Background

The anaesthetic work environment is often a complex and dynamic place; a range of tasks both mental and practical are required to be undertaken simulataneously1. When life and death decisions are made in these conditions, human error, equipment failure and organisational disturbances can lead to disastrous consequences2-4. Thus, patient safety is becoming of increasing interest to the medical profession5-7. A recent critical incident analysis in anaesthesia found, perhaps unsurprisingly, that human error was involved in 82% of preventable adverse events8; with distraction related to an estimated 43% of medical errors9. These statistics indicated the need for studying the work, tools and the environment of the anaesthetist to improve patient safety.

Concentration and attention to detail are prerequisites of safe anaesthetic practice, therefore it is imperative that we learn and understand how their breakdown, in a busy high pressured environment, leads to medical errors.

Research has been conducted into the frequency, cause and effect of distraction and interruption in the operating theatre for surgical teams7,10-12 but has yet to be studied for the anaesthetist.

Aims and Objectives

1) To measure the timing and frequency of distractions and interruptions to the anaesthetist

2) To explore the cause and effect of the relationships between concentration, distraction, interruption and error

3) To see if there are any strategies already in place which anaesthetists use to reduce distraction and interruption

4) To refine and develop the methodology for studying this topic to inform a future larger study

Methods

The research project ran over a four month period in late 2011. The project went through the following stages:

Phase 1 – Preparation

All anaesthetists at the Royal Lancaster Infirmary received a copy of the research proposal and the participant information sheet and were contacted for consent to a structured interview and for observational work to be conducted in the theatre session.

Structured interviews were held with anaesthetists to discover what types of distraction/interruptions are encountered and at which point in the anaesthetic process anaesthetists believe them to be most hazardous to patient safety. Existing strategies that are used to reduce distraction and interruption were explored. The structured interviews lasted approximately 15 minutes in duration.

An anaesthetic task recording sheet was produced to assist in data collection. Categories identified from previous research11 to record event sources included:

1. Telephone ringing

2. Bleeps/Pagers

3. An action to the radio

4. Case irrelevant communication

5. Communication difficulties

6. External staff

7. Equipment – unavailable or failing

8. Work environment

9. Procedural

10. Movement in front of the anaesthetic machine

Operating theatre managers will also receive a copy of the research proposal.

Phase 2 – Data Collection

Using the anaesthetic task recording sheet, stopwatch, pen and paper the observational work was conducted by one observer in the anaesthetic room and operating theatre to record the frequency, timing, cause and effect of distractions or interruptions on the anaesthetist. Data collection commenced when the anaesthetist entered the anaesthetic room and finished once the anaesthetist leaved recovery. To enable comparisons between studies definitions of distraction and interruption were taken from previous research10,11. Distraction being defined as a break in attention, observed by orientating away from a task or verbal response and an interruption defined a break in task activity, observed by the cessation of a task.

Fifty operations were observed. The observations occured during both morning and afternoon sessions and of varied surgical lists. A total of 50 anaesthetics was chosen based on previous research11,12 and to take into account the time frame assigned to data collection.

Phase 3 – Data Management and Analysis

The frequency, timing, cause and effect of distractions and interruptions were classified and statistically analysed.

No patient details were collected.

Phase 4 – Write Up

Phase 5 – Dissemination and Outcome

The results of this research were presented at a local meeting for the anaesthetic department and at the North West regional meeting for academic trainees. It is hoped that this project will form a basis for further research into distractions and interruptions in anaesthetic practice, which could lead to publication in a peer-reviewed journal.

Once the frequency, cause and effect of distractions and interruptions are known a strategy for managing these could be put into place for further evaluation. This could include practical solutions and recommendations for further training of theatre staff and the re-organising of workflow.

Preliminary results were presented to officers and members of the Royal College of Anaesthetists at their Patient Safety Conference in October 2011. The following meetings have already accepted presentations of our work:

Campbell G, Arfanis K, Smith AF. Barriers to the successful implementation of the WHO surgical checklist (poster). Association of Anaesthetists of Great Britain and Ireland meeting, Edinburgh, September 2012.

Arfanis K, Campbell G, Smith AF.  Distractions, interruptions and their impact on patient safety. Anaesthetists’ perceptions and existing coping strategies. To be presented at European Society of Anaesthesiology Euroanaesthesia meeting Paris, June 2012.

Ethical Issues

The research project was subject to trust and NHS Research Ethics Committee approval.

Brief summary of early findings:

This study has revealed that distracting events are frequent in anaesthetic practice. It is the first study we are aware of to observe the anaesthetic process in its entirety, following individual patients from before induction to arrival in the recovery room. Distractions were most numerous during emergence but also common in the time between leaving the anaesthetic room and the surgical incision. They most commonly arose from other members of staff in theatre, and can have negative consequences on anaesthetists and anaesthetic teams. We identified that events were more likely to be regarded as distracting if they violated a boundary, whether spatial, temporal or professional. Events are also more likely to be regarded as distracting if they occur at an inappropriate time. It is clear that distractions are an integral part of anaesthetic practice, and dealing with them is a key professional skill. Further, the ability to accomplish tasks, including two or more tasks simultaneously or in alternation, may depend not only on inherent task demands and the level of experience but also on methods of training and practice.

References

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3. Manser T, Wehner T. Analysing Action Sequences: Variations in Action Density in the Administration of Anaesthesia. Cognition, Technology and Work 2002;4:71-81

4. Stone R, McCloy R. Ergonomics in medicine and surgery. British Medical Journal 2004;328:1115-1118

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12. Sevdalis N, Healey AN, Vincent CA. Distracting communications in the operating theatre. Journal of Evaluation in Clinical Practice 2007;13(3):390-394