Advertisement

Identification and interference of intraoperative distractions and interruptions in operating rooms

  • Sophia Antoniadis
    Affiliations
    Institute and Outpatient Clinic for Occupational, Social, and Environmental Medicine, University Hospital, Ludwig-Maximilians-University, Munich, Germany

    Department of Obstetrics and Gynecology, University Hospital Munich, Großhadern, Germany
    Search for articles by this author
  • Stefanie Passauer-Baierl
    Affiliations
    Institute and Outpatient Clinic for Occupational, Social, and Environmental Medicine, University Hospital, Ludwig-Maximilians-University, Munich, Germany
    Search for articles by this author
  • Heiko Baschnegger
    Affiliations
    Clinic of Anesthesiology, University Hospital, Ludwig-Maximilians-University, Munich, Germany
    Search for articles by this author
  • Matthias Weigl
    Correspondence
    Corresponding author. Institute and Outpatient Clinic for Occupational, Social, and Environmental Medicine, Ludwig-Maximilians-University, Ziemssenstrasse 1, D-80336 Munich, Germany. Tel.: +49 89 5160 5311; fax: +49 89 5160 5306.
    Affiliations
    Institute and Outpatient Clinic for Occupational, Social, and Environmental Medicine, University Hospital, Ludwig-Maximilians-University, Munich, Germany
    Search for articles by this author
Published:December 16, 2013DOI:https://doi.org/10.1016/j.jss.2013.12.002

      Abstract

      Background

      Intraoperative interruptions potentially interfere with surgical flow, contribute to patient safety risks, and increase stress. This study aimed to observe interruption events in operating rooms (ORs) and to measure surgical team's intraoperative interference from interruptions during surgery.

      Materials and methods

      Sixty-five surgical cases were observed at two surgical clinics in Germany (mainly abdominal and orthopedic surgery). An established observational tool was successfully adapted to German ORs. Various disruptions to surgical work were captured with a predefined coding scheme. In addition, the severity of each observed interruption was rated on behaviorally anchored scale to define the level of OR team involvement. Pilot test supported tools' reliability.

      Results

      Mean intraoperative duration was 1 h, 23 min (standard deviation = 50:55 min). Overall N = 803 intraoperative interruptions and disruption events were observed. Most frequent were people entering or exiting the OR and telephone or beeper calls. On average, OR teams were distracted or interrupted 9.82 times per hour (standard deviation = 3.97). Equipment failures and OR-environment–related disruptions were rated as the highest interference of OR team functioning. The involved OR professions were differently affected by interruption events. Distribution of intraoperative interruptions within the procedure varied significantly; during early stages of the case, significantly more interruptions were observed.

      Conclusions

      The study demonstrates the high level of interference in ORs. Furthermore, it provides a useful measure for intraoperative workflow disruptions and their interference of OR team functioning. OR environments need to be well designed to reduce unnecessary interruptions and distractions, so that surgical teams can manage their surgical tasks efficiently and safely.

