Presentation
Human Factors Approach to Improving Communication in the Robotic Operating Room
SessionSurgery (HE6)
DescriptionMiscommunication in the Operating Room (OR) significantly contributes to surgical errors and patient harm, yet the current OR sound environment disrupts the communication that is essential for monitoring patient safety. Several factors hinder communication during robotic surgeries: 1) Physical distance: OR staff are often positioned 10-20 feet apart to manage equipment, sometimes necessitating a "messenger" to relay information. 2) Indirect communication: The console surgeon operates with their head in the console, facing away from the bedside assistant, and communicates through a microphone, with the message broadcasted via a speaker on the patient cart. Additionally, machines obstruct the view between anesthesia staff and others. 3) Noise: Multiple loud sound sources further interfere with communication. In our previous study, OR staff, including robotic surgeons and bedside assistants, reported that the noisy OR environment negatively impacted both job performance and team communication.
Despite extensive study, understanding why miscommunication occurs in the OR remains challenging due to its multifactorial nature, including issues like ambiguous language, difficulty interpreting messages, and the complex dynamics of team communication. Over the last two decades, research in both medicine and human factors has closely examined how the OR sound environment contributes to these communication failures. In this study, we aimed to observe communication among robotic OR staff using our validated Speech Communication Interference (SCI) instrument and suggest interventions rooted in human factors principles within the SEIPS model. The SCI instrument is defined as "surgery-related group discourse disrupted by either the communication goals or the physical and situational context." By focusing on how the OR environment affects speech, SCI identifies when and how critical messages among OR team members are obstructed.
We observed 78 robotic surgeries over a total of 215 hours, with 65.4% being General Surgery cases, most frequently cholecystectomies. Throughout the study, we documented the causes of miscommunication, near misses, and case delays associated with each SCI event, as well as strategies to address them. Post-surgery interviews with participants were conducted to reinforce our observations and analyzed thematically. We monitored all phases of surgery, including the critical moments, which are when patient safety is most at risk. For instance, in a laparoscopic cholecystectomy, the critical moment occurs during the dissection of the triangle of Calot, where the bile duct is most vulnerable to injury, making effective team communication essential.
Objective:
In this work, our objective was to observe speech communication interference events in the robotic OR to identify and describe the sound environment and tasks that hinder communication within the robotic surgical environment. By understanding the context of SCI events, better interventions can be designed to improve the robotic OR system and support team communication.
Presentation:
We will present findings from a prospective study in which we observed 78 surgeries, primarily general surgeries, to assess the frequency of SCI, defined as “group discourse disrupted due to participants, communication goals, or the physical and situational context.” Our observations spanned all phases of surgery, including critical moments where patient safety is most at risk. We also conducted supplemental observations, focusing on post-surgery interviews with participants involved in SCI events to identify contextual factors. Both observational notes and post-procedure interviews were thematically analyzed. Suggested interventions brainstormed by robotic OR frontline staff were categorized within the SEIPS model.
Results:
We identified 687 SCI events across 78 surgeries (mean 8.8±6.5 per case, or 3.2 per hour), with the number of events per case ranging from one to 28. Of these, 19.8% occurred during critical moments. Most SCI events (66.1%) happened while the receiver was engaged in another patient-related task. Tasks performed during these events included the circulating nurse updating the patient’s chart, the surgical attending or resident inserting a trocar, the scrub tech opening a package, or adjusting robotic equipment (such as docking the robot or repositioning the da Vinci monitors). Concurrent loud machine noise contributed to 10.8% of SCI events, while overlapping conversations between staff accounted for 4.2%. Machine noise was the predominant source of loud noise during SCI events (including light box fans, AirSeal fans, patient cart beeps, and surgeon console fans). Observations and post-op interviews also indicated that other loud noises, such as packaging, suction, and alarms, hindered the ability to hear requests, especially when the sender spoke quietly. Additionally, conversations in the room, whether relevant or irrelevant to the case, acted as both loud distractions and attention dividers, further complicating communication.
