Distractions in the OR Can Impact Surgical Workflow and Outcomes

Editor’s note: This article is part of the Healthcare Safety series, which highlights the work of the AAOS Committee on Healthcare Safety, whose vision is to optimize musculoskeletal health and eliminate complications.

Surgery is a complex symphony that requires physicians and the OR team to devote attention to the task at hand. Remaining alert and focused is vital to ensuring a safe and successful operation. Although adverse operative events may seem few and far between, data collected from the Joint Commission Sentinel Event Database show that there were roughly 3,300 sentinel events—patient safety events that result in death, permanent harm, or severe temporary harm—between 2015 and 2018, with 440 of them being wrong-side surgeries.

Many internal and external pressures influence the workflow of the OR. These influences can subsequently lead to distractions that can have a negative impact on patient care or members of the surgical team. Distractions can include but are not limited to:

• conversation that is not relevant to the case
• excessive traffic into or out of the OR
• use of music at elevated volumes
• substandard working conditions,
• time of day when the operation is being performed
• number of hours the team has worked

Impact of distractions in the OR
Distractions can lead to undesired effects, such as longer operative times, increased physiologic and psychologic stress, negative effects on surgeon performance, and potentially poor patient outcomes. A systematic review performed by Fu et al demonstrated the effects of higher noise levels in the operative theater and their influence on patient outcomes and performance of the surgical team. Elevated volumes are more common in orthopaedic ORs, and they have the potential to negatively affect performance in addition to contributing to noise-induced hearing loss.

A 2016 publication by the American College of Surgeons categorized OR distractions as originating from internal sources (e.g., alarms, changing of staff, necessary communication) or external sources (e.g., cell phones, pagers, incoming calls, traffic). The use of external devices such as cell phones, pagers, and computers for communication between medical teams has the potential to improve efficiency. However, “Undisciplined use of cell phones and other electronic devices may enhance distractions such as social media, email, and other forms of electronic communication for healthcare personnel,” according to the report.

Roberts et al investigated the frequency of distractions in the OR and reported an average of 56 distractions per hour of intraoperative time. Most of the distractions involved verbal communication unrelated to the case as well as issues with OR equipment, which were noted to have the greatest effect on operative workflow. In a survey of healthcare staff investigating distractions in the OR, auditory distractions were the most frequent factor cited as influencing focus.

Environmental distractions
Auditory stimuli such as music, various alarms, and noise generated by surgical equipment can be sources of distraction. The Royal College of Surgeons of England published a literature review regarding the effects of noise on operative performance. The study indicated that ORs typically have a decibel (dB) range between 51 and 79; however, orthopaedic surgery OR noise levels are often as high as 100 to 120 db. For context, a lawn mower is 90 dB, and an ambulance siren is 120 db. These levels are significantly higher than the levels recommended by the World Health Organization, which advises noise levels remain <35 db to facilitate effective communication among staff as well as a “peaceful environment for patients.”>

Music in the OR
Although noise originating from alarms and equipment may be unavoidable, other sounds can be addressed, such as music played at high volumes and loud conversations among staff unrelated to the case. For example, use of music in the OR is controversial. Many surgeons feel they perform better and can filter out unnecessary distractions when listening to music.

A systematic review performed by Boghdady et al identified studies with evidence supporting both positive and negative effects of music on surgeons’ performance. Some of the major positive effects included decreasing operative time and reducing stress on the surgical team; however, others felt that the playing of music within the OR fosters a more casual environment and can detract from the focus of the operative team. Sharon-Marie Weldon et al performed video recordings of ORs with and without music playing and found that there was significantly more distraction in ORs with music being played. Other studies have presented evidence suggesting that surgeons may have impaired auditory performance and communication when music is played in the background. The American College of Surgeons recommendation on music focuses on being respectful to all members of the team as well as the patient when selecting volume, genre, and lyrics.

Conversations
Unnecessary conversations among OR staff can be an additional source of distraction. In an observational study, Harten et al found that irrelevant conversations not pertinent to the case were the most frequent source of distraction during surgery. It is important for each member of the operative team to devote focus to their specific roles during the procedure. The ideal structure of the OR is one that aims to create a space where every member feels comfortable speaking up regarding concerns. Fostering a focused atmosphere aims to prevent errors such as opening incorrect implants, dropping instruments, or making other errors that can lead to operative complications.

Keeping focus
Distraction can occur from sources intrinsic to surgery, such as equipment, alarms, and case-relevant conversations, as well as from extrinsic sources involving conversations not pertinent to the case, use of technology, or other auditory stimuli.

In most situations, distractions in the OR do not lead to negative events. However, these distractions can potentially result in errors ranging from prolonged surgical times, improper implantation of components, and wrong-side operations. These complications and errors can be traumatic experiences for patients and may result in negative repercussions for the medical team and hospital system.

The importance of fostering trust in the healthcare system and ensuring the safety of patients and the surgical team cannot be overstated. Orthopaedic surgeons accomplish this goal by giving their undivided attention to patients while attempting to minimize distractions in the OR and following established protocols.

Distractions are a part of life, but it is the authors’ hope that by presenting some of the distractions one might encounter in the OR, they can help surgeons continue to provide each patient with the best care possible and respect the trust patients place in the surgical team.

Maxwell V. Phillips, MD, is an orthopaedic surgery resident at the Michigan State University–McLaren Health Care program in Flint, Michigan.

Zaid Memon is a fourth-year medical student at the University of Mumbai, India.

Alexander Phillips is a fourth-year medical student at the Michigan State University College of Human Medicine in Grand Rapids, Michigan.

Ajay Srivastava, MD, FAAOS, is an adult reconstruction surgeon and director of the McLaren Flint orthopaedic surgery residency program at McLaren Flint Medical Center and Hurley Medical Center in Flint, Michigan.