      Keywords

      1. Introduction

      There is a growing interest in surgical workflow with particular focus on interruptions and distractions in operating rooms (ORs) [
      • Sevdalis N.
      • Forrest D.
      • Undre S.
      • Darzi A.
      • Vincent C.
      Annoyances, disruptions, and interruptions in surgery: the Disruptions in Surgery Index (DiSI).
      ,
      • Grundgeiger T.
      • Sanderson P.
      Interruptions in healthcare: theoretical views.
      ,
      • Wiegmann D.A.
      • ElBardissi A.W.
      • Dearani J.A.
      • Daly R.C.
      • Sundt T.M.I.
      Disruptions in surgical flow and their relationship to surgical errors: an exploratory investigation.
      ,
      • Sevdalis N.
      • Undre S.
      • McDermott J.
      • Giddie J.
      • Diner L.
      • Smith G.
      Impact of Intraoperative distractions on patient safety: a prospective descriptive study using validated instruments.
      ]. It stems particularly from a holistic systems view that emphasizes the contribution of the OR team and OR environment to safe and effective surgical care [
      • Vincent C.
      • Moorthy K.
      • Sarker S.K.
      • Chang A.
      • Darzi A.W.
      Systems approaches to surgical quality and safety: from concept to measurement.
      ,
      • Reason J.
      Human error: models and management.
      ,
      • Catchpole K.
      • Wiegmann D.
      Understanding safety and performance in the cardiac operating room: from 'sharp end' to 'blunt end'.
      ]. Research outside of health care (e.g., aviation, control rooms in high risk industries) demonstrated that interruptions and distractions can have detrimental consequences [
      • NTSB
      Aircraft accident report: Northwest Airlines, Inc, McDonnell Douglas DC-9–82, N312RC, 1987 (NTSB/AAR-88/05).
      ,
      • Monk C.A.
      • Trafton J.G.
      • Boehm-Davis D.A.
      The effect of interruption duration and demand on resuming suspended goals.
      ,
      • Carvalho P.V.R.
      • dos Santos I.L.
      • Vidal M.C.R.
      Safety implications of cultural and cognitive issues in nuclear power plant operation.
      ]. Similar studies in different hospital environments emphasized the high level of interruptions in health care, for example, in emergency rooms [
      • Chisholm C.D.
      • Dornfeld A.M.
      • Nelson D.R.
      • Cordell W.H.
      Work interrupted: a comparison of workplace interruptions in emergency departments and primary care offices.
      ,
      • Westbrook J.I.
      • Coiera E.
      • Dunsmuir W.T.
      • et al.
      The impact of interruptions on clinical task completion.
      ], inpatient wards [
      • Weigl M.
      • Müller A.
      • Zupanc A.
      • Glaser J.
      • Angerer P.
      Hospital doctors' workflow interruptions and activities: an observation study.
      ], or postoperative handover procedures [
      • Nagpal K.
      • Abboudi M.
      • Fischler L.
      • et al.
      Evaluation of postoperative handover using a tool to assess information transfer and teamwork.
      ]. In regard to ORs, the empirical evidence on interruptions and distractions is still sparse [
      • Sevdalis N.
      • Undre S.
      • McDermott J.
      • Giddie J.
      • Diner L.
      • Smith G.
      Impact of Intraoperative distractions on patient safety: a prospective descriptive study using validated instruments.
      ,
      • Sevdalis N.
      • Sonal A.
      • Undre S.
      • Vincent C.A.
      Distractions and interruptions in the operating room.
      ,
      • Gillespie B.M.
      • Chaboyer W.
      • Fairweather N.
      Factors that influence the expected length of operation: results of a prospective study.
      ].
      ORs are complex working environments with a high cognitive demand and a variety of potential distractions and interruptions of the surgical workflow. There is growing evidence that highly interruptive OR environments contribute to detrimental clinical performance, for example, extended procedure durations, incomplete safety checks, or errors [
      • Wiegmann D.A.
      • ElBardissi A.W.
      • Dearani J.A.
      • Daly R.C.
      • Sundt T.M.I.
      Disruptions in surgical flow and their relationship to surgical errors: an exploratory investigation.
      ,
      • Sevdalis N.
      • Undre S.
      • McDermott J.
      • Giddie J.
      • Diner L.
      • Smith G.
      Impact of Intraoperative distractions on patient safety: a prospective descriptive study using validated instruments.
      ,
      • Gillespie B.M.
      • Chaboyer W.
      • Fairweather N.
      Factors that influence the expected length of operation: results of a prospective study.
      ]. Surgical flow interruptions are an obstacle to effective surgical progress and hinder efficient case completion [
      • Sevdalis N.
      • Forrest D.
      • Undre S.
      • Darzi A.
      • Vincent C.
      Annoyances, disruptions, and interruptions in surgery: the Disruptions in Surgery Index (DiSI).
      ,
      • Sevdalis N.
      • Sonal A.
      • Undre S.
      • Vincent C.A.
      Distractions and interruptions in the operating room.
      ]. To create efficient and safe surgical care and reduce adverse events, ORs need to be well designed to enable smooth team performance [
      • Vincent C.
      • Moorthy K.
      • Sarker S.K.
      • Chang A.
      • Darzi A.W.
      Systems approaches to surgical quality and safety: from concept to measurement.
      ,
      • Catchpole K.
      • Wiegmann D.
      Understanding safety and performance in the cardiac operating room: from 'sharp end' to 'blunt end'.
      ].
      We define intraoperative interruptions and disruptions as events during the surgical procedure that potentially distract the OR team or OR member from a primary task or momentarily interrupt their task [
      • Healey A.N.
      • Sevdalis N.
      • Vincent C.A.
      Measuring intra-operative interference from distraction and interruption observed in the operating theatre.
      ]. In OR teams, interruptions disturb surgical workflow and are responsible for goal obstruction and detrimental task execution, thus, jeopardizing effective surgery and patient care [
      • Wiegmann D.A.
      • ElBardissi A.W.
      • Dearani J.A.
      • Daly R.C.
      • Sundt T.M.I.
      Disruptions in surgical flow and their relationship to surgical errors: an exploratory investigation.
      ]. In addition, disruptive OR environments may affect the communication among OR staff and the quality of intrateam coordination [
      • Sevdalis N.
      • Sonal A.
      • Undre S.
      • Vincent C.A.
      Distractions and interruptions in the operating room.
      ,
      • Sevdalis N.
      • Healey A.N.
      • Vincent C.A.
      Distracting communications in the operating theatre.
      ]. In regard to surgical quality, one observational study by Wiegmann et al. [
      • Wiegmann D.A.
      • ElBardissi A.W.
      • Dearani J.A.
      • Daly R.C.
      • Sundt T.M.I.
      Disruptions in surgical flow and their relationship to surgical errors: an exploratory investigation.
      ] demonstrated that interruptions during surgery are associated with erroneous surgical performance.
      To the best of our knowledge, there are few studies that focused primarily on assessing distraction and interruption events in real world ORs. Applied observational studies using valid and reliable assessments within real ORs enable more robust investigation of surgical flow interruptions [
      • Sevdalis N.
      • Undre S.
      • McDermott J.
      • Giddie J.
      • Diner L.
      • Smith G.
      Impact of Intraoperative distractions on patient safety: a prospective descriptive study using validated instruments.
      ,
      • Healey A.N.
      • Sevdalis N.
      • Vincent C.A.
      Measuring intra-operative interference from distraction and interruption observed in the operating theatre.
      ]. Capture of perioperative disruptions is a major step in creating an efficient environment for surgical teams [
      • Healey A.N.
      • Sevdalis N.
      • Vincent C.A.
      Measuring intra-operative interference from distraction and interruption observed in the operating theatre.
      ,
      • Rivera-Rodriguez A.J.
      • Karsh B.T.
      Interruptions and distractions in healthcare: review and reappraisal.
      ]. Second, there is still limited knowledge of the potential interference of interruption events for surgical team functioning. In regard to the complex dynamics and multiple activities in the OR, some distractions and interruptions may involve only single team members, whereas others involve the whole surgical team [
      • Healey A.N.
      • Sevdalis N.
      • Vincent C.A.
      Measuring intra-operative interference from distraction and interruption observed in the operating theatre.
      ]. Therefore, research is necessary to identify the degree of intraoperative interference for both single clinicians and the entire OR team.
      Our study set out to objectively identify distraction and interruption events during surgical procedures and to contribute to the growing intraoperative interruptions evidence base. Specifically, we sought to:
      • (1)
        identify and count the type of interruptions that occur during surgical procedures, and measure the interference of those events for the surgical teams;
      • (2)
        compare with what extent the various OR professions are individually affected; and
      • (3)
        to identify phases with increased interruption levels during surgical procedures.

      2. Methods

      2.1 Design

      Expert observation of surgical procedures was applied, using an established tool. Structured observations have been shown to be useful in various hospital settings [
      • Rivera-Rodriguez A.J.
      • Karsh B.T.
      Interruptions and distractions in healthcare: review and reappraisal.
      ,
      • Carthey J.
      The role of structured observational research in health care.
      ]. Particularly applied to ORs, the detailed identification of workflow interruptions and distractions is a feasible way to obtain information on interruption levels [
      • Sevdalis N.
      • Undre S.
      • McDermott J.
      • Giddie J.
      • Diner L.
      • Smith G.
      Impact of Intraoperative distractions on patient safety: a prospective descriptive study using validated instruments.
      ,
      • Healey A.N.
      • Sevdalis N.
      • Vincent C.A.
      Measuring intra-operative interference from distraction and interruption observed in the operating theatre.
      ]. The Ethics Committee of the Faculty of Medicine, Munich University, gave ethical approval for this study (No. 539-11).

      2.2 Study setting and sample

      Observations were conducted in two surgical clinics of a German University Hospital as part of an internal project on OR teamwork. The study included OR teams from several surgical specialties, including general or abdominal, orthopedic, and plastic surgery.
      A total of 65 procedures were sampled from the following surgical disciplines: vascular (N = 5, 7,7%), abdominal or general (N = 33, 50,8%), orthopedic or trauma (N = 23, 35,4%), and plastic surgery (N = 4, 6,2%). The observed intraoperative phase of surgery covered the time from incision to closure. The observation dates were selected randomly. Data were collected only during day shifts, and surgical procedures were selected from the departmental case list. Emergency procedures and procedures with a prospected duration of >4 h were excluded (to avoid staff rotation during the procedure and as the observational method is particularly demanding of attention). Team composition varied, as overall eight ORs were available. However, there was generally still some consistency in surgical and nursing personnel, who are consistently assigned to particular ORs. All ORs were comparable in terms of work organization, size, equipment, and staffing levels.
      The surgical OR team was considered as the staff assigned to a surgical case, comprising three main professions [
      • Healey A.N.
      • Sevdalis N.
      • Vincent C.A.
      Measuring intra-operative interference from distraction and interruption observed in the operating theatre.
      ]: (1) anesthetists and their assistants (including anesthesia nurse); (2) nursing group consisting of sterile nurse, circulating nurse, and occasionally any assisting nurse; and the (3) surgical group that comprised the operating and assisting surgeons including any surgical trainee.

