizes the importance of alarm cus- phases of perioperative care.25 communication (e.g., numeric or alpha- tomization and using smart alarms, when numeric paging, text messages, voicemail). available, are also suggested.35 Information on hospital cell phone poli- cies is limited. Anecdotal information Both types of communication produce Reducing harm associated with clinical gathered from administrators and OR frequent interruptions, with synchronous alarm systems has been identified as a staff suggests that in hospitals that have communication being the most disrup- new 2014 National Patient Safety Goal by established such policies specific to the tive.29 Asynchronous communication the Joint Commission.36 ECRI Institute OR setting, cell phone use is typically using newer technologies provides a way has identified hazards from clinical alarms banned, though these policies are not for the sender to communicate informa- as number one on its list of the top strictly enforced, nor do they apply to tion to the receiver while allowing the 10 health technology hazards for 2014 and surgeons. In general, hospitals that have receiver to review the information and offers a free Alarm Safety Resource Site, established institution-wide policies respond at a later time, if appropriate, available at https://www.ecri.org/Forms/ regarding cell phone use tend to restrict thereby decreasing interruptions to their Pages/Alarm_Safety_Resource.aspx, the personal use of cell phones to non- workflow.30,31 that contains guidance and tools to help work time in nonpatient areas.26 Reducing distractions from noise. In addi- healthcare facilities improve alarm safety.37 In 2008, the American College of Sur- tion to the types of OR noises already discussed (from verbal communication, Tools to Ameliorate the Impact geons (ACS) issued an official statement on the use of cell phones in the operating cell phones, pagers, and PEDs), other of Distraction in the OR room in which it recognized that “the sources of noise in the OR include music, In recognition of the fact that distractions undisciplined use of cellular devices in surgical equipment, and clinical alarms. will continue to occur in the OR environ- the OR—whether for telephone, e-mail, or Noise has been linked to miscommunica- ment despite implementation of strategies data communication, and whether by the tion and impaired performance, even to limit their occurrence, secondary surgeon or by other members of the surgi- when the noise level falls within the range prevention strategies to ameliorate the cal team—may pose a distraction and may of normal conversation and ambient impact of distractions are necessary. Surgi- compromise patient care.” ACS did not background noise. Performance has been cal checklists and preoperative briefings propose a ban on cell phone use; rather, found to further deteriorate with higher are two tools that can help the OR team it listed 10 considerations to guide appro- noise levels, most notably noise from achieve and maintain situational aware- priate use, including avoiding personal music.32 Music is of particular concern, as ness and avoid and/or recover from the calls, silencing ringtones, forwarding more than 60% of personnel report listen- negative effects of distraction. calls, and setting a distinct alert for emer- ing to music in the OR and more than Surgical checklists. When distraction gency calls.27 50% prefer to listen to music at medium diverts attention from a primary task, the to high volumes.33 likelihood of committing an error upon AORN has similarly recommended that OR staff leave cell phones and pagers Well-designed and properly managed return to the primary task is increased.4 with someone outside the procedural clinical alarms may be considered distrac- Checklists are a tool to focus the atten- environment whenever possible, prop- tions or interruptions that are purposeful tion of the surgical team on the primary erly identify cell phones and pagers that and share important information. Clinical task (i.e., the operative procedure) and alarms are intended to improve problem to aid the team in quickly regaining that must be