In the perianesthesia environment, distractions can decrease the performance of the entire team and introduce error. In the preoperative holding area, anxious patients and families arrive at a steady pace, while various team members conduct assessments while filling out multiple electronic medical forms. The operating room (OR) has multiple unpreventable distractions in its environment, such as monitors, equipment, and alarms. Each of these distractions can impede the team's ability to communicate effectively. As additional distractions such as phones, pagers, music, and other people entering and leaving the OR become part of the environment, the safe functioning of the team can be threatened. When patients enter the postanesthesia care unit (PACU), handoffs occur between the OR staff and PACU nurses. A PACU nurse can often monitor overflow patients and interact with the family members as well as glance down at their personal smart phone for a quick update on Facebook. The reality is that even as surgical technology advances, other issues in patient safety emerge.
This growing concern of distraction and the nonmedical use of wireless devices within the operating suite was discussed in a recent edition of Anesthesiology News.
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The commentary explores whether anesthesiologists and certified registered nurse anesthetists (CRNA) are being distracted by something other than patient care while a patient is under anesthesia. Additionally, a recent survey of perfusionists (n= 439) revealed that half of the cardiopulmonary perfusionist techs admitted to accessing the Internet, texting, or attending a nonmedical–related call while their patient was on bypass, although they realized that this was not a safe practice.2
This survey also highlighted a clear generational difference among age groups, with younger perfusionists reporting a higher incidence of cell phone usage.2
Despite the addictive nature of electronic devices in our daily lives, little attention has been paid to how these distractions may influence the occurrence of near misses and errors within the health care system, particularly in the OR.1
So what can be done within the surgical arena?As mentioned previously, many distractions and interruptions are unpreventable. Others, however, are preventable or, at a minimum, controllable. If we can prevent and control distractions along the surgical continuum, we can hope to decrease the incidence of error. One suggestion has been to treat the surgical experience like that of the cockpit of an airplane and to consider the surgical team, including the preoperative and postanesthesia nurses as part of the crew. Just like a flight crew, the surgical crew needs to consider the critical phases of the flight, or the surgical experience. In addition to the OR experience, the induction, surgical incision, closure, anesthesia emergence, and handoff in the PACU comprise the critical phases along the surgical continuum. The Federal Aviation Administration has well-established sterile cockpit rules. These rules decrease nonessential distractions that may occur during critical periods of a flight. These same rules, if extended into the surgical setting, could decrease the tendency toward error in the surgical environment.
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AAOS Now. Distractions in the operating room threaten patient safety. 6, Available at: http://www.aaos.org/news/aaosnow/may12/clinical5.asp. Accessed November 9, 2012.
For example, one method to prevent distraction could be to limit the amount of people coming in or out of the OR during critical periods, such as induction, incision, and emergence from anesthesia. Discussion of traffic limitations before starting surgery could be important in decreasing interruptions and the subsequent introduction of error.
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AAOS Now. Distractions in the operating room threaten patient safety. 6, Available at: http://www.aaos.org/news/aaosnow/may12/clinical5.asp. Accessed November 9, 2012.
A primary area of emphasis should be the amount of time and focus taken away from the surgical procedure. The American College of Surgeons recommends that phones be left outside the OR, but if brought into the room, be placed on silent mode. Some surgeons have been using wireless earpieces to answer phone calls while performing surgery, but is that a safe practice? Emphasis has been placed on the elimination of texting or talking on a phone while driving. Could a surgeon be equally distracted with taking a phone call, which requires high-level thought processes, during a surgical procedure? If the surgeon takes a call, then the surgery should stop to avoid an error. When the call is completed, the team can be asked, “Where did we stop?” and “Where are we starting?”
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These few questions can help to eliminate any ambiguity among the team and enable a refocus on the patient and the task at hand.AAOS Now. Distractions in the operating room threaten patient safety. 6, Available at: http://www.aaos.org/news/aaosnow/may12/clinical5.asp. Accessed November 9, 2012.
A letter to the editor in the Anesthesia Patient Safety Foundation Newsletter
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raised the question as to whether a policy should be written to prohibit the use of personal computers and other electronic devices in the ORs by anesthesia providers while a patient is under anesthesia. The writer again compared the work in the OR with that of the airplane cockpit. Concern was raised that in diverting attention away from the patient and monitoring of the patient while using personal electronic devices, provider communication related to the patient's care and situational awareness of the case may be lost. The provider becomes detached from the circumstances occurring in the room. This detachment compares to the lag in response time found in that of someone distracted while driving. An unimpaired driver driving 70 mph would take 0.54 seconds to brake, but add 36 ft for an email and 70 ft for a text.Dean, S. (2010). Distractions in the operating room. Should the use of personal computers be banned during the administrations of anesthesia? APSF Newsletter. Available at: http://www.apsf.org/newsletters/html/2010/spring/14_distract.htm. Accessed November 9, 2012.
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The anesthesia provider using a computer, smart phone, or a tablet may be absorbed in the technology and disconnected from the rest of the team, leaving the patient in a vulnerable state. Many institutions are developing policies limiting the use of personal computers, smart phones, and tablets during surgical procedures. What has your institution done? Do you think your institution needs to do something? Have you witnessed unsafe practices?Dean, S. (2010). Distractions in the operating room. Should the use of personal computers be banned during the administrations of anesthesia? APSF Newsletter. Available at: http://www.apsf.org/newsletters/html/2010/spring/14_distract.htm. Accessed November 9, 2012.
If your facility, like most others, has not considered a policy, it may be prudent to start observing distractions and interruptions that are happening around your perianesthesia unit and other surgical areas, especially those during the critical periods of the surgical experience. Perianesthesia nurses are more likely to see these issues before going to the OR. Observations may include what and who is causing interruptions and distractions. What among these could be prevented and controlled? When the patient arrives in the PACU, what is happening with regards to distractions and interruptions? The same observations and questions asked before the patient goes to the OR can be asked in the PACU as well. Do you find yourself “pulled” away from your patient care to “just check” for your messages or your status updates on your Facebook? This seemingly innocent check could signal a detachment from the patient that could introduce a serious error leading to patient injury.
The introduction of technology has provided the health care arena with the ability to improve patient care, yet at the same time we need to be cautious not to abuse it. Consider if your unit needs a policy to limit the use of personal cell phones. Such a policy could be used as a means to reduce provider distraction and better assure safe patient care delivery.
References
- Electronic distraction: An unmeasured variable in modern medicine.Anesthesiology News. 2011; 37: 11
- 2010 Survey on cell phone use while performing cardiopulmonary bypass.Perfusion. 2011; 26: 375-380
AAOS Now. Distractions in the operating room threaten patient safety. 6, Available at: http://www.aaos.org/news/aaosnow/may12/clinical5.asp. Accessed November 9, 2012.
Dean, S. (2010). Distractions in the operating room. Should the use of personal computers be banned during the administrations of anesthesia? APSF Newsletter. Available at: http://www.apsf.org/newsletters/html/2010/spring/14_distract.htm. Accessed November 9, 2012.
Biography
Jacqueline Ross, PhD, RN, CPAN, TDC, is a Senior Clinical Analyst, Patient Safety, Napa, CA
Article info
Footnotes
Conflict of interest: None to report.
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Copyright
© 2013 American Society of PeriAnesthesia Nurses. Published by Elsevier Inc. All rights reserved.
