Whether it is a 16-hour case in the operating room (OR) or a small cyst excision in an ambulatory surgery center, all surgical procedures demand a high level of concentration, clear communication, a well-honed skillset, and coordinated teamwork. However, distractions in the OR can compromise surgical performance and lead to poor patient outcomes. These distractions can manifest in different forms, such as auditory, visual, or tactile disruptions. Distractions in the OR have been identified as significant factors contributing to surgical errors, including fatal incidents. Some studies have found that the operating room is one of the largest factors for adverse events in the hospital, contributing to around 50% of the events (Sarker & Vincet, 2005). Moreover, variations in the skillset and experience of a surgeon and operating room teams may influence individuals’ ability to navigate distractions efficiently. Furthermore, the move to and emphasis on simulation training may fail to adequately represent the surgical environment and its accompanying distractions (Nasri et al., 2022).
Among different categories of distraction in the OR, auditory disruptions are one of the most challenging distractions to surgical teams. These distractions are especially worse during critical parts of an operation including timeout, intubation, and critical dissection (Nasri et a., 2022). Certain noises such as bovie alarms and vital signs monitors, are necessary. Others, including handoffs between scrub techs or circulating nurses, although essential, are external sources of auditory distraction. Additional sources of auditory distraction may arise from phone calls, pagers, or beepers. They may be related to the case, other patients in the healthcare setting, private, or non-work-related (Nasri et al., 2022). Surgeons with greater experience seem to have a reduced susceptibility to the harmful impact of these distractions (Nasir et al., 2022). Excessive noise in the operating room may make it difficult to communicate effectively. The World Health Organization (WHO) recommends a noise level of 30 dB (Clark & Paunovik, 2018). However, during surgeries, the noise levels often greatly exceed this recommendation. Higher noise levels, in general, negatively impact patient outcome and performance by staff in the operating room (Fu et al., 2021). Communication impairment between team members is a primary consequence of excessive noise, leading to poorer teamwork and surgical efficacy (Hasfeldt et al., 2010). While music in the operating room increases overall decibel levels, many healthcare professionals have positive sentiments towards this practice. Music is not considered to be an impairing distraction and can potentially improve individual and team performance (Nasri et al., 2022).
Another large source of distractions in the OR is equipment and personnel limitations. Examples of these distractions include equipment unavailability, competition for equipment, equipment failure, and limited availability of various team members (Nasri et al., 2023). These distractions also hinder surgical workflow, add to operating room time, and hinder surgical efficiency.
Research on the effect of distractions on surgical team members’ behavior and cognitive processes is limited. However, a study monitoring ninety general surgery cases in real-time identified external staff-initiated distractions and case-irrelevant conversations as the most prevalent distractions. Both lead to worsened teamwork and performance. Other distractions were equipment-related distractions and acoustic distractions leading to higher stress and higher workload. These distractions, though some are inevitable, are detrimental to a surgery team. (Wheelock, et al., 2015).
Another form of distraction that appears to be the least impactful category is visual distraction. Examples of visual distraction include doors opening during the cases and staff changing. While these distractions are also very common, they do not significantly impact the flow of surgery. However, these will increase operating room time (Nasri, et al., 2023).
Ultimately, distractions in the OR vary in terms of nature and impact. Auditory, environmental, and equipment-related distractions are the most harmful and efforts must be taken to address these to improve surgical performance and patient outcomes.
References
Clark C, Paunovic K. WHO Environmental Noise Guidelines for the European Region: A Systematic Review on Environmental Noise and Quality of Life, Wellbeing and Mental Health. Int J Environ Res Public Health. 2018;15(11):2400. Published 2018 Oct 29. doi:10.3390/ijerph15112400
Fu VX, Oomens P, Merkus N, Jeekel J. The Perception and Attitude Toward Noise and Music in the Operating Room: A Systematic Review. J Surg Res. 2021;263:193-206. doi:10.1016/j.jss.2021.01.038
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):380-386. doi:10.1016/j.jopan.2010.10.001
Nasri BN, Mitchell JD, Jackson C, Nakamoto K, Guglielmi C, Jones DB. Distractions in the operating room: a survey of the healthcare team. Surg Endosc. 2023;37(3):2316-2325. doi:10.1007/s00464-022-09553-8
Sarker SK, Vincent C. Errors in surgery. Int J Surg. 2005;3(1):75-81. doi:10.1016/j.ijsu.2005.04.003
Wheelock A, Suliman A, Wharton R, et al. The Impact of Operating Room Distractions on Stress, Workload, and Teamwork. Ann Surg. 2015;261(6):1079-1084. doi:10.1097/SLA.0000000000001051
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