Raising the Standard: The Effect of Operating Room Distractions and How Objective Data Can Identify Ways to Improve Surgeon Focus and Patient Outcomes

| February 1, 2021

by Michelle P. Kallis, MD, PhD; Anthony Petrick, MD, FACS, FASMBS; and Dominick Gadaleta, MD, FACS, FASMBS

Dr. Kallis is a General Surgery Resident at North Shore University Hospital and Long Island Jewish Medical Center of Hofstra/Northwell in Manhasset, New York. Dr. Petrick is Chief Quality Officer, Geisinger Clinic; Director of Bariatric and Foregut Surgery, Geisinger Health System in Danville, Pennsylvania. Dr. Gadaleta is Chair, Department of Surgery, South Shore University Hospital; Director, Metabolic and Bariatric Surgery, North Shore and South Shore University Hospitals, Northwell Health, Manhasset, New York; Associate Professor of Surgery, Zucker School of Medicine at Hofstra/Northwell in Hempstead, New York.

FUNDING: No funding was provided for this article.

DISCLOSURES: The authors report no conflicts of interest relevant to the content of this article.

Bariatric Times. 2021;18(2):12–13

Anyone familiar with the operating room (OR) environment is undoubtedly aware of the multitude of distractions that are present. From pagers and phones ringing, to people walking in and out of the room, to side conversations between team members, to music playing, there are no shortage of disruptions within the OR that can potentially pull the surgeon’s attention away from the patient and the operation at hand. Intuitively, when the surgeon and OR team are distracted, this increases opportunities for errors. More than just intuition, the fact that distractions in the OR result in increased number of errors and poorer patient outcomes has been repeatedly demonstrated in the literature.1

Ultimately, the surgical errors that occur secondary to intraoperative distractions contribute significantly to surgery-associated morbidity and mortality in the United States (US).2 As discussed by Sevdalis et al,3 on average, one distraction occurs every 10 minutes while in the operating room. Through the use of correlational analyses, these authors demonstrate a negative association between intraoperative distractions and completion of patient directed tasks including patient vital monitoring by anesthesiologists and administration of blood and fluids by the operating room team, demonstrating that as the number of distractions increased, patient monitoring and treatment diminished.3 More recently, the American College of Surgeons Committee on Perioperative Care examined the accumulating literature correlating distractions in the OR with reductions in patient safety, and as part of this study they noted that auditory distractions occurred as frequently as every 40 seconds.4 Other similar studies in the literature specifically link auditory distractions with reduced surgical skill and accuracy.4 However, not all auditory distractions are created equal. Although music has been cited as a distraction itself, other studies have showed that specific types of music may actually enhance surgical skill.1 Jamaican music and classical music, for example, have been associated with improved task completion and accuracy.1

In bariatric surgery specifically, Ayas et al5 examined the relationship between intraoperative distractions and severe technical events during laparoscopic Roux-en-Y gastric bypass operations. These authors found that surgeons were interrupted a total of 47.6 times per hour; these interruptions included staff entering and exiting the room 17.8 times per hour and alarms sounding 26.7 times per hour.5 Machine alarms in the OR were not only the most common distraction encountered during surgery, but they were also correlated with increases in severe technical errors during critically important portions of the operation, suggesting that these distractions divert finite attention resources away from critical procedural steps.5

While it is apparent that distractions are pervasive within the OR and that these distractions contribute to suboptimal surgical performance, what is less clear is how these distractions can be mitigated and surgical performance improved. One of the limiting factors in understanding how to improve the complex ecosystem that exists within the OR has been the lack of objective data. Unlike other industries prone to high-risk accidents, such as trucking and aviation, that have objective and structured means of error analysis, the surgical profession has primarily relied upon subjective and retrospective means of error analysis including morbidity and mortality conferences and case reports.4,6 

To address the knowledge gap on how to improve safety in the OR, a Toronto-based group of surgeons developed the “OR Black Box” (Surgical Safety Technologies Inc., Toronto, Canada) to capture objective intraoperative data in real time that could be subsequently analyzed without the limitations associated with retrospective data.4 In contrast to previously used recording devices that capture only audiovisual data within the OR itself, the OR Black Box is able to continuously acquire multivariate intraoperative data including physiological data from both patients and surgeons, as well as laparoscopic and robotic video data.7

The first implementation of the OR Black Box in the US occurred in early 2019 at Long Island Jewish (LIJ) Medical Center in New York. The technology was brought to the institution by Dr. Louis Kavoussi, chair of urology for the Zucker School of Medicine at Hofstra/Northwell, who has been using the Black Box in his operating over the course of the last year.8 Although data is still in the process of being collected, preliminary data from the OR Black Box at LIJ has produced findings similar to previously published work on OR distractions, demonstrating that frequent traffic in and out of the operating room and a large number of auditory interruptions are among the most common causes of surgeon distraction.8 Given the preliminary success of the first Black Box at LIJ, the program was expanded to a second OR within the hospital at the beginning of this year, with the goal of eventually expanding the use of the OR Black Box more broadly throughout the Northwell health system.8

Throughout its history the “modern” OR has undergone a multitude of changes. Current ORs look vastly different from the open-air “operating theaters” of the early 19th century, and similarly the ORs of the future will undoubtedly be a product of continued advancement and innovation.9 The implementation of the OR Black Box is one such innovation that could vastly change how ORs function. The data amassed from the Black Box could not only be used to better understand and limit OR distractions, but it could also potentially identify and address other safety hazards within the OR. One could foresee utilizing similar computer-based technologies to identify sterility breaks or incorrect instrument counts. The use of the Black Box and other similar technologies has the potential to generate a greater understanding of how to promote a safer and more focused operative environment. The data collected will ultimately lead to evidence-based cultural and procedural changes within the OR that should improve surgical outcomes.


  1. Mentis HM, Chellali A, Manser K, et al. A systematic review of the effect of distraction on surgeon performance: directions for operating room policy and surgical training. Surg Endosc. 2016;30(5):1713–1724.
  2. Kohn L, Corrigan J, Donaldson MS. Committee on quality of health care in America. To err is human: building a safer health system. Natl Acad Press. 1999.
  3. Sevdalis N, Undre S, McDermott J, et al. Impact of intraoperative distractions on patient safety: a prospective descriptive study using validated instruments. World J Surg. 2014;38(4):751–758.
  4. Jung JJ, Jüni P, Lebovic G, Grantcharov T. First-year analysis of the operating room black box study. Ann Surg. 2020;271(1):122–127.
  5. Ayas S, Gordon L, Donmez B, Grantcharov T. The effect of intraoperative distractions on severe technical events in laparoscopic bariatric surgery. Surg Endosc. 2020 Aug 19. Online ahead of print.
  6. Singh H, Petersen LA, Thomas EJ. Understanding diagnostic errors in medicine: A lesson from aviation. Qual Saf Heal Care. 2006; 15(3):159–164.
  7. Goldenberg MG, Jung J, Grantcharov TP. Using data to enhance performance and improve quality and safety in surgery. JAMA Surg. 2017;152(10):972–973.
  8. Colangelo L. Lights, camera, surgery: LI hospital among first using “black box” technology. Newsday. January 12, 2020. Accessed December 11, 2020.
  9. Bharathan R, Aggarwal R, Darzi A. Operating room of the future. Best Pract Res Clin Obstet Gynaecol. 2013;27(3):311–322. 

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