Each case had at least one SCI event, with up to 28 events occurring in a single case. Evidence of these events included the sender requesting repetition or clarification in 484 instances (70.5%), the sender repeating their message in 177 instances (25.8%), and no response from the receiver in 26 instances (3.8%). In these unacknowledged or unrepeated events, the message was lost. Successful strategies included repetition or deferment of the request until competing tasks were complete.
Attending surgeons were the most common sender (346, 50.6%), circulating nurses were the most common receiver (234, 34.9%), and scrub techs were the most common messenger (238, 57.2%). 61.7% of SCI events involved a messenger, most commonly the scrub tech (238, 57.2%)
During SCI events that involved a messenger, participants described the situation resembling a "telephone game," where the message was relayed through one or more team members before reaching the intended recipient. This often meant that instructions from the attending surgeon, delivered through the console microphone, were not clearly heard by the bedside assistant. In 247 instances (36.0%) of SCI events, the surgeon had to lean out of the console and turn towards the bed to repeat the instruction, yet the message still remained unclear.
Out of 634 SCI events, 601 (94.8%) were associated with a case delay. Delays had a median duration of 12.0 seconds. 5 seconds was the most common delay. Most case delays were resolved by clarification or repetition by the sender.
Conclusions:
Environmental noises, such as machine sounds and other conversations in the room, interfere with communication among the entire surgical team and can jeopardize patient safety. Research on the robotic OR noise environment supports the generalizability of our primary findings. Understanding why miscommunication occurs in the OR remains challenging, but utilizing SEIPS and other human factors systems will deepen our understanding of the elements that impact communication in the operating room. By reorganizing workflow, redefining team member tasks, and refining communication practices, we can minimize miscommunication and enhance surgical safety, efficiency, and patient care.
Suggestions to Reduce Speech Communication Interference in the Robotic OR categorized by SEIPS
Internal Environment
- Improve room layout so console surgeons’ backs are not to the bed
- Remove loud machines located between team members (i.e.: between scrub tech and CRNA)
- Improve line of sight between team members
- Sound absorbing materials on the loudest machines
Tools and Technology
- Equip staff with headsets and microphones, directed for key communications
- Add more microphones and speakers to the patient cart
- Install a surgeon-controlled light on circulating nurse’s station to get their attention
Tasks
- Do a sound check during the timeout to ensure the patient cart speaker is loud enough
- Decrease RN charting during the case
Organization
- Set a standard for acceptable dB levels on speakers for music
- Compose robotic teams with high familiarity to each other and the surgery itself
- Standardized scripts for common tasks
Despite extensive study, understanding why miscommunication occurs in the OR remains challenging due to its multifactorial nature, including issues like ambiguous language, difficulty interpreting messages, and the complex dynamics of team communication. Over the last two decades, research in both medicine and human factors has closely examined how the OR sound environment contributes to these communication failures. In this study, we aimed to observe communication among robotic OR staff using our validated Speech Communication Interference (SCI) instrument and suggest interventions rooted in human factors principles within the SEIPS model. The SCI instrument is defined as "surgery-related group discourse disrupted by either the communication goals or the physical and situational context." By focusing on how the OR environment affects speech, SCI identifies when and how critical messages among OR team members are obstructed.
We observed 78 robotic surgeries over a total of 215 hours, with 65.4% being General Surgery cases, most frequently cholecystectomies. Throughout the study, we documented the causes of miscommunication, near misses, and case delays associated with each SCI event, as well as strategies to address them. Post-surgery interviews with participants were conducted to reinforce our observations and analyzed thematically. We monitored all phases of surgery, including the critical moments, which are when patient safety is most at risk. For instance, in a laparoscopic cholecystectomy, the critical moment occurs during the dissection of the triangle of Calot, where the bile duct is most vulnerable to injury, making effective team communication essential.
Objective:
In this work, our objective was to observe speech communication interference events in the robotic OR to identify and describe the sound environment and tasks that hinder communication within the robotic surgical environment. By understanding the context of SCI events, better interventions can be designed to improve the robotic OR system and support team communication.