answered, place any nonessential identification and appropriately refocus focus after encountering a distraction. communication devices on mute or the attention of clinicians.2 False alarms, Checklists make explicit the minimum standby during surgery, and limit external also called nuisance alarms, are sources of expected steps that comprise a complex Page 48 Pennsylvania Patient Safety Advisory Vol. 11, No. 2—June 2014 ©2014 Pennsylvania Patient Safety Authority process and aid memory recall, particularly staff can become disengaged and “miss taught as part of this domain apply most in situations that are distraction-prone and subtle migrations toward error during a directly to the challenge of managing require high cognitive workload.38 When procedure.”45 AORN specifically includes distractions.49 used during an operative procedure, a time for a briefing, time-out, and debrief- Both CRM and TeamSTEPPS training checklist serves as an event-based cue that ing as part of the Comprehensive Surgical include tools already mentioned, such as aids memory recall by providing information Checklist.16 checklists and briefings. But beyond the about what steps in a procedure have been use of these standardized processes and completed and what steps remain to be Empowering the Surgical Team tools, both programs stress the impor- performed.39 It is only within a culture of patient safety, tance of cross-monitoring and advocacy Surgical checklists have been developed with effective teamwork, skilled lead- and assertion.47,48 by the Joint Commission,40 the World ers, and clear communication, that OR —— Cross-monitoring (i.e., “watching Health Organization (WHO),41 and team members may feel empowered to each other’s back”) is the action of AORN.42 The Authority has also devel- take action to promote an environment “monitoring other team members oped a preoperative checklist, which is with reduced distractions and to speak by keeping track of their behavior available as part of an extensive collection up when distraction is recognized to be and providing feedback [to ensure] of tools and resources designed to help impairing performance. that procedures are being followed hospitals prevent wrong-site surgeries.43 Teamwork training. Crew resource man- appropriately.”49 This skill allows This collection is available on the agement (CRM) was developed by the team members to help each other Authority’s website at http://patient aviation industry in 1979 in response to maintain focus on the primary task safetyauthority.org/EducationalTools/ the devastating crash of United Airlines in the face of distraction. PatientSafetyTools/PWSS/Pages/home. flight 173 that occurred as a result of —— Advocacy and assertion involves aspx and includes a tool titled Actions distraction (the plane ran out of fuel speaking up about patient safety to Satisfy Universal Protocol and WHO while the flight crew was distracted by concerns, especially when the leader Surgical Safety Checklist that presents troubleshooting a problem with the land- or other members of the team have expanded advice from the Authority ing gear).46 CRM was later adapted to failed to recognize the concern or do alongside recommendations from the healthcare following the 1999 Institute of not believe the concern to be valid.49 Joint Commission and WHO. Medicine report To Err Is Human: Building This skill empowers all team mem- Preoperative briefings. A checklist, in a Safer Health System, in which a recom- bers, including surgeons, to speak and of itself, does not communicate the mendation was made to apply aviation up when they recognize a distraction complexity of a surgical case to all the safety concepts to healthcare systems. or interruption is impairing perfor- members of the OR team. This is the CRM is a team-based training model that mance or when they have identified purpose of a preoperative briefing. A teaches cognitive and social skills that the need for an intraoperative brief- briefing conveys “precise instructions or empower all team members to promote ing because a critical phase in the essential information”44 about the pri- safety and improve performance. The