      2.3 Data collection procedure

      All participants were informed before observation through departmental meetings and intranet information. Participation was voluntary, and consent was obtained from all OR staff members before the scheduled observation. Patient consent was not sought as patient identities and details were not gathered.
      Two observers (authors SA and MW) were trained before the study. They jointly conducted four pilot observations to gain a shared understanding of recording events and assigning ratings, as well to discuss potential inconsistencies. Before the main study data collection, inter-rater reliability on distraction events, and interference levels were obtained (see the following section). Both observers shadowed OR teams during the procedure and positioned themselves, so that all OR team members could be observed. Before surgery, the OR manager was asked where the observers could watch the case. They were instructed not to distract OR staff or to cause potentially interruptive events.

      2.4 Measures: observation of workflow interruptions

      An established tool to identify intraoperative workflow interruptions in ORs was applied [
      • Sevdalis N.
      • Undre S.
      • McDermott J.
      • Giddie J.
      • Diner L.
      • Smith G.
      Impact of Intraoperative distractions on patient safety: a prospective descriptive study using validated instruments.
      ,
      • Healey A.N.
      • Sevdalis N.
      • Vincent C.A.
      Measuring intra-operative interference from distraction and interruption observed in the operating theatre.
      ,
      • Sevdalis N.
      • Healey A.N.
      • Vincent C.A.
      Distracting communications in the operating theatre.
      ]. In line with previous research, we considered intraoperative interruption as an intrusion of an unplanned and unscheduled task or event, potentially causing a discontinuation of tasks, a noticeable break, or task switch behavior [
      • Wiegmann D.A.
      • ElBardissi A.W.
      • Dearani J.A.
      • Daly R.C.
      • Sundt T.M.I.
      Disruptions in surgical flow and their relationship to surgical errors: an exploratory investigation.
      ,
      • Sevdalis N.
      • Undre S.
      • McDermott J.
      • Giddie J.
      • Diner L.
      • Smith G.
      Impact of Intraoperative distractions on patient safety: a prospective descriptive study using validated instruments.
      ,
      • Healey A.N.
      • Sevdalis N.
      • Vincent C.A.
      Measuring intra-operative interference from distraction and interruption observed in the operating theatre.
      ]. The observational tool was translated and adapted into German. It enables coding of (1) predefined categories of interruptions and distracting events, and (2) the ratings for the extent the interruption event interferes with OR team functioning [
      • Sevdalis N.
      • Undre S.
      • McDermott J.
      • Giddie J.
      • Diner L.
      • Smith G.
      Impact of Intraoperative distractions on patient safety: a prospective descriptive study using validated instruments.
      ,
      • Healey A.N.
      • Sevdalis N.
      • Vincent C.A.
      Measuring intra-operative interference from distraction and interruption observed in the operating theatre.
      ,
      • Healey A.N.
      • Primus C.P.
      • Koutantji M.
      Quantifying distraction and interruption in urological surgery.
      ].

      2.4.1 Type of intraoperative interruption

      Eleven predefined sources of interruption events were coded: (1) people entering or exiting the OR; (2) phone or beeper calls; (3) radio-related distraction (e.g., radio too loud or noisy); (4) case irrelevant communication (CIC) by surgeons; (5) CIC by anesthetists; (6) CIC by nurses; (7) CIC by external personnel (e.g., patient transport and position staff); (8) equipment (missing or nonfunctioning provisions); (9) work environment (distraction related to OR environment, e.g., diathermy pedals in the wrong place); (10) procedural (distractions intrinsic to surgical work, e.g., surgeon teaching students or waiting for instantaneous sections results); (11) Movement in front or behind laparoscopic monitors (applicable during laparoscopic procedures).

      2.4.2 Severity or interference with team functioning

      To rate the observed effects for the surgical team, involvement in an interruption event was rated respectively on a nine-point ordinal scale [
      • Sevdalis N.
      • Undre S.
      • McDermott J.
      • Giddie J.
      • Diner L.
      • Smith G.
      Impact of Intraoperative distractions on patient safety: a prospective descriptive study using validated instruments.
      ,
      • Healey A.N.
      • Sevdalis N.
      • Vincent C.A.
      Measuring intra-operative interference from distraction and interruption observed in the operating theatre.
      ]. Scale points 1–3 refer to salient events that potentially or actually distract or interrupt the work of a circulating nurse: 1,potentially distracting source (e.g., beeper call but no one responds to it); 2, interference noticed by floating personnel (e.g., beeper call is noticed by the circulating nurses but not dealt with); 3, floating member attends to noncase distraction (e.g., the floating nurse responds to the beeper call). Scale points 4–6 refer to a single member of the OR team: 4, single team member momentarily distracted from the task (e.g., anesthetist orients away from the focal task of documentation to a beeper call while continuing with the documentation); 5, team member pauses current task (e.g., surgeon pauses laparoscopic examination to view surgical instruments tray while retaining control of instruments inserted in patient's abdomen); 6 team member attends to distraction (e.g., anesthetist responds to queries about the upcoming case). Scale points 7 (OR team member distracted momentarily) and 8 (team attends to distraction) include similar events but where two or more OR team members are involved. The highest point 9 (operation flow disrupted) refers to events when the whole surgical team is interrupted and needs to attend to the break-in event (e.g., equipment failure that stops the surgical procedure or the OR manager enters the room and discusses the case list with the entire team).
      The following additional information was noted by observers: number of OR professionals present; time of incision and closure (obtained from the surgical case documentation); time of the interruption events; those involved and affected by the interruption event (professional subgroups: surgical, nursing, and anesthesia team); surgical specialty, and open or minimally invasive procedures.

      2.5 Observation instrument: pilot testing of reliability

      Four pilot observations were conducted before the main study to test the reliability of the tool in terms of interobserver agreement [
      • Landis J.R.
      • Koch G.G.
      Measurement of observer agreement for categorical data.
      ]. Four intraoperative observations were conducted by two observers simultaneously (four procedures; range 41–171 min, sum 7 h, 39 min). One hundred seventeen intraoperative interruptions were identified (rater 1: N = 56; rater 2: N = 61). The resulting Kappa-coefficient based on detecting an interruption event was 0.93 (T = 20.08; P < 0.001) and the resulting Kappa-coefficient based on the correct categorization for each source was 0.61 (T = 19.91, P < 0.01). Regarding the interference ratings, observer scores correlated with r = 0.87 (N = 54). All results indicate substantial inter-rater agreement and support previous reliability tests of the observational tool [
      • Healey A.N.
      • Sevdalis N.
      • Vincent C.A.
      Measuring intra-operative interference from distraction and interruption observed in the operating theatre.
      ,
      • Landis J.R.
      • Koch G.G.
      Measurement of observer agreement for categorical data.
      ].

      2.6 Analyses

      Observational data were tabulated manually on clipboards, transferred via double data entry into a database and checked for errors and implausible values. Statistical tests included Spearman Rho correlation testing the observer agreement on their rating of interference (see the previous section). χ2 tests were applied for each intraoperative interruption source, tabulated across OR professions. Analysis of Variance was applied to compare interference levels across OR disciplinary groups. For investigating potential differences between the four phases of the surgical procedure, χ2 and mean difference tests were applied (t-test for paired samples). For all analyses that involved inferential statistics, a P value <0.05 was considered statistically significant.

