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Distractions in the Operating Room Threaten

Patient Safety
Do cell phones and tablets affect communication and concentration?
A resident observing the surgery takes a call on his cell phone. The scrub nurse flips through images
of wedding dresses on her smartphone. The operating surgeons assistant steps in to ask a question
about another patient. The anesthesiologist taps his foot in time to the beat of the music in his
earbud. Its just another day in the operating room (OR).
Recently, AAOS Now editorial board member Michael F. Schafer, MD,assembled a group of surgeons
with a particular interest in patient safety to discuss distractions in the OR, their potential impact on
patient safety, and steps that can be taken to address the issue. Joining Dr. Schafer were Dwight W.
Burney III, MD; William J. Robb III, MD, chair of the AAOS Patient Safety Committee; and Col
Daniel W. White, MD, U.S. Army.

Electronic distractions in the operating roomsuch as cell phone use,
Internet access, and even electronic documentation requirements
have a potential impact on patient safety.
Courtesy of Thinkstock
Dr. Schafer: Lets start by defining the issue. Dr. Burney, what do you see as the problem in
the OR with distractions?
Dr. Burney: Well, this came to our attention from a number of sources. A commentary by Peter J.
Papadakos, MD, that appeared inAnesthesiology News (November 2011) focused on his concerns that
the nonmedical use of wireless devices, such as smartphones and tablet computers, would be
distracting. He also related his anecdotal experience of seeing OR staff surfing the Internet during a
The New York Times later picked up and expanded upon this issue, referencing an article
in Perfusion that reported the results of a survey of cardiopulmonary bypass technicians, almost half
of whom admitted that they had texted or taken cell phone calls while they were managing patients
on cardiopulmonary bypass. But most of those surveyed also thought that was not a safe thing to do,
so there was a disconnect between their ideas about safety and their actual practices.
Dr. White: I believe it is reaching epidemic levels. Nurses texting and playing Words with Friends,
anesthesiologists surfing the Net, and alarms and notices throughout the case. All of it can be quite a
distraction. The patient monitors and the necessary noises are enough. Add to that the deafening
sound of some of our power tools, and the noise level is quite high. The louder it gets, the harder it is
to communicate effectively.
Dr. Robb: One article measured and categorized distractions as being unpreventable or preventable
and controllable. Unpreventable distractions might be noises created by monitoring equipment in the
OR. The most frequent distraction was doors opening and closing, people just entering the room
whether by necessity or not. The noise level was also much higher than would be allowable in most
work environments. Although phones and pagers were mentioned, they were last on the list of
measured distractions.

