Position Statement on Distraction in the Operating Room

Position Statement on Distraction in the Operating Room

A Risk to Patient Safety

Problem

Medical errors are the third leading cause of death in the United States. A four year study completed in 2013 showed 400,000 premature deaths per year are due to preventable medical errors (James, 2013). Patient adverse events, (PAE’s), occurring in the operating room, (OR), or as a result of an operation were undocumented in previous studies and therefore unavailable. However, OR involvement in PAE’s are accounted for in the James (2013) study. James (2013) states surgical site infections, (SSI’s), alone have a 3% mortality rate and 75% of those deaths are attributed directly to the SSI. Tremendous strides towards infection control have been made to improve surgical outcomes; however, the common denominator in all medical errors is human involvement. Human beings are imperfect and all have individual needs and desires when pertaining to the working environment. In the OR, loud equipment, clanging instruments and case relevant conversations are necessary and commonplace. Also present are avoidable distractions such as pagers, cell phones, tablets, radios and random conversations. Some controversy exists as to how much distraction would affect the outcome of a case, because not everyone requires silence in order to perform well. The issue of distraction may be debatable among individuals, but as a whole, the task of the surgery is interrupted by the task created by the stimulus. “Attending to the new task increases the risk of an error with one or both of the tasks because the stress of the distraction or interruption causes cognitive fatigue, which leads to omissions, mental slips or lapses, and mistakes” (Institute for Safe Medical Practices, 2012, para. 2). The overall problem of medical errors is an overwhelming prospect. Improving outcomes may be more easily accomplished by honing in on the smaller scale. The OR has a significant hand in the issue of medical errors (James, 2013). Distraction in the OR needs more attention.

Position

If properly addressed, distraction in the OR can be greatly minimized improving patient outcomes. Production of some distraction is unavoidable due to equipment and instruments, and necessary OR accoutrements. Examples of unavoidable distractions in the OR are: an individual sneezing, an instrument falling to the floor, the OR room phone ringing, and OR staff members may arrive late causing disruption. Considering the amount of unavoidable distraction, irrelevant distractions need to be minimized to optimize the level of safety available to an anesthetized patient. Examples of avoidable distractions are: pagers, cell phones, tablets, visitors in and out of the OR, and conversations amongst the surgical team. According to the Association of periOperative