      3. Results

      Overall, 65 surgical procedures were observed with an overall observation time of 89 h and 57 min. Mean intraoperative case duration, from incision to closure, was 1 h, 23 min with a range from 12.0 min to 3 h and 40 min (standard deviation, SD = 0:50:51).
      The open procedures (N = 44, 67.7%) included four vascular operations (11.4%), 17 visceral (38.6%), 15 orthopedic or trauma (34.1%), three plastic or hand (6.8%), and four nonclassified operations (e.g., change of vacuum bandage material, performed by different surgical specialties); minimally invasive procedures (N = 21, 32.3%) included 16 visceral (76.2%) and five orthopedic or trauma cases (23.8%).

      3.1 Sources of intraoperative surgical flow disruptions

      Overall, 803 intraoperative interruptions and distractions were identified. On average, 12.35 interruptions were coded per surgical procedure (SD = 7.35; range 2–32). This means that surgical teams were on average disrupted 9.82 times per hour (SD = 3.97; range 2.82–20.57). Table 1 presents total count and sum interference per interruption source from sampled 65 procedures.
      Table 1Observed intraoperative interruptions and distraction events: frequency and levels of interference for each source (N = 65 surgical procedures).
      SourceObserved intraoperative interruptions and distractionsInterferenceInterruptions per hour
      nn (%)n casesMax countMean interference per case (SD)Sum I-samplen per h
      (1)People entering OR24830.959142.95 (1.82)7312.76
      (2)Phone or beeper18823.453153.85 (1.92)7232.09
      (3)Radio50.6423.40 (1.52)170.06
      (4)CIC: surgeon718.83454.48 (1.13)3180.79
      (5)CIC: anesthetist486.03044.85 (1.38)2330.53
      (6)CIC: nurse354.42134.20 (1.43)1470.39
      (7)CIC: external personnel192.41545.42 (1.84)1030.21
      (8)Equipment failures607.53456.70 (1.78)4020.67
      (9)Work environment475.93046.11 (1.55)2870.52
      (10)Procedural799.83955.15 (2.33)4060.88
      (11)Movement in front or behind laparoscopic monitors (if applicable)30.4314.67 (1.15)140.03
      Overall8031004.19 (2.13)33819.82
      65 observations with overall observation time = 89 h, 57 min, 01 sec; CIC = Case irrelevant communication; I-sample = sum interference ratings from each source for cases where those events were recorded; max count = shows the maximum count of a recorded event for each source in a single case; mean interference per case (SD standard deviation) = the mean interference rating from each source to cases where those events where recorded (SD) scale 1 (potentially distracting event) to 9 (operation flow disrupted); n = number of interruptions; n cases = number of cases where a particular source was recorded; SD = standard deviation.
      Of all observed interruptions, most were caused by people entering OR (N = 248, 30.9%). The rest were attributed to phone or beeper interruptions (n = 188, 23.4%) and to procedural delays (N = 79; 9.8%).
      Additionally, Table 1 reports respective interferences for observed intraoperative interruptions sources. Comparatively, low interference levels were rated for the events people enter the OR (M = 2.95) and radio distractions (M = 3.40), whereas high interferences of team functioning were evaluated for equipment failures (M = 6.70) and work environment disruptions (M = 6.11). In addition, the last column in Table 1 presents the average prevalence for each interruption source. These prevalence numbers support that people entering the OR and phone or beeper interruptions were most frequently observed. In conclusion, all predefined interruption sources were observed and summed up to an overall interruption prevalence of M = 9.8 intraoperative interruptions per hour (cf., Table 1).

      3.2 Interruptions and interferences: relationships to OR professions

      We also coded which OR profession was affected by the observed interruptions. In the following analysis we analyzed if a single member (anesthetist, surgeon, or nurse) or the entire OR team was affected by the interruption. Table 2 displays the frequencies.
      Table 2Sources of observed intraoperative interruptions and distraction events and OR group (65 surgical procedures).
      SourcesAnesthetistsSurgeonsNursesTeamχ2 (df = 3)>P
      (1)People entering or exiting4427521228.350.001
      (2)Phone or beeper403844530.630.001
      (3)Radio01023.67n. s.
      (4)CIC: surgeon7404467.260.001
      (5)CIC: anesthetist72101323.290.001
      (6)CIC: nurse01051415.280.001
      (7)CIC: external personnel47243.0n. s.
      (8)Equipment failures34111271.770.001
      (9)Work environment01013466.730.001
      (10)Procedural63291825.150.001
      (11)Movement in front or behind laparoscopic monitors (if applicable)03004.59n. s.
      Overall11123011811868.190.001
      CIC = case irrelevant communication.
      With regard to single intraoperative interruption, the results reveal that the OR professions are affected differently (cf., Table 2). The surgeons' sub-team (i.e., surgeons and assistant surgeons) is significantly more often affected by intraoperative interruptions compared with their colleagues from nursing and anesthesia. The entire team is particularly affected if the OR environment causes the disruptions (cf., Table 2).
      With regard to mean interference caused by interruption events, we found significant differences between the involved OR professions. As Table 3 displays, interruption events that affected the entire team interfered most severely with OR team functioning. Furthermore, if surgeons' and anesthetists' intraoperative workflow was disrupted, interference ratings were higher compared with their nursing colleagues. Post hoc analyses for mean group differences showed that discrepancies were significant.
      Table 3Mean interference for OR professions.
      OR professionsInterference levelTest for significance difference (ANOVA)
      MeanSDF (df), P
      Anesthetists4.881.03112.97 (3), <0.001
      Surgeons5.211.62
      Nurses2.990.63
      Entire team6.381.89
      Overall4.931.81
      ANOVA = analysis of variance; SD = standard deviation.

