Presentation
Operating Room Interruptions in First and Final Surgical Counts: Insights and Mitigations From 4 Hospitals
DescriptionBackground and Rationale:
Surgical adverse events (AEs), such as instruments being left in the body (retained foreign objects, RFOs), remain a leading contributor to preventable injury and death. Despite surgical advances, RFOs remain a common problem, indicating gaps in existing safety measures, such as surgical counts. Performing surgical counts require the nursing team to account for all instruments and materials used during the procedure to ensure nothing is unintentionally left inside the patient. This process involves an initial and final count. While surgical counts are crucial for preventing RFOs, they are often challenging to execute accurately due to frequent interruptions.
Although not always harmful, task interruptions (defined as when a provider is impeded from performing their task by stopping to attend to another task) are recognized leading contributors to errors resulting in AEs or RFOs. Minimizing interruptions during critical moments of intense focus, is crucial for maintaining safety and accuracy. Previous interruption research often focuses narrowly on provider behavior, using retrospective analyses prone to recall bias. This approach overlooks system factors like tools, processes, and environment. To mitigate negative impacts in ORs, a paradigm shift is needed by: (1) moving beyond narrow focuses on individual provider behavior (2) using innovative methods to fully understand system factors that contribute to interruptions.
Study Objectives:
This study aims to: (1) identify the prevalence of interruptions and (2) characterize the interruptions (e.g., related or unrelated to task, by whom) during first and final surgical counts.
Methods:
We describe an exploratory observational study involving analysis of video recordings captured by the Operating Room Black Box® (ORBB, Surgical Safety Technologies Inc., Toronto, Canada), a novel system that collects and synchronizes sources of audio-visual data from the operating room. Observational data collected from the ORBB originate from operating rooms dedicated to a variety of surgeries at three large academic hospitals and one large community hospital. The target sample is approximately 30 cases per hospital (total: 120 cases).
Human factors specialists reviewed videos and manually transcribed events of interest (e.g., interruptions during surgical counts) into a Microsoft Excel spreadsheet. Each interruption was then further coded with 1) type of interruption and 2) the clinicians involved in the event (i.e. who does the interruption, who receives the interruption). Iterative qualitative coding of observed interruptions resulted in two high level categories of types of interruptions (unrelated vs related to current task), which were then further sub-divided as described below:
(1) Unrelated to Current Task: Person is interrupted (i.e., stop their counting task) by someone or something that is not related to their counting task. The interruption cause is further coded as:
- Physical: Person is asked to perform a new, unrelated task (i.e. sequential tasks) requiring them to do a physical action.
- Communication: Person is disrupted by someone engaging in small talk, greetings, or unrelated verbal communication.
Environment-audio: Person is disrupted by external sounds, such as a pager or phone call
(2) Related to Current Task. Person is interrupted (i.e., stop their counting task) by someone or something that is related to their counting task. The interruption cause is further coded as:
- Physical: Person is asked to perform another physical task related to their surgical count
- Communication: Person is disrupted by someone asking a question or communicating about patient care.
Preliminary Results:
As of October 9, 2024, 89 (of 120) surgical cases have been analyzed, incorporating 15 cases from hospital 1, 14 cases from hospital 2, 28 cases from hospital 3, and 32 cases from hospital 4. The prevalence and characterization of interruptions within the first surgical count and final surgical count was determined for all four hospitals.
First Surgical Count:
During the first surgical count, interruptions at hospitals 1, 2 and 3 were common with an average interruption per case of 27% (4 of 15 cases), 36% (5 of 14 cases), and 21% (6 of 28 cases), respectively. In contrast, hospital 4 had an average interruption per case of 3% (1 of 32 cases).
In the first surgical count across all hospitals, RNs received all interruptions. For all hospitals, the most common interruptions were unrelated to the first count due to physical requests from staff (hospital 1: 100%; hospital 2: 60%, hospital 3: 64%; hospital 4: 100%). Hospital 3 also had environment-audio unrelated interruptions (12%). 83% of all task-unrelated interruptions were initiated by surgeons.
Only hospital 2 and 3 had interruptions related to the first count from physical- (20% hospital 2, 12% hospital 3) and communication-related (20% hospital 2, 12% hospital 3) requests. Additionally, 100% of task-related interruptions were caused by external sources, involving communication (e.g., new individuals entering the OR, external staff asking questions about the next patient), task (e.g., request for gowns to be tied), or environmental factors (e.g. phone calls or pagers).
Final Surgical Count:
During the final surgical count, all hospitals struggled with interruptions. Hospital 1 had an average interruption per case of 27% (4 of 15 cases), hospital 2 had 50% (7 of 14 cases), hospital 3 had 39% (11 of 28 cases), and hospital 4 had 22% (7 of 32 cases).