Dwight W. Burney III,

William J. Robb III, MD

Michael F. Schafer, MD

Col Daniel W. White, MD
Dr. Schafer: How does the term sterile cockpit apply to the OR?
Dr. Burney: Several articles in the anesthesia literature talk about the critical phases of anesthesia
induction and emergencethat are analogous to critical phases in aviationtake off and landing.
Studies on distracting events during the critical phases have found few distractions during induction
but a large number of distractions during emergence.
This corresponded with the findings that led to the Federal Aviation Administrations passage of the
Sterile Cockpit Rules in aviation to reduce the number of accidents created by extraneous
conversation or nonflying-related tasks that were being performed by pilots during taxi, takeoff, or
approach to landing. The sterile cockpit means that no tasks are to be undertaken by the flight crew
during the critical phases of taxi, takeoff, and landing in any operation below 10,000 feet above
ground level other than level flight and cruising.
We can make the analogy between emergence and landing or induction and takeoff, and its been
suggested that we adopt the sterile cockpit idea for the critical phases of surgical procedures.
Dr. Robb: The specific definition of the regulationU.S. FAR Part 121,542comes from the Aviation
Safety Agency: No command pilot and no flight crew may allow any other activity during a critical
phase or flight which may confuse any flight crew member from the performance of his or her duties
or interfere in any way in the performance of their duties.
Dr. Schafer: Anesthesiologists shouldnt be on the telephone or the Internet while theyre
waking patients up or putting them to sleep and probably not on at all during the surgery. I
can understand the circulator nurse not talking on the cell phone during the procedure. But
what about distractions with the scrub nurse and the surgeon during procedures?
Dr. Robb: Within the OR environment, you have critical phases. Because everyone must work as an
effective team, anything that interferes with team performance has a significant impact. Distraction
has been shown to do that; it degrades the performance of the entire team and introduces errors that
wouldnt otherwise occur.
Thats why the sterile cockpit rules apply to the entire crew, not just the pilot. Were talking about
team performance and degradation of team performance, introducing errors, basically as observed in
flight aviation, and similarly as a concern in ORs.
Dr. White: Personally, Ive begun to wonder whether weve created an environment that leads to
distracted teamwork with the implementation of all-electronic documents. Our facility has converted
all OR documentation to an electronic format. The time-sensitive nature of date/time stamping
documentation of the time out, antibiotics delivery, incision time, tourniquet times, and other required
documentation is an issue for the OR staff. At times, the OR nurses are so occupied or preoccupied
with entering the documentation that the focus on the case and patient care can be lost.
Dr. Burney: Only about 2 percent to 3 percent of people can actually multitask; most of us have a
measurable decrease in performance if we try to do too many things. The widespread adoption of
wireless devices such as tablets, computers, and smartphones is problematic. Its really a question of
being aware of the possible adverse effects of these activities on performance. If were not very
careful about how we use these devices, we can introduce more chances for error and patient harm.
Dr. Schafer: Okay. What if I give my circulator nurse my smartphone and the phone goes off
during surgery and she says to me, This seems to be an important call, would you like to
take it? Number one, should she do that, and number two, if it is important, should I take
Dr. Robb: The American College of Surgeons has actually already published a position paper on this,
with several recommendations. It says that such devices should be left outside the OR. If they are
brought into the OR, they should be on silent function so that theyre not disruptive or distracting. If a
critical call has to be taken, theres a way of communicating that. When the team is distracted or
interrupted, you have to go back and actually ask, Where did we stop? Where are we starting? They
do this in cockpits.
Im not sure surgeons do that. The processes to manage distraction or interruption arent commonly
practiced in the OR. Changing the way we deal with these various communication devices is going to
be important to maintain the integrity and focus of the OR team.
Dr. Burney: We know that disruption of the surgical flow is a major cause of potential errors. For
example, with automated medication dispensers, nurses had to create a sterile zone around the
dispenser so that the nurse who is trying to dispense medications or stock wont be distracted by
extraneous conversations or questions. One of the strategies for dealing with this is to put these
machines away from high traffic areas or enforce a no-interruption zone when the nurse is actually
dispensing medication.
Dr. White: It is frustrating to be distracted during a multistep procedure and lose the flow of the
operation. When excessive extraneous activity occurs in the ORpersonnel changes, breaks, non
case-oriented discussions, phone callsthe surgeon can feel as though he or she is the only one in the
room focused on the case. This feeling of being alone is exactly what the sterile cockpit is intended
to avoid.
Dr. Schafer: I see the problem, but how do we prevent it? Dr. Robb, will you expound on
those ACS recommendations?