      3.3 Intraoperative interruptions during the procedure: variation of time

      Furthermore, we were interested in the extent to which interruptions vary across procedure. With regard to the count of intraoperative interruptions and distractions, we found a significant effect across the four major phases of the procedure (cf., Fig.). In the initial phase (quartile 1: first 25% of the procedure length) significantly more interruptions and distractions were observed, compared with the consecutive phases of the procedure (χ2² [df = 3] = 35.35, P < 0.001).
      Figure thumbnail gr1
      FigIntraoperative interruptions and distractions during the course of N = 65 surgical procedures (procedure length divided into quartiles respectively). (Color version of figure is available online.)
      To test the robustness of this finding, we additionally weighted the interruption frequencies for each quartile to the overall length of the procedure respectively for each observation. This is necessary because the duration of the individual quartiles vary between the observed procedures with a mean duration of 20.76 min (SD = 12.72 min; range: 3–55 min). Then we tested the average frequencies of the observed interruptions and found similar patterns: during the first phase significantly more interruptions were observed (M = 3.15 interruptions during weighted quartile, SD = 1.91), compared with the second phase (M = 2.46, SD = 1.51, T [df = 3] = 2.23, P < 0.05), the third phase (M = 2.33, SD = 1.86, T [df = 3] = 2.47, P < 0.05), and the final phase (M = 1.83, SD = 1.74, T [df = 3] = 4.07, P < 0.001). In addition we found a significant difference between the second and fourth quartile (T [df = 3] = 2.36, P < 0.05).
      In a further step, we tested if this distribution is similar in all three affected OR professions (frequencies not presented): we found a similar significant variation for the surgeons (χ2 [df = 3] = 9.79, P < 0.05) and the entire team (χ2 [df = 3] = 21.32, P < 0.001). For the anesthesia sub-team (χ2[df = 3] = 3.78, n.s.) and nurses sub-team (χ2[df = 3] = 0.31, n.s.) the distribution of intraoperative interruptions was nonsignificant across the four OR phases.
      Last, we tested if the average interference level differed across the intraoperative phase. Overall, we obtained no significant effect of the mean interference across the four procedure quartiles (F [df = 3] = 0.49; n.s.). Also in a further analysis for the affected OR professions, we obtained no significant differences for surgical team (F [df = 3] = 2.27, n.s.), nursing sub team (F [df = 3] = 1.83, n.s.), anesthesia (F [df = 3] = 0.92, n.s.), and interferences that affected the entire team (F[df = 3] = 0.18, n.s.).

      4. Discussion

      This study aimed to investigate the prevalence, character, and distribution of intraoperative interruptions in ORs by applying an expert observation-based design. Overall, drawing on a sample of 65 procedures, intraoperative interruptions and distractions were observed 9.82 times per hour on average. These results illustrate that OR environments are prone to frequent workflow interruptions and match similar observational studies from the UK [
      • Healey A.N.
      • Sevdalis N.
      • Vincent C.A.
      Measuring intra-operative interference from distraction and interruption observed in the operating theatre.
      ,
      • Sevdalis N.
      • Healey A.N.
      • Vincent C.A.
      Distracting communications in the operating theatre.
      ].
      A closer look revealed that interruptions through people entering or exiting the OR and telephone or beeper calls were by far most frequent, in line with previous findings [
      • Healey A.N.
      • Sevdalis N.
      • Vincent C.A.
      Measuring intra-operative interference from distraction and interruption observed in the operating theatre.
      ,
      • Sevdalis N.
      • Healey A.N.
      • Vincent C.A.
      Distracting communications in the operating theatre.
      ]. Intraoperative interruptions caused by external staff, telephone or beeper, and irrelevant communication occurred most often. Thus, the study supports the relative contribution of different sources of workflow interruptions previously shown in the literature [
      • Sevdalis N.
      • Healey A.N.
      • Vincent C.A.
      Distracting communications in the operating theatre.
      ]. Although interruptions attributed to telephone or beeper indicate the high degree of intra- and interprofessional communication among hospital professionals, it also reflects the common tendency of hospital staff to engage in “communication mechanisms” that cause distractions and interruptions [
      • Sevdalis N.
      • Undre S.
      • McDermott J.
      • Giddie J.
      • Diner L.
      • Smith G.
      Impact of Intraoperative distractions on patient safety: a prospective descriptive study using validated instruments.
      ,
      • Sevdalis N.
      • Healey A.N.
      • Vincent C.A.
      Distracting communications in the operating theatre.
      ,
      • Rivera-Rodriguez A.J.
      • Karsh B.T.
      Interruptions and distractions in healthcare: review and reappraisal.
      ,
      • Coiera E.
      • Tombs V.
      Communication behaviours in a hospital setting: an observational study.
      ]. Similar to previous studies, procedure, equipment, and environment events were less frequent than the aforementioned, however, they often involved several OR team members [
      • Healey A.N.
      • Sevdalis N.
      • Vincent C.A.
      Measuring intra-operative interference from distraction and interruption observed in the operating theatre.
      ].
      Drawing on a systems perspective, our study considers the performance of all OR team members and addresses the surgical team as singular units of analysis [
      • Vincent C.
      • Moorthy K.
      • Sarker S.K.
      • Chang A.
      • Darzi A.W.
      Systems approaches to surgical quality and safety: from concept to measurement.
      ,
      • Sevdalis N.
      • Sonal A.
      • Undre S.
      • Vincent C.A.
      Distractions and interruptions in the operating room.
      ,
      • Healey A.N.
      • Sevdalis N.
      • Vincent C.A.
      Measuring intra-operative interference from distraction and interruption observed in the operating theatre.
      ]. Thus, our study also contributes to the growing evidence that distractions interfere with OR team functioning and effective surgical practice [
      • Sevdalis N.
      • Undre S.
      • McDermott J.
      • Giddie J.
      • Diner L.
      • Smith G.
      Impact of Intraoperative distractions on patient safety: a prospective descriptive study using validated instruments.
      ]. Although we found a large variation in interference score, surgical cases were included that showed high and intense interference during the procedure (cf., Table 1). Our results also show that frequent interruptions are not necessarily associated with increased interference. Specifically, certain frequent events (e.g., people entering or beeper calls) appeared less interfering because only rotating or fewer team members were affected. This increases the workload of the rotating nurse as she is dealing with extraneous interruption sources while simultaneously supporting the sterile nurse. Notwithstanding, equipment, work environment, and procedural events were responsible for a considerable amount of interference (cf., Table 1). This underlines previous findings, which show that if equipment or procedural problems occur, then surgical teamwork suffers and the surgical flow is disrupted [
      • Sevdalis N.
      • Sonal A.
      • Undre S.
      • Vincent C.A.
      Distractions and interruptions in the operating room.
      ,
      • Healey A.N.
      • Sevdalis N.
      • Vincent C.A.
      Measuring intra-operative interference from distraction and interruption observed in the operating theatre.
      ]. This refers to psychological research on task switching that shows detrimental effects of people switching from a primary to a secondary task [
      • Monsell S.
      Task switching.
      ]. Distractions stretch surgeons' cognitive resources and thus increase the potential for error. This calls for careful preoperative preparation and check ups to prepare equipment and test functioning, particularly in procedures that involve high technology like laparoscopic procedures. Intraoperative interference was especially exacerbated if material and equipment was not at hand or stored closely to the OR. Often we found operating doors opened for an extended time period, which contributes to increased environmental distraction, for example, noise from the hallway or induction room [
      • Healey A.N.
      • Sevdalis N.
      • Vincent C.A.
      Measuring intra-operative interference from distraction and interruption observed in the operating theatre.
      ].
      Aim 2 of our study was to examine potential differences between the OR professions. Our study shows that the frequency of intraoperative workflow interruptions was different for the involved OR professionals. This complements previous literature on OR team members' demands of completing individual and team tasks while dealing with distractions [
      • Sevdalis N.
      • Healey A.N.
      • Vincent C.A.
      Distracting communications in the operating theatre.
      ]. There is a broad scope of multilayered interruption events during the procedure that may differently affect the involved OR professionals. In addition, our study provides further insights into surgical teams' way of dealing with intraoperative interruptions; for example, the results show that if people enter the OR, mainly the rotating nurse and the anesthetists deal with the event (cf. Table 2). This may perpetuate conflict and stress in certain OR team members, as their primary tasks are compromised and surgeons may eventually recognize compromised performance [
      • Healey A.N.
      • Sevdalis N.
      • Vincent C.A.
      Measuring intra-operative interference from distraction and interruption observed in the operating theatre.
      ]. This raises potential conflict, as systemic problems of the organization and work environment may be responsible for inefficient practices that eventually increase stress and inefficient collaboration [
      • Vincent C.
      • Moorthy K.
      • Sarker S.K.
      • Chang A.
      • Darzi A.W.
      Systems approaches to surgical quality and safety: from concept to measurement.
      ,
      • Sexton J.B.
      • Thomas E.J.
      • Helmreich R.L.
      Error, stress, and teamwork in medicine and aviation: cross sectional surveys.
      ]. Our results complement previous findings on CIC in OR teams [
      • Sevdalis N.
      • Healey A.N.
      • Vincent C.A.
      Distracting communications in the operating theatre.
      ]. Surgeons often appeared to be at the center of staff's CICs as they received and initiated CICs, also across professions (which often is ‘small talk’ or relates to patients not at hand). We cannot conclude on potential consequences for surgical practices, and further research is needed into boundary conditions of harmful CIC. Under stressful surgical demands it could lead to the risk that the efficiency of overall communication is compromised [
      • Sevdalis N.
      • Healey A.N.
      • Vincent C.A.
      Distracting communications in the operating theatre.
      ,
      • Arora S.
      • Hull L.
      • Sevdalis N.
      • et al.
      Factors compromising safety in surgery: stressful events in the operating room.
      ]. Notwithstanding, small talk could also serve as a mean to establish positive social climate and effective rapport in the beginning of the procedure what may be effective for OR communication.
      Aim 3 was to identify potential variations of interruptions in time during the surgical procedure. The pattern of observed intraoperative interruptions across the respective surgical procedures revealed a significant decrease of disruption events in course of the surgical procedure. A significant peak of interruption events during the initial phases of the procedure was identified, that is, in our case the first two quartiles of the procedure. There is growing evidence that distractions add to the length of the procedure [
      • Healey A.N.
      • Primus C.P.
      • Koutantji M.
      Quantifying distraction and interruption in urological surgery.
      ]. We assume that particularly during initial stages, where surgeons carry out strategic planning, decision making, and resource planning, there is an increased cognitive demand and need for undisturbed attention. Surgeons value mental readiness and the ability to maintain focus. In the light of our findings, there is a particular risk that distractions in initial phases of the surgical procedure contribute to heightened cognitive load, extended durations for strategic decisions, incomplete check ups, delayed approaches to the target structure, and impaired surgical performance [
      • Sevdalis N.
      • Undre S.
      • McDermott J.
      • Giddie J.
      • Diner L.
      • Smith G.
      Impact of Intraoperative distractions on patient safety: a prospective descriptive study using validated instruments.
      ]. Furthermore, frequent distractions in the initial stages may be conducive to surgeons' stress and therefore, impact surgical performance during the consecutive phases of the procedure [
      • Sevdalis N.
      • Sonal A.
      • Undre S.
      • Vincent C.A.
      Distractions and interruptions in the operating room.
      ]. If interruptions elicit significant levels of stress and impose additional stressful demands upon the surgeons (or an OR team), safety and surgical performance will be compromised [
      • Arora S.
      • Hull L.
      • Sevdalis N.
      • et al.
      Factors compromising safety in surgery: stressful events in the operating room.
      ].
      Overall, our results emphasize that interruptions are ubiquitous in ORs. Often, surgical procedures demand undivided attention with high cognitive demands. Consequently, highly interruptive OR environments may interfere with and weaken cognitive alertness or memory processes that are important in carrying out the procedure and resuming the interrupted tasks effectively [
      • Grundgeiger T.
      • Sanderson P.
      Interruptions in healthcare: theoretical views.
      ,
      • Sevdalis N.
      • Sonal A.
      • Undre S.
      • Vincent C.A.
      Distractions and interruptions in the operating room.
      ].

