Statement on distractions
in the operating room
There are many opportunities for distraction in the operating room (OR). Some can be attributed to
the introduction of new technology, such as smartphone and mobile technology, and some are a function of noise levels, unnecessary conversation, and
other variables that dilute the focus of perioperative
team members because their attention is drawn “to…
different object[s] or different directions at the same
time.” 1, 2 Because of the deleterious effects of distraction on cognitive processing and the performance of
complex tasks and because of the potential impact of
distraction on patient safety, it is important to recognize and mitigate the risks of distraction in the OR.
Distraction can result from both intrinsic sources,
including alarms, noise from surgical devices, shift
changes, and necessary communications, as well as
extrinsic sources such as cell phones, beepers, computers and personal electronic devices, calls from outside
the OR, communication that is not relevant to the
case, visitors, and traffic in and throughout the OR.
All members of the surgical team may be affected.
The surgical checklist was developed as an analogy to flight crew checklists, which is a series of
procedures performed preliminary to takeoff that are
intended to ensure safety during flight operations.
By extension, the concept of the “sterile cockpit” has
been introduced to describe protocols intended to
limit distraction during critical periods in the OR. The
sterile cockpit protocol is designed to limit activities
that might “distract any flight crew member from
the performance of his or her duties or which could
interfere in any way with the proper conduct of those
duties.” 3, 4 One important difference between the OR
and the cockpit, however, lies in the timing of critical events. They are much more tightly concentrated
during flight. In the OR, critical events can and do
occur throughout the operation.
When the timing of critical events, such as the
clipping of an intracranial aneurysm or the initia-
tion of a cardiopulmonary bypass, can be predicted,
a structured communication protocol should be
implemented to reduce the risk of distraction and mis-
communication. The identification of critical phases
of surgery has been shown not only to reduce mis-
communication and distraction, but also operating
time and costs. 5
Distractions arising from technology
Newer technologies, including smartphones and
other handheld electronic devices, have become ubiquitous. In many hospitals, they have been integrated
into routine hospital communications and serve as
access points to patient data and images. As useful
and as important as they may be when used correctly,
the undisciplined use of these devices may enhance
distractions such as social media, e-mail, and other
forms of electronic communication for health care
As a practical matter, many surgeons have come
to rely on digital devices, including smartphones,
for voice and data communication outside the office.
Some institutions have established restrictive policies
regarding the use of digital devices whereas others
Therefore the ACS recommends that the use of
smartphones in the OR be guided by the following
• The undisciplined use of smartphones in the OR—
whether for voice, e-mail, or data communication,
and whether by the surgeon or by other members of
the surgical team—may pose a distraction and may
compromise patient care.
•Surgeons should be considerate of the duties of personnel in the OR suite and refrain from engaging them
unnecessarily in activities, including assistance in cellular communication, that might divert attention from
the patient or the conduct of the procedure.
This statement was developed by the American College of Surgeons (ACS) Committee on
Perioperative Care and approved by the ACS Board of Regents at its June 2016 meeting.