Distractions in the Operating Room – More Than Just a Humorous Travel Website Commercial
You’ve probably seen the KAYAK commercial below where a surgeon is operating on someone’s brain, while simultaneously causing the patient to search for the best travel deals by ‘poking’ at his brain. Outrageous, humorous, but yet, it hints at a very real problem.
Even minor distractions in the OR can have a domino effect that can ultimately results in patient harm. Electronic devices have been linked to reduced medical errors, but serious problems arise when healthcare providers stray from work to check Facebook, buy airfare or text a friend. In response, some hospitals are restricting physicians’ use of smartphones, iPads and other devices in the Operating Room, to avoid an emerging phenomenon called “distracted doctoring.”
In hospitals that have established cell phone policies for their staff specific to the OR setting, cell phone use is typically banned, though these policies are not strictly enforced, nor do they apply to surgeons.
Surveys have found 55 percent of operating room technicians who monitor heart bypass machines in surgery admitted that they had talked on their cellphones during surgery. Another half had even texted. Hospitals are beginning to put the brakes on such activity. One health system, for instance, has made all operating rooms “quiet zones” and banned any activity that is not related to patient care.
Distractions occur naturally in the OR, and many are necessary and part of the procedure. For example, equipment alarms, or communication among the surgical team about the procedure they are performing. However, many distractions are from outside sources – external staff coming in the OR, computer use not associated with the procedure, cellphones and smartphones. Distraction from smartphones and other mobile devices was identified as one of the top 10 health technology hazards for 2013 by ECRI Institute. (ECRI Institute is an independent, nonprofit organization that researches the best approaches to improving the safety, quality, and cost-effectiveness of patient care.)
Is this a problem in Pennsylvania hospitals? Absolutely. In June, the Pennsylvania Patient Safety Authority published a Patient Safety Advisory that addressed Distractions in the operating room.
Analysis of events reported through the Authority’s Pennsylvania Patient Safety Reporting System (PA-PSRS) from January 2010 through May 2013 revealed 304 reports of serious events (i.e., events involving patient harm) occurring in the OR in which distractions and/or interruptions were indicated as contributing factors.
The following are examples of “serious events” reported through PA-PSRS associated with distraction in the OR:
- Wrong-side surgery
- Wrong-site surgery
- Transfusion of the wrong blood to the wrong patient
- Failure to remove a piece of resected bowel, requiring a return to the OR
- Injection of a patient using an unlabeled syringe and needle previously used on another patient
- Failure to notice a significant loss of evoked potential from a patient’s arm during spinal surgery
- Inflation of a tourniquet applied to a patient’s leg for longer than intended, resulting in neurovascular changes
To help hospitals in trying to deal with distraction and its potential for bad outcomes, the Pennsylvania Patient Safety Authority sought to find examples of best practices and specific tools currently in clinical use that could be shared with hospitals in Pennsylvania.
One fascinating strategy to reduce distraction in the OR includes implementing the “sterile cockpit” rule and reducing distractions from technology and noise.
The concept of the “sterile cockpit” comes from aviation. It describes a protocol that applies during critical periods of high mental workload and high risk, when all communication in the cockpit is restricted to information necessary for handling the plane (i.e., during taxi, takeoff, landing, and any flight operations below 10,000 feet). This rule not only prohibits nonessential conversation but also eating, reading materials not relevant to operating the plane, and any activity that “could 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.” In order to apply the “sterile cockpit” rule in the OR, it is necessary to first define the critical phases of operative procedures during which the rule would apply.
It is only within a culture of patient safety, with effective teamwork, skilled leaders, and clear communication, that OR team members and hospital administrators may feel empowered to take action to promote an environment with reduced distractions and to speak up when distraction is recognized to be impairing performance. Advocacy and assertion involves speaking up about patient safety concerns, especially when the leader or other members of the surgical team have failed to recognize the concern or do not believe the concern to be valid. This skill empowers all team members, including surgeons, to speak up when they recognize a distraction or interruption is negatively affecting performance, or when they have identified the need for an intraoperative briefing or applying the ‘sterile cockpit’ rule, because a critical phase in the procedure has been reached. Lack of engagement from surgeons has been cited as a barrier to promoting a culture of patient safety in the OR. Guidelines, checklists, and protocols alone will not be effective without the input and ongoing support of surgeons
The Pennsylvania Patient Safety Authority encourages hospitals to engage surgeons and form multidisciplinary teams charged with addressing the issue of distraction in the operating room by identifying sources of distraction and designing improvements.