      4.1 Limitations of the study

      First, our study uses an observational design. Although expert observations in ORs have been shown to be a reliable way to capture interruption events, observational approaches have limitations [
      • Catchpole K.
      • Wiegmann D.
      Understanding safety and performance in the cardiac operating room: from 'sharp end' to 'blunt end'.
      ,
      • Sevdalis N.
      • Sonal A.
      • Undre S.
      • Vincent C.A.
      Distractions and interruptions in the operating room.
      ,
      • Healey A.N.
      • Sevdalis N.
      • Vincent C.A.
      Measuring intra-operative interference from distraction and interruption observed in the operating theatre.
      ]. Our prior test of inter-rater agreement showed sufficient reliability for the observational tool. The interference level was defined as the relative involvement of the OR team. Although this is an established approach it cannot capture the subjective or experienced interference in the OR [
      • Healey A.N.
      • Sevdalis N.
      • Vincent C.A.
      Measuring intra-operative interference from distraction and interruption observed in the operating theatre.
      ]. This raises particular concerns if OR professionals are interrupted during individual tasks that are very sensitive to interruptions or distractions, for example, anesthetists calculates drug dose. Expertise and individual coping strategies to deal with interruptions are not taken into account either [
      • Sevdalis N.
      • Sonal A.
      • Undre S.
      • Vincent C.A.
      Distractions and interruptions in the operating room.
      ]. Thus, as our measure is focused towards surgical action, it may not fully account for such qualitative differences [
      • Healey A.N.
      • Sevdalis N.
      • Vincent C.A.
      Measuring intra-operative interference from distraction and interruption observed in the operating theatre.
      ]. Furthermore, it cannot capture the context of potentially interruptive events during the procedure what refers particularly to CIC. Observation tool's guidelines define to what extent communication events are rated as interruption events, that is, when significant risks for distraction or task switch behavior occur or are observed. CIC behaviors can be positive like for maintaining a good working relationship or reducing monotony during low demanding activities, that is, draping the patient. Notwithstanding, similar behaviors can pose significant risks for patient safety during complex and challenging phases of the case, for example, during a distal anastomosis of a tibial bypass. Future research attempts shall seek to disentangle the inherent cognitive and technical demands during the operation, case complexity, interruptive behaviors, and potential patient- and staffrelated outcomes.
      Second, the results are based on a university hospital in Germany. Although we obtained data in two different surgical centers with different ORs, selection bias may have occurred. In regard to surgical disciplines, we focused on mainly general and orthopedic surgery. Further limitations stem from that we only observed procedures from the regular case list. We cannot exclude that specific intraoperative interruptions may be more likely in other surgical specialties and emergency procedures. For this exploratory research, we did not include any information for complexity, type, and length of surgical tasks. Since we observed cases with an anticipated duration <4 h, our findings cannot simply be transferred to longer procedures that inherently have further interruptions because of staff rotation or breaks, for example, rotating staff takes lunch break and is replaced.
      Third, potential observer effects may have biased the prevalence of interruption frequencies. In addition, participant observations stress attention resources of the observers [
      • Healey A.N.
      • Sevdalis N.
      • Vincent C.A.
      Measuring intra-operative interference from distraction and interruption observed in the operating theatre.
      ]. Although we tried to conduct only one observation per day and that during the mornings, we cannot exclude that because of extended observation length, observers' fatigue increases, and interruption events are occasionally overlooked.
      One major issue concerns the ‘necessity’ or ‘legitimacy’ of workflow interruptions [
      • Weigl M.
      • Müller A.
      • Vincent C.
      • Angerer P.
      • Sevdalis N.
      The association of workflow interruptions and hospital doctors' workload: a prospective observational study.
      ]. A disruption in itself does not necessarily equate with compromised safety. Thus, intraoperative interruptions can be essential for surgical care and may have different effects and safety implications [
      • Sevdalis N.
      • Sonal A.
      • Undre S.
      • Vincent C.A.
      Distractions and interruptions in the operating room.
      ]. CIC may reduce boredom, social tension, monotonous work, or help to maintain awareness and vigilance [
      • Healey A.N.
      • Sevdalis N.
      • Vincent C.A.
      Measuring intra-operative interference from distraction and interruption observed in the operating theatre.
      ,
      • Jett Q.R.
      • George J.M.
      Work interrupted: a closer look at the role of interruptions in organizational life.
      ]. Therefore, a nuanced standpoint to considerably discuss the nature and potential consequences is required. This refers also to ‘opportune’ moments for surgical flow interruptions, that is, senior surgeon pausing and taking time for teaching. Such an event may be integral to the OR teaching environment and may bring the whole surgical team to the same intellectual point in the case.
      We also cannot exclude that intraoperative interruption were subjectively appraised differently among the OR staff, for example, that a surgeon does not acknowledge a specific interruption event or evaluates it as nondistracting. Moreover, there may be interruptive work routines that differ between the involved OR professions, whereas senior surgeons are mostly involved in the procedure, senior anesthetists regularly step into and exit OR to supervise junior anesthetists.

