​Statement on Distractions

Developed By: Committee on Quality Management and Departmental Administration
Last Amended: October 15, 2025 (Original Approval: October 28, 2015)

Introduction 

Anesthesiologists perform complex tasks and are often required to have parallel cognitive awareness of more than one patient or work stream. Distractions and interruptions from normal workflow often occur in the operating room and in procedural areas (e.g., Pre-operative holding, Cardiac Catheterization Lab, Endoscopy, Interventional Radiology, Post Anesthesia Care Unit). An essential aspect of the safe anesthesia care environment includes managing the working environment to limit, and when possible to eliminate distractions that reduce appropriate attention to the patient. Equally important are the deleterious effects distractions have on anesthesia providers resulting in higher mental stress and poorer teamwork.¹ It is important to understand the multitude of possible distractions in order to mitigate potential detrimental effects.^2,3

Categories of Distraction

Technology Required for Direct Patient Care 
The use of technology is integral to the anesthesiologist’s workday. Electronic technologies including computers, smartphones, and handheld tablets are ubiquitous in the care environment and can improve medical decision making through rapid access to needed medical information and improved communication. Although the use of this technology is an essential part of medical practice, anesthesiologists must be disciplined in the use of these tools while providing direct patient care to avoid distraction.^3,4,5 Phone and electronic messaging use has increased significantly in the OR particularly for those also tasked with supporting clinical activity while providing direct patient care. In addition to fielding phone calls, much of the Electronic Health Record (EHR) as well as real-time patient data is becoming available on phone and tablet applications. Access to this information is critical to providing safe and modern anesthetic care; however, the added technology can distract the clinician from direct patient care. 

Other Technology
Personal electronic devices (PEDs) represent existing and evolving technologies that can become a direct and indirect source of occupational distraction and potentially contribute to clinician distraction. PEDs include, but are not limited to cell phones, tablets, smart watches, and laptop computers. Anesthesiologists, as leaders of the anesthesia care team, should defer nonessential activities such as social media, personal email, and other non-context relevant web searches.⁶

Interruptions related to the care of other patients
Whether practicing solo or in an anesthesia care team model, anesthesiologists are often responsible for the simultaneous care of multiple patients. Interruptions and distractions related to the care of other patients are inevitable and can occur even during critical periods. While focusing on the care of one patient in the operating room, an anesthesiologist may receive calls from the Post Anesthesia Care Unit (PACU) or pre-operative area regarding clinical management, orders, or medication changes of other patients. These types of interruptions may be unavoidable, and techniques should be considered to mitigate the impact of these distractions when possible. Ensuring that best practices for perioperative handoffs are followed, with attention to contingency planning and closed-loop communication may also help reduce the need for post-operative interruptions.

Distractions Due to Administrative Responsibilities
Anesthesiologists may also be faced with a variety of distractions related to administrative responsibilities necessary for the functioning of the operating rooms. These may include answering pages and phone calls related to the management of the operating room schedule, allocating resources for urgent or emergent cases, pre-operatively reviewing future surgical cases, and addressing immediate and future staffing needs. When possible, activities related to these responsibilities should be avoided by those providing direct care for patients or should be delayed until another clinician can safely assume direct care of the patient.

Using Technology to Limit Interruptions and Distractions
Information technology and PEDs can facilitate the management of unavoidable distractions and administrative responsibilities by helping the anesthesiologist resolve those responsibilities quickly and more efficiently while continuing to provide safe and effective care. Institutions and practices investing in OR communication and data availability technologies can be considered as a solution to some of the distractions anesthesiologists face while providing direct patient care, however the training and ability developed by the anesthesiologist to multitask in an OR and perioperative environment is critical to compensating for the unavoidable distractions.⁷