In the final surgical count across all hospitals, RNs received all interruptions. For all hospitals, most common interruptions were unrelated to the final count due to physical requests from staff (hospital 1: 80%; hospital 2: 72%; hospital 3: 88%; hospital 4: 80%). 100% of unrelated-physical interruptions were caused by surgeons. Hospital 1 also had communication interruptions unrelated to counting (20%) and hospitals 2 and 4 had environment audio interruptions (14% hospital 2, 10% hospital 4). 100% of unrelated-communication or environment-audio interruptions were caused by external sources.
All hospitals, except Hospital 1, had interruptions related to the counting task; more specifically hospitals 2, 3 and 4 had interruptions for physical requests related to counting (14% hospital 2; 12% hospital 3; 10% hospital 4).
Discussion:
The results depict that most interruptions during instrument counting were unrelated to the counting tasks themselves, and involved interruptions requiring the physical completion of another task. This suggests a lack of system design to manage overlapping and conflicting requirements by different OR team members. ORBB data helped reveal deeper insights into unique issues between first and final surgical counts by comparing issues across hospitals, revealing potential improvements.
A notable finding within the first surgical count was that hospital 2 had 12 times higher prevalence of interruptions than hospital 4. This stark difference in interruption proportion between two hospitals provide fascinating avenues of analyses in determining system factors that lead to these differences. For example, the nurses at hospital 2 struggled with interruptions both related (e.g., surgeons’ asking to locate instruments) and un-related (e.g., surgeons’ asking tie gowns) predominantly from surgeons aiming to get set up for the case. In contrast, ORBB data revealed that hospital 4 implemented a policy that protected time (not permitting other activities to be performed simultaneously) for the first surgical count, thereby almost eliminating interruptions. Therefore, a similar policy should be reviewed and considered at other hospitals given its safety benefit.
A notable finding within the final surgical count was that all hospitals seem to struggle with interruptions, marking this as a critical area of further study. In particular, all hospitals saw at least four times more unrelated (89%) than related (11%) interruptions, with many interruptions notably caused by other team members’ communication and external sources. Through ORBB data, built-in multi-tasking was observed to have occurred at all hospitals during this phase (e.g. simultaneous management of tools/equipment, responding to requests from team members, etc.). Therefore, identified issues are consistent across hospitals, highlighting the opportunity collaborative research.
Surgical adverse events (AEs), such as instruments being left in the body (retained foreign objects, RFOs), remain a leading contributor to preventable injury and death. Despite surgical advances, RFOs remain a common problem, indicating gaps in existing safety measures, such as surgical counts. Performing surgical counts require the nursing team to account for all instruments and materials used during the procedure to ensure nothing is unintentionally left inside the patient. This process involves an initial and final count. While surgical counts are crucial for preventing RFOs, they are often challenging to execute accurately due to frequent interruptions.
Although not always harmful, task interruptions (defined as when a provider is impeded from performing their task by stopping to attend to another task) are recognized leading contributors to errors resulting in AEs or RFOs. Minimizing interruptions during critical moments of intense focus, is crucial for maintaining safety and accuracy. Previous interruption research often focuses narrowly on provider behavior, using retrospective analyses prone to recall bias. This approach overlooks system factors like tools, processes, and environment. To mitigate negative impacts in ORs, a paradigm shift is needed by: (1) moving beyond narrow focuses on individual provider behavior (2) using innovative methods to fully understand system factors that contribute to interruptions.
Study Objectives:
This study aims to: (1) identify the prevalence of interruptions and (2) characterize the interruptions (e.g., related or unrelated to task, by whom) during first and final surgical counts.
Methods:
We describe an exploratory observational study involving analysis of video recordings captured by the Operating Room Black Box® (ORBB, Surgical Safety Technologies Inc., Toronto, Canada), a novel system that collects and synchronizes sources of audio-visual data from the operating room. Observational data collected from the ORBB originate from operating rooms dedicated to a variety of surgeries at three large academic hospitals and one large community hospital. The target sample is approximately 30 cases per hospital (total: 120 cases).
Human factors specialists reviewed videos and manually transcribed events of interest (e.g., interruptions during surgical counts) into a Microsoft Excel spreadsheet. Each interruption was then further coded with 1) type of interruption and 2) the clinicians involved in the event (i.e. who does the interruption, who receives the interruption). Iterative qualitative coding of observed interruptions resulted in two high level categories of types of interruptions (unrelated vs related to current task), which were then further sub-divided as described below:
(1) Unrelated to Current Task: Person is interrupted (i.e., stop their counting task) by someone or something that is not related to their counting task. The interruption cause is further coded as:
- Physical: Person is asked to perform a new, unrelated task (i.e. sequential tasks) requiring them to do a physical action.