      4.2 Implications of the study

      The results of the present study carry several implications. Clinically, addressing and reducing unnecessary workflow interruptions is a potentially effective option for improving OR surgical performance [
      • Sevdalis N.
      • Sonal A.
      • Undre S.
      • Vincent C.A.
      Distractions and interruptions in the operating room.
      ]. Various systemic sources of distractions hinder surgical teams' ability to remain fully mentally engaged during a procedure. To reduce future mistimed workflow interruptions by external staff, an enhanced interprofessional collaboration through better organization of various tasks and deliberate design of joint activities, communication processes, and information transfer is advised. As poor OR teamwork predisposes surgical errors, we suggest team-based interventions to identify and reduce inadequate interruptions to contain interruptibility in ORs [
      • Wiegmann D.A.
      • ElBardissi A.W.
      • Dearani J.A.
      • Daly R.C.
      • Sundt T.M.I.
      Disruptions in surgical flow and their relationship to surgical errors: an exploratory investigation.
      ]. Reducing mutual workflow interruptions and structuring interprofessional collaboration is a promising strategy to enhance clinical safety.
      With regard to future research, these study implications address particularly the scope of intraoperative interruptions and potential consequences of frequent distraction events. Future research should address the single and cumulative effect of surgical flow disruptions, using cumulative interruption measures that take into account the multilayered interruptions during surgical procedures [
      • Healey A.N.
      • Sevdalis N.
      • Vincent C.A.
      Measuring intra-operative interference from distraction and interruption observed in the operating theatre.
      ]. Further research should also investigate the ‘ambiguous nature’ of interruption events. There are certainly interruptions that are beneficial to OR team functioning such as providing valuable clinical or process-related information, for example, for better clarification, immediate emergency response, acute error capture, or essential information on subsequent tasks [
      • Rivera-Rodriguez A.J.
      • Karsh B.T.
      Interruptions and distractions in healthcare: review and reappraisal.
      ,
      • Chisholm C.D.
      • Collison E.K.
      • Nelson D.R.
      • Cordell W.H.
      Emergency department workplace interruptions: are emergency physicians “interrupt-driven” and “multitasking”?.
      ]. Future research needs to investigate which interruptions lead to bad outcomes and unsafe OR practices and which interruption events serve effective surgical care. Last, doctors' individual expertise for coping and subjective appraisal of interruptive events may differ substantially according to severity, temporal duration, or nature of the event [
      • Sevdalis N.
      • Forrest D.
      • Undre S.
      • Darzi A.
      • Vincent C.
      Annoyances, disruptions, and interruptions in surgery: the Disruptions in Surgery Index (DiSI).
      ,
      • Healey A.N.
      • Sevdalis N.
      • Vincent C.A.
      Measuring intra-operative interference from distraction and interruption observed in the operating theatre.
      ]. Research in ward physicians (including surgical inpatient wards) demonstrates that frequent interruptions add to professionals' subjective workload [
      • Weigl M.
      • Müller A.
      • Vincent C.
      • Angerer P.
      • Sevdalis N.
      The association of workflow interruptions and hospital doctors' workload: a prospective observational study.
      ]. To our knowledge, there is no study that investigates the cumulative and prolonged effect of intraoperative workflow interruptions on OR professionals' workload. Investigating the impact of interruptions on stress and performance is a promising avenue for future research, particularly in training of junior surgeons and their coping strategies for demanding and stressful conditions in the OR [
      • Arora S.
      • Aggarwal R.
      • Moran A.
      • et al.
      Mental practice: effective stress management training for novice surgeons.
      ].

      5. Conclusions

      Surgery is a high-risk activity. This study found that there is considerable distraction and interruption in the OR interfering with the work of surgical teams. Eventually, these events may impact OR team performance and surgical outcome [
      • Wiegmann D.A.
      • ElBardissi A.W.
      • Dearani J.A.
      • Daly R.C.
      • Sundt T.M.I.
      Disruptions in surgical flow and their relationship to surgical errors: an exploratory investigation.
      ]. We found interruption sources extrinsic to operating procedures, particularly people entering or exiting the OR and beeper and phone calls, interfered with the surgical teamwork. However, factors intrinsic to the case at hand like interruptions because of equipment failures, distractions from the work environment and procedural problems, caused more intense interference in OR team functioning.
      Our results emphasize that ORs should be well-designed socio-technical systems [
      • Vincent C.
      • Moorthy K.
      • Sarker S.K.
      • Chang A.
      • Darzi A.W.
      Systems approaches to surgical quality and safety: from concept to measurement.
      ,
      • Catchpole K.
      • Wiegmann D.
      Understanding safety and performance in the cardiac operating room: from 'sharp end' to 'blunt end'.
      ]. Future attempts should address efforts for diminishing unnecessary intraoperative interruptions that jeopardize effective and safe surgical performance while maintaining effective and safe communication OR practices. Establishing a low level of interference, through balanced communication, high level of control in the OR environment, and high reliability in technology and equipment is a major avenue to foster surgical teamwork and safe patient care.