References

1. American College of Surgeons: Statement on Distractions in the Operating Room. Available at: https://www.facs.org/about-acs/statements/distractions-in-the-operating-room. Accessed Jan. 18, 2024.
2. Berglund B, Lindvall T, Schwela DH: Guidelines for Community Noise. Available at: https://www.who.int/publications/i/item/a68672. Accessed Jan. 18, 2024.
3. Hasfeldt D, Laerkner E, Birkelund R: Noise in the operating room: what do we know? A review of the literature. J Perianesth Nurs 2010; 25(6):380-6.
4. Szalma JL, Hancock PA: Noise effects on human performance: a meta-analytic synthesis. Psychol Bull 2011;137(4):682-707.
5. Stringer B, Haines TA, Oudy JD: Noisiness in operating theatres: nurses’ perceptions and potential difficulty communicating. J Perioper Pract 2008;18(9):384,386-91.
6. 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):933-8.
7. Ishikawa K, Boyce S, Kelchner L, et al: The effect of background noise on intelligibility of dysphonic speech. J Speech, Lang Hear Res 2017;60(7):1919-29.
8. Moorthy K, Munz Y, Dosis A, et al: The effect of stress-inducing conditions on the performance of a laparoscopic task. Surg Endosc 2003;17(9):1481-4.
9. Moorthy K, Munz Y, Undre S, et al: Objective evaluation of the effect of noise on the performance of a complex laparoscopic task. Surgery 2004;136(1):25-30.
10. Mcleod R, Myint-Wilks L, Davies SE, et al: The impact of noise in the operating theatre: a review of the evidence. Ann R Coll Surg Engl 2021;103(2):83-7.
11. Wiseman MC: The Mozart effect on task performance in a laparoscopic surgical simulator. Surg Innov 2013;20(5):444-53.
12. Lies SR, Zhang AY: Prospective randomized study of the effect of music on the efficiency of surgical closures. Aesthet Surg J 2015;35(7):858-63.
13. Gerra G, Zaimovic A, Franchini D, et al: Neuroendocrine responses of healthy volunteers to ‘techno-music’: relationships with personality traits and emotional state. Int J Psychophysiol 1998;28(1):99-111.
14. Sills D, Todd A: Does music directly affect a person’s heart rate? J Emerg Invest doi: 10.59720/14-058.
15. Conrad C, Konuk Y, Werner PD, et al: A quality improvement study on avoidable stressors and countermeasures affecting surgical motor performance and learning. Ann Surg 2012;255(6):1190-4.
16. El Boghdady M, Ewalds-Kvist BM: The influence of music on the surgical task performance: a systematic review. Int J Surg 2020;73:101-12.
17. Roberts ER, Hider PN, Wells JM, et al: The frequency and effects of distractions in operating theatres. ANZ J Surg 2021;91(5):841-6.
18. Croke L: Updated statistics underscore the importance of the surgical time out. AORN J 2019;109(6):P5.
19. Gui JL, Nemergut EC, Forkin KT: Distraction in the operating room: a narrative review of environmental and self-initiated distractions and their effect on anesthesia providers. J Clin Anesth 2021;68:110110.
20. McMullan RD, Urwin R, Gates P, et al: Are operating room distractions, interruptions and disruptions associated with performance and patient safety? A systematic review and meta-analysis. Int J Qual Health Care 2021;28;33(2):mzab068.
21. Tschan F, Seelandt JC, Keller S, et al: Impact of case-relevant and case-irrelevant communication within the surgical team on surgical-site infection. Br J Surg 2015;102(13):1718-25.
22. Wiegmann DA, ElBardissi AW, Dearani JA, et al: Disruptions in surgical flow and their relationship to surgical errors: an exploratory investigation. Surgery 2007;142(5):658-65.
23. Wheelock A, Suliman A, Wharton R, et al: The impact of operating room distractions on stress, workload, and teamwork. Ann Surg 2015;261(6):1079-84.
24. Weigl M, Antoniadis S, Chiapponi C, et al: The impact of intra-operative interruptions on surgeons’ perceived workload: an observational study in elective general and orthopedic surgery. Surg Endosc 2015;29(1):145-53.
25. Willett M, Gillman O, Shin E, et al: The impact of distractions and interruptions during cesarean sections: a prospective study in a London teaching hospital. Arch Gynecol Obstet 2018;298(2):313-8.
26. Healey AN, Sevdalis N, Vincent CA: Measuring intra-operative interference from distraction and interruption observed in the operating theatre. Ergonomics 2006;49(5-6):589-604.
27. Avidan A, Yacobi G, Weissman C, et al: Cell phone calls in the operating theater and staff distractions: an observational study. J Patient Saf 2019;15(4):e52-5.
28. Antoniadis S, Passauer-Baierl S, Baschnegger H, et al: Identification and interference of intraoperative distractions and interruptions in operating rooms. J Surg Res 2014;188(1):21-9.
29. Weldon SM, Korkiakangas T, Bezemer J, et al: Music and communication in the operating theatre. J Adv Nurs 2015;71(12):2763-74.
30. Shambo L, Umadhay T, Pedoto A: Music in the operating room: is it a safety hazard? AANA J 2015;83(1):43-8.
31. Fu VX, Oomens P, Merkus N, et al: The perception and attitude toward noise and music in the operating room: a systematic review. J Surg Res 2021;263:193-206.
32. Nasri BN, Mitchell JD, Jackson C, et al: Distractions in the operating room: a survey of the healthcare team. Surg Endosc 2023;37(3):2316-25.
33. van Harten A, Gooszen HG, Koksma JJ, et al: An observational study of distractions in the operating theatre. Anaesthesia 2021;76(3):346-56.