Ancillary Sounds and Alarms 
Excessive noise in the operating room environment makes it difficult to discern and understand information, hinders the ability to communicate effectively, and may lead to miscommunication, errors, and adverse patient events.^8,9,10 It is known that noise negatively impacts concentration and task performance among anesthesiologists as well as reduces the ability to detect signals from monitors and other equipment.^4,11,12 Studies focused on anesthesia have found the noisiest periods during surgery are associated with induction and emergence of anesthesia.¹³

Care-related or intrinsic sources of sound in the operating room include monitors and their alarms, surgical and anesthetic equipment and devices (e.g., lasers, robotics, forced air warmers, powered surgical tools), team communications, hand-offs and case-related conversations with anesthesia colleagues, and education of trainees. Anesthetic equipment alarms are meant to reduce harm and focus attention, and thus play a crucial role in safe anesthetic practice.¹⁴ The high frequency of “false alarms” and clinicians’ responses to address them, can be a significant operating room distraction for anesthesiologists.¹¹ This cycle can ultimately lead to “alarm fatigue,” due to the continuous effort required to differentiate true from false alarms. Efforts to address alarm and alert fatigue have focused on enhancing the informational value of each alarm, rather than increasing the sheer number of alarms. The Joint Commission has proposed the introduction of “smart alarms” for patient specific needs, clinician input and standardized evidence-based design criteria during operating room equipment development, as well as creation of tools to assist in institutional alarm safety protocols.¹⁵

Extrinsic or non-patient care related causes of noise in the operating room include music, irrelevant conversation, and excessive OR traffic.¹⁶ Music volume, genre, and lyrics must be selected with sensitivity to all team members and must be modulated during periods of critical care.¹⁷ Irrelevant and parallel conversations should be minimized, and operating room traffic should be controlled for both distraction and infection control reasons.

While eliminating all sources of noise in the OR is not feasible as many are necessary and unavoidable, organizations should consider a systems approach to minimize noise and improve patient safety and staff performance.¹⁸ Perioperative Team members should define no-interruption periods.^19,20,21 These are critical times in the operating room when any excessive noise or distraction may interfere with the patient’s safety and outcome. Some of these critical phases include time-outs, induction and emergence from anesthesia, critical surgical dissections, surgical counts, and post-operative debriefs.²² Anesthesiologists should educate the perioperative staff present in the operating room to help them understand that distractions to anesthesia providers represent a patient safety issue, pause any music on arrival to the operating room, and remind the staff in the operating room to provide silence during induction.²¹

Recommendations and Conclusions

Anesthesia groups and departments should work within their organizational structures to address the impact of distractions on the safe delivery of patient care.11 Development of local standards should always take into account Society and National accrediting body guidelines. Mitigation strategies and interventions may include:

• Establish a risk-stratified policy for acceptable and unacceptable use of PEDs
• Develop protocols for institutional alarm safety to prevent alarm fatigue 
• Establish guardrails regarding optional noise such as music played in critical areas 
• Minimize noise during critical time-periods
• Monitor and reinforce adherence to pre-procedure safety time out without distraction 
• Ongoing evaluation of new technologies for benefit and potential risk of distraction

Given the multi-factorial nature of distraction, communication, alarm and other technologies available in the perioperative space should be used to support the vigilance and skill of the anesthesiologist to multitask while providing patient care. Education about distraction and mitigation strategies can increase an organization’s and individual’s self-awareness and also provide tools to engage effective responses at both the individual and organizational level.¹

References:

1.  Wheelock A, Suliman A, Wharton R, et al. The Impact of Operating Room Distractions on Stress, Workload, and Teamwork. Ann Surg. 2015;261(6):1079‐1084.
2. Bretonnier M, Michinov E, Morandi X, Riffaud L. Interruptions in Surgery: A Comprehensive Review. J Surg Res. 2020;247:190‐196.
3. Feil MA. Distractions in the operating room. In: PJ Papadakos, S Bertman, eds. Distracted Doctoring. Pennsylvania Patient Safety Authority, Harrisburg, PA: Springer International Publishing, 2017:144-160. Accessed May 18, 2020.
4. Stevenson RA, Schlesinger JJ, Wallace MT. Effects of divided attention and operating room noise on perception of pulse oximeter pitch changes: a laboratory study. Anesthesiology. 2013;118(2):376‐381.
5. Jorm CM, O'Sullivan G. Laptops and smartphones in the operating theatre - how does our knowledge of vigilance, multi-tasking and anaesthetist performance help us in our approach to this new distraction?. Anaesth Intensive Care. 2012;40(1):71‐78.
6. Domino KB, Sessler DI. Internet use during anesthesia care: does it matter?. Anesthesiology. 2012;117(6):1156‐1158.
7. Jane L. Gui MD, Edward C. Nemergut MD and Katherine T. Forkin MD, Journal of Clinical Anesthesia, 2021-02-01, Volume 68, Article 110110
8. Oliveira CR, Arenas GW. Occupational exposure to noise pollution in anesthesiology. Rev Bras Anestesiol. 2012;62(2):253‐261.
9. Enser M, Moriceau J, Abily J, et al. Background noise lowers the performance of anaesthesiology residents' clinical reasoning when measured by script concordance: A randomised crossover volunteer study. Eur J Anaesthesiol. 2017;34(7):464‐470.
10. van Pelt M, Weinger MB. Distractions in the Anesthesia Work Environment: Impact on Patient Safety? Report of a Meeting Sponsored by the Anesthesia Patient Safety Foundation [published online ahead of print, 2017 Jun 9]. Anesth Analg. 2017;10.1213/ANE.0000000000002139.
11. Keller S, Tschan F, Beldi G, Kurmann A, Candinas D, Semmer NK. Noise peaks influence communication in the operating room. An observational study. Ergonomics. 2016;59(12):1541‐1552.
12. Joseph, Anjali & Ulrich, Roger. (2007). Sound Control for Improved Outcomes in Healthcare Settings. The Center for Health Design. 4.
13. Ginsberg SH, Pantin E, Kraidin J, Solina A, Panjwani S, Yang G. Noise levels in modern operating rooms during surgery. J Cardiothorac Vasc Anesth. 2013;27(3):528‐530.
14. Joint Commission. R3 report: Requirement, Rational, Reference: Alarm system safety. December 11, 2013. 
15. Rayo MF, Moffatt-Bruce SD. Alarm system management: evidence-based guidance encouraging direct measurement of informativeness to improve alarm response. BMJ Qual Saf. 2015;24:282-286.) 
16. Keller S, Tschan F, Semmer NK, et al. Noise in the Operating Room Distracts Members of the Surgical Team. An Observational Study. World J Surg. 2018;42(12):3880‐3887.
17. Nahai F. Music in the Operating Room: "Can You Hear Me Now?". Aesthet Surg J. 2015;35(7):899‐901.
18. Joint Commission. Minimizing noise and distractions in the OR and procedural units. August 2017;35. www.jointcommission.org/assets/1/23/Quick_Safety_Issue_35_2017_Noise_in_OR_FINAL.pdf. Accessed June 12, 2020.
19. Broom MA, Capek AL, Carachi P, Akeroyd MA, Hilditch G. Critical phase distractions in anaesthesia and the sterile cockpit concept. Anaesthesia. 2011;66(3):175‐179.
20. Saxton R, Cahill R. Impact of No-Interruption Intervention on Safety and Efficiency. J Nurs Care Qual. 2017;32(4):281‐284.
21. Crockett CJ, Donahue BS, Vandivier DC. Distraction-Free Induction Zone: A Quality Improvement Initiative at a Large Academic Children's Hospital to Improve the Quality and Safety of Anesthetic Care for Our Patients. Anesth Analg. 2019;129(3):794‐803.
22. Freundlich RE, Bulka CM, Wanderer JP, Rothman BS, Sandberg WS, Ehrenfeld JM. Prospective Investigation of the Operating Room Time-Out Process. Anesth Analg. 2020;130(3):725‐729.