      Acknowledgment

      This study is a part of the Doctoral Dissertation Thesis of Sophia Antoniadis. We thank Rudolf Jörres for his comments on data analysis. The study was supported by Nick Sevdalis, who is affiliated with the Imperial Centre for Patient Safety and Service Quality (www.cpssq.org).
      This study was partly funded by the Research and Teaching Program of the Medical Faculty, Munich University (FöFoLE, Grant No. 752).
      Competing interests: None.
      This study was conducted with the approval of the Munich University, Ethics Committee of the Medical Faculty (No 539-11).
      Sophia Antoniadis coordinated and conducted data collection at the two sites. She drafted the initial manuscript and approved the final manuscript as submitted.
      Stefanie Passauer-Baierl was involved in tool development and data collection. She critically reviewed the initial draft and approved the final manuscript as submitted.
      Heiko Baschnegger was involved in tool development and preparation of data assessment. He critically reviewed and revised the manuscript, and approved the final draft as submitted.
      Matthias Weigl designed the study, obtained funding, and adapted the observational tool. He was involved in data assessment and performed the statistical analyses. He drafted the initial manuscript and approved the final manuscript as submitted.

      References

        • Sevdalis N.
        • Forrest D.
        • Undre S.
        • Darzi A.
        • Vincent C.
        Annoyances, disruptions, and interruptions in surgery: the Disruptions in Surgery Index (DiSI).
        World J Surg. 2008; 32: 1643
        • Grundgeiger T.
        • Sanderson P.
        Interruptions in healthcare: theoretical views.
        Int J Med Inform. 2009; 78: 293
        • Wiegmann D.A.
        • ElBardissi A.W.
        • Dearani J.A.
        • Daly R.C.
        • Sundt T.M.I.
        Disruptions in surgical flow and their relationship to surgical errors: an exploratory investigation.
        Surgery. 2007; 142: 658
        • Sevdalis N.
        • Undre S.
        • McDermott J.
        • Giddie J.
        • Diner L.
        • Smith G.
        Impact of Intraoperative distractions on patient safety: a prospective descriptive study using validated instruments.
        World J Surg. 2013; : 1
        • Vincent C.
        • Moorthy K.
        • Sarker S.K.
        • Chang A.
        • Darzi A.W.
        Systems approaches to surgical quality and safety: from concept to measurement.
        Ann Surg. 2004; 239: 475
        • Reason J.
        Human error: models and management.
        BMJ. 2000; 320: 768
        • Catchpole K.
        • Wiegmann D.
        Understanding safety and performance in the cardiac operating room: from 'sharp end' to 'blunt end'.
        BMJ Qual Saf. 2012; 21: 807
        • NTSB
        Aircraft accident report: Northwest Airlines, Inc, McDonnell Douglas DC-9–82, N312RC, 1987 (NTSB/AAR-88/05).
        National Transportation Safety Board, Washington1988
        • Monk C.A.
        • Trafton J.G.
        • Boehm-Davis D.A.
        The effect of interruption duration and demand on resuming suspended goals.
        J Exp Psychol Appl. 2008; 14: 299
        • Carvalho P.V.R.
        • dos Santos I.L.
        • Vidal M.C.R.
        Safety implications of cultural and cognitive issues in nuclear power plant operation.
        Appl Ergon. 2006; 37: 211
        • Chisholm C.D.
        • Dornfeld A.M.
        • Nelson D.R.
        • Cordell W.H.
        Work interrupted: a comparison of workplace interruptions in emergency departments and primary care offices.
        Ann Emerg Med. 2001; 38: 146
        • Westbrook J.I.
        • Coiera E.
        • Dunsmuir W.T.
        • et al.
        The impact of interruptions on clinical task completion.
        Qual Saf Health Care. 2010; 19: 284
        • Weigl M.
        • Müller A.
        • Zupanc A.
        • Glaser J.
        • Angerer P.
        Hospital doctors' workflow interruptions and activities: an observation study.
        BMJ Qual Saf. 2011; 20: 491
        • Nagpal K.
        • Abboudi M.
        • Fischler L.
        • et al.
        Evaluation of postoperative handover using a tool to assess information transfer and teamwork.
        Ann Surg. 2011; 253: 831
        • Sevdalis N.
        • Sonal A.
        • Undre S.
        • Vincent C.A.
        Distractions and interruptions in the operating room.
        in: Flin R. Mitchell L. Safer Surgery: Distractions and Interruptions in the Operating Room. Ashgate, Farnham2009: 405
        • Gillespie B.M.
        • Chaboyer W.
        • Fairweather N.
        Factors that influence the expected length of operation: results of a prospective study.
        BMJ Qual Saf. 2012; 21: 3
        • Healey A.N.
        • Sevdalis N.
        • Vincent C.A.
        Measuring intra-operative interference from distraction and interruption observed in the operating theatre.
        Ergonomics. 2006; 49: 589
        • Sevdalis N.
        • Healey A.N.
        • Vincent C.A.
        Distracting communications in the operating theatre.
        J Eval Clin Pract. 2007; 13: 390
        • Rivera-Rodriguez A.J.
        • Karsh B.T.
        Interruptions and distractions in healthcare: review and reappraisal.
        Qual Saf Health Care. 2010; 19: 304
        • Carthey J.
        The role of structured observational research in health care.
        Qual Saf Health Care. 2003; 12: ii13
        • Healey A.N.
        • Primus C.P.
        • Koutantji M.
        Quantifying distraction and interruption in urological surgery.
        Qual Saf Health Care. 2007; 16: 135
        • Landis J.R.
        • Koch G.G.
        Measurement of observer agreement for categorical data.
        Biometrics. 1977; 33: 159
        • Coiera E.
        • Tombs V.
        Communication behaviours in a hospital setting: an observational study.
        BMJ. 1998; 316: 673
        • Monsell S.
        Task switching.
        Trends Cogn Sci. 2003; 7: 134
        • Sexton J.B.
        • Thomas E.J.
        • Helmreich R.L.
        Error, stress, and teamwork in medicine and aviation: cross sectional surveys.
        BMJ. 2000; 320: 745
        • Arora S.
        • Hull L.
        • Sevdalis N.
        • et al.
        Factors compromising safety in surgery: stressful events in the operating room.
        Am J Surg. 2010; 199: 60
        • Weigl M.
        • Müller A.
        • Vincent C.
        • Angerer P.
        • Sevdalis N.
        The association of workflow interruptions and hospital doctors' workload: a prospective observational study.
        BMJ Qual Saf. 2012; 21: 399
        • Jett Q.R.
        • George J.M.
        Work interrupted: a closer look at the role of interruptions in organizational life.
        Acad Manage Rev. 2003; 28: 494
        • Chisholm C.D.
        • Collison E.K.
        • Nelson D.R.
        • Cordell W.H.
        Emergency department workplace interruptions: are emergency physicians “interrupt-driven” and “multitasking”?.
        Acad Emerg Med. 2000; 7: 1239
        • Arora S.
        • Aggarwal R.
        • Moran A.
        • et al.
        Mental practice: effective stress management training for novice surgeons.
        J Am Coll Surg. 2011; 212: 225