procedure has been reached. mary task (i.e., the operative procedure) training focuses on communication, deci- For more information on TeamSTEPPS, to all members of the surgical team. The sion making, interpersonal relations, team see “TeamSTEPPS Training.” beneficial impact of briefing on reduc- coordination, and leadership.47 ing distractions is illustrated in a study Surgeon engagement and leadership. Similar to CRM, Team Strategies and by Henrickson et al., which found a Lack of engagement from surgeons has Tools to Enhance Performance and statistically significant (p < 0.05) decrease been cited as a barrier to promoting Patient Safety (TeamSTEPPS) is a team- in surgical flow disruptions after imple- a culture of patient safety in the OR. based training program that teaches skills menting a cardiovascular-surgery-specific, Guidelines, checklists, and protocols alone in four domains: leadership, mutual multidisciplinary briefing protocol will not be effective without the input support, situation monitoring, and com- designed with input from all members and ongoing support of surgeons.47,50 In munication.48 Situation monitoring is of the OR team. The authors proposed surveys of perioperative professionals, “the process of actively scanning and that this is because a briefing promotes between 29%51 and 43%52 of respondents assessing elements of the situation to mindful engagement, open communica- report being encouraged to speak up and gain information or maintain an accurate tion, and a shared mental model for the report concerns during procedures. As understanding of the situation in which team. Without active participation in OR team leaders, surgeons are expected the team functions.”49 The skills and tools the briefing by all members of the team, to demonstrate leadership skills that are Vol. 11, No. 2—June 2014 Pennsylvania Patient Safety Advisory Page 49 ©2014 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S during critical phases of operative —— Ensure that surgeons and other OR TeamSTEPPS TRAINING procedures.8,16,19 team leaders promote a culture of —— Use preoperative and procedural patient safety, encouraging all team Pennsylvania healthcare reporting checklists.16,38,40,41,43 members to practice skills necessary facilities that would like more infor- mation about Team Strategies and —— Design and implement a multidisci- for situation monitoring and to Tools to Enhance Performance and plinary briefing tool.45 voice concerns at any point during a Patient Safety (TeamSTEPPS) train- procedure.47-50 —— Use a structured communication the-trainer programs can contact the tool, such as SBAR (Situation, LIMITATIONS Pennsylvania Patient Safety Authority at (717) 346-0469 or by e-mail at Background, Assessment, Recom- mendation), especially during critical In-depth analysis by the Authority for patientsafetyauthority@pa.gov. phases of a procedure.45,47,48 events occurring in the OR associated If an organization wishes to explore with distraction is limited by the informa- —— Minimize communication by mem- this program, TeamSTEPPS master tion provided in PA-PSRS event report trainers recommend first complet- bers of the OR team that is irrelevant narratives. Much of what is known about ing the TeamSTEPPS Organizational to the current procedure, and limit distractions in the OR has been gained Readiness Assessment Checklist, interruptions from outside staff and from observational studies in real or which can be found at http:// other visitors to the OR.9 simulated OR environments. Given the teamstepps.ahrq.gov/readiness. —— Establish guidelines and expecta- complexity of the OR work environment tions, applicable to all members of and the ubiquity of distraction, the events the surgical team, for the appropriate reported through PA-PSRS may represent foundational to establishing a culture of use of cell phones, pagers, smart- a small number of all events occurring in patient safety, as emphasized in CRM phones, and other PEDs in the OR, the OR as a result of distraction. and TeamSTEPPS training. TeamSTEPPS and monitor for compliance.24,26-28 Additionally, distraction in the OR may training specifically