- Communication: Person is disrupted by someone engaging in small talk, greetings, or unrelated verbal communication.
Environment-audio: Person is disrupted by external sounds, such as a pager or phone call
(2) Related to Current Task. Person is interrupted (i.e., stop their counting task) by someone or something that is related to their counting task. The interruption cause is further coded as:
- Physical: Person is asked to perform another physical task related to their surgical count
- Communication: Person is disrupted by someone asking a question or communicating about patient care.
Preliminary Results:
As of October 9, 2024, 89 (of 120) surgical cases have been analyzed, incorporating 15 cases from hospital 1, 14 cases from hospital 2, 28 cases from hospital 3, and 32 cases from hospital 4. The prevalence and characterization of interruptions within the first surgical count and final surgical count was determined for all four hospitals.
First Surgical Count:
During the first surgical count, interruptions at hospitals 1, 2 and 3 were common with an average interruption per case of 27% (4 of 15 cases), 36% (5 of 14 cases), and 21% (6 of 28 cases), respectively. In contrast, hospital 4 had an average interruption per case of 3% (1 of 32 cases).
In the first surgical count across all hospitals, RNs received all interruptions. For all hospitals, the most common interruptions were unrelated to the first count due to physical requests from staff (hospital 1: 100%; hospital 2: 60%, hospital 3: 64%; hospital 4: 100%). Hospital 3 also had environment-audio unrelated interruptions (12%). 83% of all task-unrelated interruptions were initiated by surgeons.
Only hospital 2 and 3 had interruptions related to the first count from physical- (20% hospital 2, 12% hospital 3) and communication-related (20% hospital 2, 12% hospital 3) requests. Additionally, 100% of task-related interruptions were caused by external sources, involving communication (e.g., new individuals entering the OR, external staff asking questions about the next patient), task (e.g., request for gowns to be tied), or environmental factors (e.g. phone calls or pagers).
Final Surgical Count:
During the final surgical count, all hospitals struggled with interruptions. Hospital 1 had an average interruption per case of 27% (4 of 15 cases), hospital 2 had 50% (7 of 14 cases), hospital 3 had 39% (11 of 28 cases), and hospital 4 had 22% (7 of 32 cases).
In the final surgical count across all hospitals, RNs received all interruptions. For all hospitals, most common interruptions were unrelated to the final count due to physical requests from staff (hospital 1: 80%; hospital 2: 72%; hospital 3: 88%; hospital 4: 80%). 100% of unrelated-physical interruptions were caused by surgeons. Hospital 1 also had communication interruptions unrelated to counting (20%) and hospitals 2 and 4 had environment audio interruptions (14% hospital 2, 10% hospital 4). 100% of unrelated-communication or environment-audio interruptions were caused by external sources.
All hospitals, except Hospital 1, had interruptions related to the counting task; more specifically hospitals 2, 3 and 4 had interruptions for physical requests related to counting (14% hospital 2; 12% hospital 3; 10% hospital 4).
Discussion:
The results depict that most interruptions during instrument counting were unrelated to the counting tasks themselves, and involved interruptions requiring the physical completion of another task. This suggests a lack of system design to manage overlapping and conflicting requirements by different OR team members. ORBB data helped reveal deeper insights into unique issues between first and final surgical counts by comparing issues across hospitals, revealing potential improvements.
A notable finding within the first surgical count was that hospital 2 had 12 times higher prevalence of interruptions than hospital 4. This stark difference in interruption proportion between two hospitals provide fascinating avenues of analyses in determining system factors that lead to these differences. For example, the nurses at hospital 2 struggled with interruptions both related (e.g., surgeons’ asking to locate instruments) and un-related (e.g., surgeons’ asking tie gowns) predominantly from surgeons aiming to get set up for the case. In contrast, ORBB data revealed that hospital 4 implemented a policy that protected time (not permitting other activities to be performed simultaneously) for the first surgical count, thereby almost eliminating interruptions. Therefore, a similar policy should be reviewed and considered at other hospitals given its safety benefit.
A notable finding within the final surgical count was that all hospitals seem to struggle with interruptions, marking this as a critical area of further study. In particular, all hospitals saw at least four times more unrelated (89%) than related (11%) interruptions, with many interruptions notably caused by other team members’ communication and external sources. Through ORBB data, built-in multi-tasking was observed to have occurred at all hospitals during this phase (e.g. simultaneous management of tools/equipment, responding to requests from team members, etc.). Therefore, identified issues are consistent across hospitals, highlighting the opportunity collaborative research.
Event Type
Oral Presentations
TimeTuesday, April 12:15pm - 2:37pm EDT
LocationQueens Quay
Patient Safety and Research Initiatives (PS)