Dr. Robb: Number one: Leave pagers and cell phones outside the OR or turn them to silent mode.
No web surfing, text messaging, or cell phone conversations in the OR. No loud or distracting music.
And then finally, only pertinent conversation from the anesthesia team related to the case. The banter
between the anesthesia, surgery, and/or nursing teams needs to be related to the surgical care.
Limiting all nonessential conversation maintains the central focus of the surgical team. Thats
particularly true for critical periods of the surgery. Nonessential conversation degrades the
environment and is distracting.
Dr. Burney: A lot of the surgical literature deals with the two types of required skillsthe technical
skills, which are the actual performance skills, and the nontechnical skills, which have more to do with
communication, coordination, and teamwork. Lab studies in which distractions were introduced into a
simulated procedure have found that the technical skills hold up fairly well but the nontechnical skills
If youre trying to maintain a smooth flow of the surgical process and your ability to communicate well
and to coordinate is being affected, it can introduce the potential for error and harm.
Dr. White: I agree that distractions from the portable electronic realm should be minimized if not
eliminated. A sterile cockpit environment should be established during critical phases of the
operation such as critical dissections and when opening implants.
Dr. Schafer: Thats a good point. What about observers? Are they okay?
Dr. Burney: Some evidence suggests that interrupting the surgical flow to make teaching points may
degrade your performance a little bit, but thats part of the mission in the teaching institution. I think
its incumbent on the surgeon to be aware and ensure that the process flow does not suffer. The
patients safety is the overriding interest, and teaching has to be done within the context of a safe
Dr. White: Teaching has a distracting component, but patient safety must trump all distractions,
including teaching and other intended distractions.
Dr. Schafer: What about computer-assisted surgery? Is that okay?
Dr. Robb: I do computer-assisted surgery, and its part of the workflow. If anything, it increases
focus; its not a distraction.
Dr. Burney: At least one surgical simulation study showed that when you introduce a controlled level
of distraction into the simulation, the performance really decreases the most for laparoscopy, less for
robotic surgery, and least for standard open surgery.
Dr. Schafer: Do you think we should mandate that none of these distractions is allowed in
the OR?
Dr. Burney: I dont believe so, in part because wireless tablet computers are becoming a very big
part of medical education. So the same device that gives access to text messaging, movies, and music
also has medical school textbooks and lecture notes. That makes these multifunctioning devices
potentially very valuable for enhancing patient care.
I think its going to be a question of individuals being very self-aware and understanding that their
ability to monitor situations can be significantly degraded by using these devices for nonpatient-care
Dr. Robb: As we accumulate information regarding the effects of different types of communication
and distraction in the OR, regulations may evolve from various agencies, such as the Joint
Commission. I think we will have regulation, but, until then, its the responsibility of the individual
surgeon and surgical team to ensure that the patients have the best outcomes.
Dr. White: In our OR, we do the TeamSTEPPS brief in the morning and before each case. During
these briefs we strive to point out the critical surgical portions of the case and request that staff
turnover, breaks, and movement in and out of the OR be minimized during this time.
Dr. Burney: I think this really plays into the role of structured team communication, and I think that
the more structured and the more formalized the communication techniques are, the more likely we
will have a safe environment. Thats what were pursuing with TeamSTEPPS, but eliminating
distractions in the OR will have the same effect. I think that communicating very carefully and in a
very precise way will have a great deal to do with that.
I think its very interesting that the initial concern with smartphones and tablets was that people were
taking work home to the detriment of their personal relationships. Now the concern is that people are
bringing home to work to the detriment of patient safety.
Disclosures: Dr. Schafer DePuy, A Johnson & Johnson Company; Medtronic; Journal of Bone and
Joint SurgeryAmerican; Spine; Dr. Burneyno conflicts; Dr. RobbInnomed; Blue Cross Blue Sheild
Association; Abbott; Baxter; emmi Solutions; Johnson & Johnson; Stryker; Dr. Whiteno conflicts.
The opinions presented by Dr. White are his own and not the official positions of the U.S. Army,
Department of Defense, or U.S. government.
Online resources:
1. Papadakos PJ: Electronic Distraction: An Unmeasured Variable in Modern
Medicine. Anesthesiology News 2011;37:11. Accessed online 3/30/2012 (Login required)
2. Richtel M: As Doctors Use More Devices, Potential for Distraction Grows. The New York
Times, Dec. 14, 2011; accessed online 3/30/2012
3. Smith T, Darling E, Searles B: 2010 Survey on cell phone use while performing cardiopulmonary
bypass. Perfusion.2011;26(5):375-380. Epub 2011 May 18. Accessed online 3/30/2012
4. Pereira BM, Pereira AM, Correia Cdos S, Marttos AC Jr, Fiorelli RK, Fraga GP: Interruptions and
distractions in the trauma operating room: Understanding the threat of human error. Rev Col
Bras Cir2011;38(5):292-298. Accessed online 3/30/2012
May 2012 Issue