notes that leaders —— Educate staff about electronic dis- contribute to procedural errors not rec- should be able to effectively empower traction and its potential detrimental ognized until the postoperative period team members to speak up and openly effect on patient safety.10-13,22-25 (e.g., a leaking anastomosis on post-op challenge when appropriate and that —— Raise awareness of the addictive day five), at which point the event may be effective leaders are responsible for component of PEDs and other reported as occurring on the postsurgi- ensuring that team members are sharing technologies.24 cal unit rather than the OR and may be information, monitoring situational cues, —— Reduce noise level in the OR attributed to other causes. At this point, resolving conflicts, and helping each other whenever possible, especially during the distraction that may have contrib- when needed49—all skills essential to both critical phases in the procedure32,33 uted to the procedural error may not avoiding distraction and handling distrac- (e.g., limit conversation not relevant be recognized. tion in the OR. to the current procedure; lower the volume of background music; adjust CONCLUSION RISK REDUCTION STRATEGIES surgical equipment settings to reduce excess noise, as able). Distraction is a threat to patient safety In addition to the risk reduction strategies that is present in all healthcare settings. outlined in the March 2013 Pennsylvania —— Customize alarm settings for individ- Distraction can be especially dangerous Patient Safety Advisory article “Distractions ual patients, and use smart alarms, during performance of highly complex and Their Impact on Patient Safety,”17 when available, to reduce distraction procedures that require higher levels the following strategies are suggested for from false or nuisance alarms.35 of cognitive processing, such as those reducing distractions in the OR setting: —— Provide teamwork training, such as performed in the OR setting. There is a —— Assemble multidisciplinary teams to CRM or TeamSTEPPS, using case growing body of research examining the identify critical phases in operative study scenarios specific to the OR.47,48 impact of distractions in the OR setting. procedures, specific to individual —— Engage surgeons in patient safety Substantial work has been done by peri- teams and procedure types as neces- teamwork training and quality operative professional associations and sary, that should not be interrupted.8 improvement projects targeted to patient safety agencies to create guidelines —— Implement a “sterile cockpit” or reducing distraction.47,48,50 and tools that can be used in hospital “no interruption zone” protocol Page 50 Pennsylvania Patient Safety Advisory Vol. 11, No. 2—June 2014 ©2014 Pennsylvania Patient Safety Authority ORs to limit distraction and/or amelio- identifying sources of distraction that may occurrence of distraction in the OR rate the negative impact of distraction. be unique to individual hospitals, surgical environment), secondary prevention The Authority encourages hospitals to teams, or procedures and designing (i.e., use of tools and processes that help engage surgeons and form multidisci- process improvements based on existing OR teams maintain situational awareness plinary teams charged with addressing the guidelines and tools. An approach that and avoid distraction or recover from the issue of distraction in the OR setting by includes primary prevention (i.e., imple- negative effects of distraction), and team- menting strategies that decrease the based training is suggested. NOTES 1. Merriam-Webster dictionary. Distract 11. Gamble M. Distracted doctoring: team-based practice. J Am Coll Surg 2008 [online]. [cited 2014 Feb 4]. http://www. physicians text, check Facebook in the Dec;207(6):865-73. merriam-webster.com/dictionary/distract OR [online]. Beckers Hosp Rev 2011 22. Katz-Sidlow RJ, Ludwig A, Miller S, et al. 2. Magrabi F, Li SY, Dunn AG, et al. Dec 15 [cited 2013 Nov 14]. http:// Smartphone use during inpatient attending Challenges in measuring the impact www.beckershospitalreview.com/ rounds: Prevalence, patterns and poten- of interruption on patient safety and healthcare-information-technology/ tial for distraction. J Hosp Med 2012 workflow outcomes. Methods Inf Med distracted-doctoring-physicians-text-check- Oct;7(8):595-9. 