Andrew N Healey
BSc PhD CPsychol CSci
Clinical Safety Research Unit
Imperial College University of London
Department of Biosurgery and Surgical Technology
St Mary’s Hospital
The operating room (OR) is a place of intense and complex cooperative work among anaesthetists, nurses and surgeons. These teams usually carry out a succession of operations in a single day, and in varying degrees they achieve their objectives in meeting the demands of efficiency, quality and patient safety. However, on occasion things do go wrong; a cost manifested in adverse events, litigation and stress for all concerned.(1) To prevent future failure we need to understand the background to past failure through retrospective investigation.(2) However, we also need to obtain a thorough picture of what determines and affects performance in the OR through prospective research. To improve the systems of surgery, we must consider the constituent parts and how they interact throughout the process of operational work, so we may engineer them toward higher reliability.(3) In other domains of a high-risk nature, such as the nuclear industry or aviation, human factors or ergonomics research help achieve and maintain high reliability over time. These approaches may be usefully applied in the OR, not least to counteract the operational change that occurs in surgery.(4)
It is important to consider how OR personnel might be affected during surgery by the design of their individual and collective tasks and the environment in which they carry them out. Given the high interdependence among OR professionals, there is a strong possibility that their tasks interfere with one another. There are many different tasks to coordinate, so the demand on personnel to multitask is great.(5) There is a limit to how many tasks one person can achieve before performance declines. Reducing concurrent tasks may not be possible or desirable, and a perfect environment for all concerned may not be achieved. However, we can aim to minimise the factors that interfere with the work of the individual and the OR team as a whole and attempt to optimise their work and environment.
Without appropriate measures, it is difficult to make any changes to improve surgical systems. Recently there have been attempts to measure intraoperative interference from distraction and interruption observed in the OR.(6) Researchers developed an observational method whereby the surgical team’s behaviour and their task activity observed determined distraction and interruption recorded. Using an ordinal scale, an observer rated each salient distraction or interruption observed in relation to the team’s involvement. Ambient noise levels and OR door opening during surgery were also recorded. From a sample of 50 general surgical operations, the observer recorded that an average of one distracting or interrupting event occurred every three minutes. Noise levels exceeded recommended levels in many cases, and door-opening averaged 0.68 per minute across the sample, an average frequency of 33 per operation. The sources of this interference derived from equipment problems, untimely communications, including telephone calls and bleepers, and numerous visits from external staff. Similar findings were subsequently found in urological surgery.(7)
The research findings also indicated how multiple cumulative factors interfere with workflow in the OR. For instance, consider the work of the circulating nurse passing instruments to the scrub nurse, monitoring patient safety and preparing for the next case. When a telephone rings or a bleeper activates this can not only distract the whole team but also interrupt the circulating nurse in the aforementioned tasks because they must attend to the call or bleeper. The surgeon, whose work might already have been interrupted by a failing instrument, may now have to attend to the call, which the circulating nurse relays. Exacerbating the delay in the operation is the fact that a replacement instrument is situated outside of the OR and can only be retrieved once the circulating nurse has finished with the call to the surgeon. The result is a workflow impaired by numerous interruptions, which perhaps puts the patient at greater risk of inadvertent harm from an operational failure. An omitted step of a procedure, a slip of the knife, a misread medication or a miscounted instrument can have serious effects on a patient, and it is quite possible that the level of distraction and interruption may increase the probability of such events.
Practice and policy issues
Aviation has a metaphorical “sterile cockpit policy” for the critical phases of flight, which prohibits distraction and interruption from irrelevant talk or activity, but no equivalent policy exists for the critical phases of surgery. More prospective research is needed to quantify levels of work interference in the OR before improvements can be made to reduce work interference, not least because its causes are rather complex. On the other hand, common sense suggests that in the meantime preliminary policies could be considered and agreed upon among OR personnel. Policies and rules specifying safe operational conditions for the OR will make transparent the boundaries of acceptable working practice to help protect personnel and patients alike. Policies could range from a recommendation for certain high-risk surgery and guidelines on best practice for most surgery to strict basic conditions for all surgery.
Observational research is uncommon in surgery. Ethics committees and OR personnel are understandably cautious about it. With the trend in litigation we must carefully consider the data collected. However, issues of sensitive data can be resolved by simply making data anonymous and coding cases observed. The fundamental question is whether we should allow such research for improving safety or not. It is important to recognise that the aim of human factors and ergonomics research is to improve systems of work rather than to apportion blame. In other domains safety science is not an add-on to the systems under analysis; they are integral to them and so the work is simply not contentious.
There is indeed a clear ethical and financial rationale for healthcare to invest more heavily in safety research per se. It could improve safety, the quality of the service to patients, reduce an escalating cost of litigation and provide secondary benefits from the evaluation and improvement of various aspects of human and organisational performance. A focus on reducing workload and interference in the OR could improve teamwork, efficiency and work satisfaction. Unfortunately, feedback and learning mechanisms for interprofessional OR teams are not well established in the UK NHS, so even if operating theatre teams were able to exploit such measures they may not necessarily get the change they need. This highlights the need for research to go upstream beyond the OR to management levels in order to understand the complete picture as to why failure in surgery occurs.
OR work is highly complex and interprofessional, so many factors can affect performance in surgery. Evidence shows that OR personnel deal with considerable work interference, for reasons ranging from unreliable equipment, poor coordination and untimely visits to the OR by external staff and some problems derive from organisational design. Events which distract and interrupt will affect workload and the ability to concentrate on primary tasks, and may amount to unnecessary stress. If we can measure this interference in the OR we should be able to address it and regulate it. Such measures could be useful in team debriefing in the OR and to inform management of necessary changes needed to improve performance through active learning.
- Brennan TA, et al. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. N Engl J Med 1991;324:370-6.
- Department of Health. An organisation with a memory. 2000. Available at : www.dh.gov.uk/assetRoot/04/06/50/8604065086.pdf
- Vincent C, et al. Systems approach to surgical quality and safety: from concepts to measurements. Ann Surg 2004;239(4):475-82.
- Weinger MB, Englund CE. Ergonomic and human factors affecting anesthetic vigilance and monitoring performance in the operating room environment. Anesthesiology 1990;73:995-1021.
- Chisholm CD, et al. Emergency department workplace interruptions: are emergency physicians ‘interrupt-driven’ and ‘multitasking’? Acad Emerg Med 2000;7,11:1239-43.
- Healey AN, et al. Measuring intra-operative interference from distraction and interruption in the operating theatre. Ergonomics 2006;49(5-6):589-604.
- Healey AN, et al. Quantifying distraction and interruption in urological surgery. Qual Safety Health Care 2007;16:135-9.