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5 Steps to Limit OR Interruptions

Publish Date: 3/6/2013
Interruptions are a dangerous reality in the OR, notes Mary J. Ogg, MSN, RN, CNOR, perioperative nursing specialist in AORN's nursing department. Interruptions and distractions divert attention away from the patient and critical clinical tasks, and can jeopardize the safety of the patient and perioperative team members.

In fact, recent research has demonstrated that interruptions lasting four seconds or longer increased the rate of sequence errors by a factor of three. (Altmann, E. M., Trafton, J. G., & Hambrick, D. Z. Momentary interruptions can derail the train of thought. Journal of Experimental Psychology, 2013)

While it is not possible to completely avoid distractions in the perioperative environment, here are five steps Ogg says perioperative professionals should take to minimize the number and type of interruptions not serving a clinical function in order to create a safer perioperative environment.

1. During critical phases of the surgical procedure, create a "no interruption zone" where non-essential conversation and activities should be prohibited. Ogg says critical phases may include time-out periods; critical dissections; surgical counts; confirming and opening implants; induction and emergence from anesthesia; and care and handling of specimens.

"It is during such critical phases when the people performing these tasks should not be interrupted, whether it's the surgeon and the team at the field or if it's when the scrub and circulating nurse are performing their sponge, needle and instrument counts," she notes. "This idea of a 'no interruption zone' relates to the aviation concept sometimes referred to as the 'sterile cockpit.' When the pilot and copilot are conducting a preflight safety checklist and during critical phases like landing, they're considered to be in this sterile cockpit and are never interrupted."

Ogg says perioperative team members are usually mindful of keeping interruptions at a minimum when critical dissections are performed because there's a general understanding of the importance of this phase. However, she notes that this focus tends to waver for other critical phases, such as during counts and the induction and emergence from anesthesia.

"Sometimes when you're finishing up a case, people will take a deep breath, relax and start to chat, answer their cell phone or begin to cleanup," Ogg says. "But if the nurses are performing counts, it should be a time when that is the singular focus of what's going on in the OR. It's also very important to have a quiet environment for patients emerging from anesthesia."

To keep interruptions at a minimum and better preserve the no interruption zone, Ogg says perioperative professionals should work to educate their fellow team members that it is during all of these critical phases that conversations and excessive noises should be kept at a minimum.

"I think it's creating this awareness with the other team members," she says. "When the two nurses are performing the counts, they're very involved and concentrating on it, but I think sometimes the other team members are a little bit more relaxed, so maybe they start chatting and making noise. I think we need to call attention to this, and point out to all team members that they need to be quiet until all of the counts are resolved."

2. Limit extraneous conversations. This step can apply any time during the procedure, Ogg says. "For example, there are times when the surgical team might be focused on what they're doing, but it might be more of a downtime for anesthesia or the circulating nurse, so sometimes side conversations can start happening," she says. "Depending on who is involved, and how many people are taking part in the conversation, this can quickly get loud and become an interruption and a distraction."

3. Limit personnel movement in and out of the room. Physicians feel this is one of the most common causes of interruptions and distractions, Ogg says. "It's more that people that aren't needed in the room come in and out," she says. "If somebody's not busy in another room, they might just come in and visit, and start an extraneous conversation. Only the people that need to be in the room should be in the room, and any spent time going in and out of the room should be limited."

An effective way to support this objective is to plan to have all the supplies necessary for the procedure in the room before the case starts, which will cut back on the need for staff members to exit the OR to find a supply and re-enter the OR with it.

"There are times when that's not possible, when you need to leave the OR to obtain a certain supply or suture, but with good pre-planning, you can have these extras in the room, which will help limit that in and out movement," Ogg says.

4. Limit use of personal communication devices to non-patient care areas. Whenever possible, Ogg says perioperative personnel should avoid using cell phones, smartphones, tablets and other communication devices in the OR.

"You need to be focusing on the procedure instead of what's going on with your phone or tablet," she says. "Whether it's surfing the Internet, playing a game or sending a text message, these all distract you from what you're supposed to be doing, which is taking care of that patient and focusing on the patient's safety. Sometimes you'll hear people say that they're listening to what's happening around them while they're on their phones, but they're not really focused on the patient; they're focused on the screen rather than what's happening in the room."

5. Silence all personal communication devices in patient care areas. When you consider that monitors, equipment, the HVAC system and alarms already contribute to the level of noise and distraction in the OR, there's no need for the addition of the different sounds that come from personal communication devices, Ogg says.

"Everybody has their different, special little ringtones for specific people calling and purposes other than calls, such as text messages, emails and appointment reminders," she says. "If there are multiple phones going off with different songs and tones, it's going to be very disruptive to what's going on in the OR. It might be hard, but in most scenarios it would be better not to have these devices in the OR at all. Every time you remove your focus from the task at hand, it takes some amount of time to get back on task, and you might skip a step because your attention was diverted. Remember: Your primary focus always needs to be the patient."

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