2011;50(5):447-53. facebook-in-the-or.html 23. Smith T, Darling E, Searles B. 2010 sur- 3. Rivera-Rodriguez AJ, Karsh BT. Inter- 12. Richtel M. As doctors use more devices, vey on cell phone use while performing ruptions and distractions in healthcare: potential for distraction grows [online]. cardiopulmonary bypass. Perfusion 2011 review and reappraisal. Qual Saf Health N Y Times 2011 Dec 14 [cited 2013 Nov Sep;26(5):375-80. Care 2010 Aug;19(4):304-12. 14]. http://www.nytimes.com/2011/12/ 24. Papadakos PJ. The rise of electronic 15/health/as-doctors-use-more-devices- 4. Li SY, Magrabi F, Coiera E. A systematic distraction in health care is addiction potential-for-distraction-grows.html review of the psychological literature to devices contributing. J Anesthe Clinic on interruption and its patient safety 13. ECRI Institute. Top 10 health technology Res 2013;4(3):e112. Also available at implications. J Am Med Inform Assoc 2012 hazards for 2013 [guidance article]. Health http://www.omicsonline.org/2155-6148/ Jan-Feb;19(1):6-12. Devices 2012 Nov;41(11):342-65. pdfdownload.php?download=2155-6148- 5. ElBardissi AW, Sundt TM. Human factors 14. Cohoon B. Causes of near misses: percep- 4-e112.pdf&&aid=11833 and operating room safety. Surg Clin North tions of perioperative nurses. AORN J 25. Association of periOperative Registered Am 2012 Feb;92(1):21-35. 2011 May;93(5):551-65. Nurses. Take a stand: a 4-step program to 6. Martinez EA, Thompson DA, Errett 15. Steelman VM, Graling PR, Perkhounkova Y. stop eDevice distraction [online]. 2013 NA, et al. High stakes and high risk: a Priority patient safety issues identified Sep 18 [cited 2013 Nov 25]. http://www. focused qualitative review of hazards dur- by perioperative nurses. AORN J 2013 aorn.org/News.aspx?id=10737418310 ing cardiac surgery. Anesth Analg 2011 Apr;97(4):402-18. 26. Saver C. Cell phones are everywhere, but May;112(5):1061-74. 16. Steelman VM, Graling PR. Top 10 patient do they belong in the OR? OR Manager 7. Healey AN, Sevdalis N, Vincent CA. Mea- safety issues: what more can we do? AORN 2011 Feb;27(2):1, 13-4, 19. suring intra-operative interference from J 2013 Jun;97(6):679-98. 27. College’s Committee on Perioperative distraction and interruption observed in 17. Feil M. Distractions and their impact Care. Statement on use of cellphones in the operating theatre. Ergonomics 2006 on patient safety. Pa Patient Saf Advis the operating room. Bull Am Coll Surg Apr 15-May 15;49(5-6):589-604. [online] 2013 Mar [cited 2013 Nov 2008 Sep;93(9):33-4. Also available at 8. Wadhera RK, Parker SH, Burkhart HM, 25]. http://patientsafetyauthority.org/ http://www.facs.org/fellows_info/ et al. Is the “sterile cockpit” concept appli- ADVISORIES/AdvisoryLibrary/2013/ statements/st-59.html cable to cardiovascular surgery critical Mar;10(1)/Pages/01.aspx 28. Association of periOperative Registered intervals or critical events? The impact of 18. 14 CFR § 124.542 (1981). Also available Nurses. Noise in the perioperative prac- protocol-driven communication during at http://rgl.faa.gov/Regulatory_and_ tice setting [position statement online]. cardiopulmonary bypass. J Thorac Cardio- Guidance_Library/rgFAR.nsf/0/ [cited 2013 Nov 25]. http://www. vasc Surg 2010 Feb;139(2):312-9. dd19266cebdac9db852566ef006d346f aorn.org/WorkArea/DownloadAsset. 9. Sevdalis N, Healey AN, Vincent CA. 19. Patterson P. Adopting a ‘no interruption aspx?id=21925 Distracting communications in the zone’ for patient safety. OR Manager 2013 29. Conn LG, Lingard L, Reeves S, et al. operating theatre. J Eval Clin Pract 2007 Feb;29(2):20-2. Communication channels in general Jun;13(3):390-4. 20. Broom MA, Capek AL, Carachi P, et al. internal medicine: a description of 10. Nguyen S. Distracted doctoring is a Critical phase distractions in anaesthesia baseline patterns for improved interpro- workplace safety issue [online]. Work- and the sterile cockpit concept. Anaesthe- fessional collaboration. Qual Health Res place Psychol 2012 Jan 17 [cited 2013 sia 2011 Mar;66(3):175-9. 