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Distractions in OR Make Errors More Likely

Surgery residents committed eight times as many errors during simulated procedures when realistic distractions and interruptions were introduced than when they completed procedures without interruption, investigators reported.

The residents made major surgical errors during eight of 18 simulated procedures with distractions versus only one of 18 operations that occurred without intrusions.

Additionally, more than half of the residents forgot a key memory task related to the surgery when they were interrupted as compared with 22% during uninterrupted surgery, as reported online in Archives of Surgery.

"This study provided statistically significant evidence to support the hypothesis that realistic operating-room (OR) distractions and interruptions increase the likelihood of errors in a simulated laboratory setting with novice surgeons," Robin L. Feuerbacher, PhD, of Oregon State University-Cascades in Bend, Ore., and co-authors wrote in conclusion.

"This finding is important because it implies that OR distractions and interruptions may lead to adverse patient outcomes," they added.

Despite the high error rate, the authors said the results should not be interpreted as representative of operating-room (OR) experience in general.

"It must be noted that the distractions and interruptions were timed to occur at critical points and occurred more frequently than observed in an OR," they wrote. "Consequently, these results should not be used to infer that almost half of all surgical procedures with distractions and interruptions are expected to have major surgical errors."

Interruptions and distractions during surgery are common occurrences that are generally acknowledged by healthcare professionals. However, efforts to quantify and describe OR interruptions and the errors they might induce have been few and uninformative, Feuerbacher and colleagues wrote.

In particular, prior studies have introduced atypical distractions (such as mental arithmetic) or confounded the OR environment with substandard conditions or circumstances (such as faulty equipment).

The authors sought to examine the impact of realistic distractions and interruptions on the performance of novice surgeons during clinical simulations. Participants consisted of 18 general surgery residents recruited from Oregon Health & Science University in Portland.

Each participant performed a simulated laparoscopic cholecystectomy with and without distractions or interruptions.

On the basis of 9 months of observation in an OR during actual surgery, investigators formulated four distractions:

  • Unexpected movement by an observer
  • A ringing cell phone answered by an observer
  • An unrelated conversation between an observer and a third party
  • Noise from dropping a metal tray

Additionally, investigators introduced two interruptions that required action by the surgeon: a question about a problem that had arisen in a recovering patient and a question about the participant's career choice.

Interruptions and distractions were timed to occur at critical decision-making points during the simulated procedure.

The primary outcome was the frequency of major surgical errors with OR distractions and interruptions versus no interruptions or distractions. The secondary outcome was the frequency of failure to remember to make a required announcement near the end of the procedure.

Overall, the difference in error rate between the two simulations achieved statistical significance (P=0.02). Four errors occurred in association with the question about the recovering patient and three in association with the conversation between the observer and a third person.

The eight errors were almost evenly distributed among second-year (3), third-year (3), and research-year residents (2).

Additionally, 10 of 18 participants (56%) forgot to make the announcement when distracted or interrupted versus four of 18 (22%) during the control simulation (P=0.04).

During the distracted condition, six of eight participants who made major surgical errors also forgot to make the announcement.

Post hoc analyses identified an association between surgical errors and time of day. Outcomes for the distracted and undistracted simulations occurred at approximately the same time. The authors found that all eight errors occurred after 1 p.m. (P=0.001).

Measures of fatigue had no association with surgical errors, nor did the order of the simulations (distracted condition first or second).

The time-of-day effect "suggests the participants had enough cognitive resources to perform the simulated surgical procedure when not distracted or interrupted, but not enough cognitive resources to simultaneously deal with OR distracts and interruptions," the authors wrote. "It is as if the OR distractions and interruptions put them over the edge after 1 p.m."

Because fatigue had no apparent association with errors, Feuerbacher and colleagues speculated that diurnal variations in blood concentrations of nutrients and hormones, whether the participant had lunch and if so at what time, and consumption of coffee or energy drinks might have contributed to the errors.

Primary source: Archives of Surgery     

Source reference: Feuerbacher RL, et al "Realistic distractions and interruptions that impair simulated surgical performance by novice surgeons" Arch Surg 2012; DOI:10.1001/archsurg.2012.1480.

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