Presentation:
We will present findings from a prospective study in which we observed 78 surgeries, primarily general surgeries, to assess the frequency of SCI, defined as “group discourse disrupted due to participants, communication goals, or the physical and situational context.” Our observations spanned all phases of surgery, including critical moments where patient safety is most at risk. We also conducted supplemental observations, focusing on post-surgery interviews with participants involved in SCI events to identify contextual factors. Both observational notes and post-procedure interviews were thematically analyzed. Suggested interventions brainstormed by robotic OR frontline staff were categorized within the SEIPS model.
Results:
We identified 687 SCI events across 78 surgeries (mean 8.8±6.5 per case, or 3.2 per hour), with the number of events per case ranging from one to 28. Of these, 19.8% occurred during critical moments. Most SCI events (66.1%) happened while the receiver was engaged in another patient-related task. Tasks performed during these events included the circulating nurse updating the patient’s chart, the surgical attending or resident inserting a trocar, the scrub tech opening a package, or adjusting robotic equipment (such as docking the robot or repositioning the da Vinci monitors). Concurrent loud machine noise contributed to 10.8% of SCI events, while overlapping conversations between staff accounted for 4.2%. Machine noise was the predominant source of loud noise during SCI events (including light box fans, AirSeal fans, patient cart beeps, and surgeon console fans). Observations and post-op interviews also indicated that other loud noises, such as packaging, suction, and alarms, hindered the ability to hear requests, especially when the sender spoke quietly. Additionally, conversations in the room, whether relevant or irrelevant to the case, acted as both loud distractions and attention dividers, further complicating communication.
Each case had at least one SCI event, with up to 28 events occurring in a single case. Evidence of these events included the sender requesting repetition or clarification in 484 instances (70.5%), the sender repeating their message in 177 instances (25.8%), and no response from the receiver in 26 instances (3.8%). In these unacknowledged or unrepeated events, the message was lost. Successful strategies included repetition or deferment of the request until competing tasks were complete.
Attending surgeons were the most common sender (346, 50.6%), circulating nurses were the most common receiver (234, 34.9%), and scrub techs were the most common messenger (238, 57.2%). 61.7% of SCI events involved a messenger, most commonly the scrub tech (238, 57.2%)
During SCI events that involved a messenger, participants described the situation resembling a "telephone game," where the message was relayed through one or more team members before reaching the intended recipient. This often meant that instructions from the attending surgeon, delivered through the console microphone, were not clearly heard by the bedside assistant. In 247 instances (36.0%) of SCI events, the surgeon had to lean out of the console and turn towards the bed to repeat the instruction, yet the message still remained unclear.
Out of 634 SCI events, 601 (94.8%) were associated with a case delay. Delays had a median duration of 12.0 seconds. 5 seconds was the most common delay. Most case delays were resolved by clarification or repetition by the sender.
Conclusions:
Environmental noises, such as machine sounds and other conversations in the room, interfere with communication among the entire surgical team and can jeopardize patient safety. Research on the robotic OR noise environment supports the generalizability of our primary findings. Understanding why miscommunication occurs in the OR remains challenging, but utilizing SEIPS and other human factors systems will deepen our understanding of the elements that impact communication in the operating room. By reorganizing workflow, redefining team member tasks, and refining communication practices, we can minimize miscommunication and enhance surgical safety, efficiency, and patient care.
Suggestions to Reduce Speech Communication Interference in the Robotic OR categorized by SEIPS
Internal Environment
- Improve room layout so console surgeons’ backs are not to the bed
- Remove loud machines located between team members (i.e.: between scrub tech and CRNA)
- Improve line of sight between team members
- Sound absorbing materials on the loudest machines
Tools and Technology
- Equip staff with headsets and microphones, directed for key communications
- Add more microphones and speakers to the patient cart
- Install a surgeon-controlled light on circulating nurse’s station to get their attention
Tasks
- Do a sound check during the timeout to ensure the patient cart speaker is loud enough
- Decrease RN charting during the case
Organization
- Set a standard for acceptable dB levels on speakers for music
- Compose robotic teams with high familiarity to each other and the surgery itself
- Standardized scripts for common tasks
Authors
Event Type
Oral Presentations
TimeTuesday, April 12:15pm - 2:37pm EDT
LocationHarbour C
Hospital Environments (HE)