2009 Jul;19(7):943-53. Nov 14]. http://workplacepsychology. 21. Lee BT, Tobias AM, Yueh JH, et al. net/2012/01/17/distracted-doctoring-is-a- Design and impact of an intraoperative workplace-safety-issue pathway: a new operating room model for Vol. 11, No. 2—June 2014 Pennsylvania Patient Safety Advisory Page 51 ©2014 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S 30. Wu RC, Lo V, Morra D, et al. The 38. Gawande A. The checklist [online]. 46. National Transportation Safety Board. intended and unintended consequences New Yorker 2007 Dec 10 [cited 2013 Aircraft accident report: United of communication systems on general Nov 21]. http://www.newyorker.com/ Airlines, Inc. McDonnell-Douglas, DC-8- internal medicine inpatient care delivery: reporting/2007/12/10/071210fa_fact_ 61 [online]. 1978 Dec 28 [cited 2013 Nov a prospective observational case study of gawande 21]. http://libraryonline.erau.edu/online- five teaching hospitals. J Am Med Inform 39. Schacter DL. The seven sins of memory. New full-text/ntsb/aircraft-accident-reports/ Assoc 2013 Jul-Aug;20(4):766-77. York: Houghton Mifflin; 2001. AAR79-07.pdf 31. Edwards A, Fitzpatrick LA, Augustine S, 40. Joint Commission. Lessons learned: 47. Powell SM, Hill RK. My copilot is a nurse- et al. Synchronous communication facili- wrong site surgery [online]. Sentinel -using crew resource management in the tates interruptive workflow for attending Event Alert 1998 Aug 28 [cited 2013 Nov OR. AORN J 2006 Jan;83(1):179-80, 183- physicians and nurses in clinical settings. 21]. http://www.jointcommission.org/ 90, 193-8. Int J Med Inform 2009 Sep;78(9):629-37. assets/1/18/SEA_6.pdf 48. TeamSTEPPS National Implementation 32. Way TJ, Long A, Weihing J, et al. Effect 41. Safe surgery saves lives [website]. [cited [website]. [cited 2013 Dec 6]. Chicago: of noise on auditory processing in the 2013 Nov 14]. Geneva (Switzerland): Agency for Healthcare Research and operating room. J Am Coll Surg 2013 World Health Organization. http://www. Quality. http://www.teamsteppsportal.org May;216(5):933-8. Also available at who.int/patientsafety/safesurgery/en 49. Agency for Healthcare Research and http://www.journalacs.org/article/ Quality. TeamSTEPPS 2.0 essentials 42. Association of periOperative Registered S10727515(13)00044-6/abstract course [instructor’s manual online]. [cited Nurses. Comprehensive checklist [online]. 33. Ullmann Y, Fodor L, Schwarzberg I, [cited 2014 Jan 9]. http://www. 2013 Dec 9]. http://www.ahrq.gov/ et al. The sounds of music in the operat- aorn.org/Clinical_Practice/ToolKits/ professionals/education/curriculum- ing room. Injury 2008 May;39(5):592-7. Correct_Site_Surgery_Tool_Kit/ tools/teamstepps/instructor/essentials/ 34. Korniewicz DM, Clark T, David Y. A Comprehensive_checklist.aspx igessentials.pdf national online survey on the effective- 43. Pennsylvania Patient Safety Authority. Pre- 50. Association of periOperative Registered ness of clinical alarms. Am J Crit Care venting wrong-site surgery [online]. [cited Nurses. 8 checklist mistakes to avoid 2008 Jan;17(1):36-41. 2013 Nov 21]. http://patientsafetyauthority. [online]. 2013 Mar 20 [cited 2013 Dec 9]. 35. Konkani A, Oakley B, Bauld TJ. Reduc- org/EducationalTools/PatientSafetyTools/ https://aorn.org/News.aspx?id=24542 ing hospital noise: a review of medical PWSS/Pages/home.aspx 51. Fleming M, Smith S, Slaunwhite J, et al. device alarm management. Biomed Instrum 44. Merriam-Webster dictionary. Briefing Investigating interpersonal competencies Technol 2012 Nov-Dec;46(6):478-87. [online]. [cited 2014 Feb 11]. http://www. of cardiac surgery teams. Can J Surg 2006 36. National Patient Safety Goals [website]. merriam-webster.com/dictionary/briefing Feb;49(1):22-30. [cited 2014 Jan 8]. Oakbrook Terrace (IL): 45. Henrickson SE, Wadhera RK, Elbardissi 52. Bognar A, Barach P, Johnson JK, et al. Joint Commission. http://www. AW, et al. Development and pilot evalu- Errors and the burden of errors: attitudes, jointcommission.org/standards_ ation of a preoperative briefing protocol perceptions, and the culture of safety in information/npsgs.aspx for cardiovascular surgery. J Am Coll Surg pediatric cardiac surgical teams. Ann Tho- 37. Alarm Safety Resource Site [website]. 2009 Jun;208(6):1115-23. rac Surg 2008 Apr;85(4):1374-81. [cited 2014 Jan 8]. Plymouth Meeting (PA): ECRI Institute. https://www. ecri.org/Forms/Pages/Alarm_Safety_ Resource.aspx Reviewer Commentary I firmly believe that situational awareness is an essential characteristic for operating room person- nel and is key to recognizing behaviors and actions that may be appropriate at one time and distracting at a different time. I also offer the following additional thoughts and questions for the reader to consider. One, other distractions worthy of attention are those introduced by exceedingly complex, detailed, and time-consuming computer data entry required of the circulating nurse and extremes in room temperature preferred by surgeons that may be too hot or cold for other OR team members. Two, while useful, the checklist and briefing may need to be fractionated into shorter, more frequent, focused episodes utilized throughout the course of complex procedures, rather than be treated as a single obligatory task to be accomplished at the beginning of a case, then forgotten. Three, does the act of identifying critical periods mean that it is okay to engage in distracting behaviors at other noncritical periods? Charles P Kingsley, MD . Anesthesiologist Hummelstown, Pennsylvania Page 52 Pennsylvania Patient Safety Advisory Vol. 11, No. 2—June 2014 ©2014 Pennsylvania Patient Safety Authority PENNSYLVANIA PATIENT SAFETY ADVISORY This article is reprinted from the Pennsylvania Patient Safety Advisory, Vol. 11, No. 2—June 2014. The Advisory is a publication of the Pennsylvania Patient Safety Authority, produced by ECRI Institute and ISMP under contract to the Authority. Copyright 2014 by the Pennsylvania Patient Safety Authority. This publication may be reprinted and distributed without restriction, provided it is printed or distributed in its entirety and without alteration. Individual articles may be reprinted in their entirety and without alteration provided the source is clearly attributed. This publication is disseminated via e-mail. To subscribe, go to http://visitor.constantcontact.com/ d.jsp?m=1103390819542&p=oi. To see other articles or issues of the Advisory, visit our website at http://www.patientsafetyauthority.org. Click on “Patient Safety Advisories” in the left-hand menu bar. THE PENNSYLVANIA PATIENT SAFETY AUTHORITY AND ITS CONTRACTORS The Pennsylvania Patient Safety Authority is an independent state agency created by Act 13 of 2002, the Medical Care Availability and Reduction of Error (Mcare) Act. Consistent with Act 13, ECRI Institute, as contractor for the Authority, is issuing this publication to advise medical facilities of immediate changes that can be instituted to reduce Serious Events and Incidents. For more information about the Pennsylvania Patient Safety Authority, see the Authority’s An Independent Agency of the Commonwealth of Pennsylvania website at http://www.patientsafetyauthority.org. ECRI Institute, a nonprofit organization, dedicates itself to bringing the discipline of applied scientific research in healthcare to uncover the best approaches to improving patient care. As pioneers in this science for more than 40 years, ECRI Institute marries experience and indepen- dence with the objectivity of evidence-based research. More than 5,000 healthcare organizations worldwide rely on ECRI Institute’s expertise in patient safety improvement, risk and quality management, and healthcare processes, devices, procedures and drug technology. The Institute for Safe Medication Practices (ISMP) is an independent, nonprofit organization dedicated solely to medication error prevention and safe medication use. ISMP provides recommendations for the safe use of medications to the healthcare community including healthcare professionals, government agencies, accrediting organizations, and consumers. ISMP’s efforts are built on a nonpunitive approach and systems-based solutions. Scan this code with your mobile device’s QR reader to subscribe to receive the Advisory for free.