Abstract
Background
Efficient and safe perioperative care is critical to optimizing surgical outcomes and reducing preventable errors. Orthopedic procedures, ranging from minimally invasive techniques to complex surgeries, place significant cognitive and physical demands on surgical teams. Disruptions in workflow can compromise efficiency, coordination, and patient safety. This study aimed to systematically identify and categorize surgical flow disruptions to inform quality improvement efforts.
Method
Forty orthopedic surgeries were observed. A human factors taxonomy was used to classify disruptions, and descriptive statistical analysis was applied.
Result
Of the 2343 total disruptions observed, Interruptions (46.39 %) were the most frequent, followed by communication failures (33.25 %), coordination challenges (13.19 %), layout inefficiencies (5.25 %), equipment issues (1.20 %), and usability concerns (0.73 %). This translated into one disruption every 3.7 min for the 40 surgeries.
Conclusions
Addressing surgical flow disruptions proactively can enhance perioperative efficiency, safety, and team coordination. This study presents system vulnerabilities, enabling the possibility of shifting the focus from reactive error analysis to proactive mitigation strategies.
1
Introduction
Distractions and disruptions at work are an inherent part of our daily lives. Cell phones, which notify us of phone calls, text messages, emails, and updates, along with interruptions from questions, comments, equipment issues, poor team coordination, and casual “water cooler conversations,” hinder our ability to complete our tasks efficiently. While many of these disruptions are harmless, the consequences can be severe in high-risk and complex tasks.
Distractions in operating theatres prevent team members from concentrating on the complex tasks required for a successful operation. Orthopedic surgery is known for its physical demands and technical complexity, with procedures like hip and knee arthroplasty involving the replacement of damaged sections with durable materials such as metal, ceramic, or polyethylene, designed for longevity and wear resistance. Balancing technical skills with communication is crucial in orthopedic surgery. Although time pressure is less of a concern compared to trauma surgery, communication breakdowns can pose significant risks. The pervasive use of personal electronic devices has introduced distractions that can lead to errors and accidents by dividing users’ attention.
Smith and Hancock’s (1995) model for situational awareness helps us understand resilience. Situational awareness is not inherent in the surgeon or the environment but results from the surgeon’s externally directed focus during a task. During surgery, the surgeon continuously monitors the environment for cues regarding the status of the operation and adjusts actions based on the interpretation of these cues. No surgery goes exactly as planned, and this externally directed focus amidst a dynamic task is what we call situational awareness.
Process inefficiencies or distractions can significantly impact this awareness, as they present cues irrelevant to the primary task. Increasing distractions consume cognitive resources that would be better focused on patient status and the central task. The role of process inefficiencies can be understood through the study of flow disruptions. Several studies have examined flow disruptions in the healthcare industry to understand the nature of these inefficiencies, which threaten the system. These disruptions are often investigated concerning the collective team rather than individual disciplines.
The theory of broken windows suggests that visible signs of anti-social behavior and minor criminal activity if left unaddressed, contribute to a sense of disorder and further problems in the environment. Recently, this theory has been linked to neighborhood disorders, highlighting the substantial negative impact of such disorders and behaviors on staff and patients. Boquet et al. likened flow disruptions to the broken windows in Wilson and Kelling’s theory, suggesting that these disruptions represent a form of system disorder that shifts surgery from order towards chaos. , Consequently, disruptions can be seen as threat windows, providing opportunities for errors and adverse events. As these disruptions accumulate during a surgical procedure, the threat window expands, increasing the likelihood of system breakdown.
Sociopsychological behavior disturbances in the orthopedic surgical room can significantly disrupt the flow, jeopardizing patient safety and surgical efficiency. Behavioral modeling in hand hygiene, workplace violence in hospitals, and clutter in surgical rooms are factors incorporated in the broken windows theory. Other surgical issues include negative deviations, tradeoffs, and time-pressured environments.
Studies have documented that the extent of flow disruptions (FDs) in a surgical setting range from minimal to maximum depending upon the procedural length. De Leval et al reported numerous minor flow disruption events which finally resulted in the mortality of the patient. Assistance in managing flow disruptions can be achieved through situational awareness and risk mitigation to enhance patient safety. The registered nurse (RN) circulator plays a crucial role in addressing flow disruptions and increasing surgical efficiency, thereby improving patient safety. Effective supervision and team leadership have been identified as key factors in mitigating workflow disruptions, necessitating the presence of perioperative leaders to ensure efficient workflow.
The objectives of this study are: (1) to introduce the concept of threat windows within the framework of the broken windows theory, providing a deeper insight into the impact of flow disruptions in orthopedic surgery; (2) to identify threat windows within an orthopedic surgical center; (3) to assess the practicality of applying an existing human factors classification system to categorize the identified threat windows.
2
Methods
This study used a prospective observational cohort design to examine flow disruptions (FDs) during orthopedic procedures at a community hospital in East Central Florida. A total of 40 orthopedic procedures were systematically observed by human factors researchers to identify and categorize disruptions in workflow.
Following the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) guidelines, this study systematically observed and classified workflow disruptions to identify patterns that may inform quality improvement efforts. The study was approved as a quality improvement project by the hospital’s research oversight committee and was exempt from Institutional Review Board (IRB) review, as it focused on process-related disruptions rather than patient outcomes. Hospital staff and team members were informed of the study’s purpose and the presence of observers. The observers were fourth year Ph.D. candidates in the Human Factors program at Embry-Riddle Aeronautical University. Researchers applied the RIPCHORD-TWA taxonomy (Realizing Improved Patient Care through Human-Centered Operating Room Design for Threat Windows Analysis) to systematically identify and classify flow disruptions. Observations were conducted independently, and classification was finalized through an iterative consensus process involving the human factors researchers and an orthopedic services manager, a certified surgical registered nurse, served as the study’s subject matter expert (SME). Each observation was first assessed to determine whether it constituted an FD, requiring unanimous agreement before classification. Once identified, the disruption was assigned a major and minor category from the RIPCHORD-TWA taxonomy using a predefined reference table to ensure consistency.
The SME also provided subjective assessments of FD frequency and qualitative comments to offer additional clinical context. To enhance validity, the SME provided independent ratings on the clinical impact of each FD using a 1-to-7 scale (1 = no impact, 7 = severe/egregious impact). Ratings were conducted in isolation to minimize bias. The SME also provided subjective assessments regarding the frequency of each type of FD and qualitative comments to provide additional context. By adhering to STROBE guidelines and employing a structured methodology, this study ensured rigorous classification and validation of flow disruptions, supporting the study’s goal.
3
Procedure
3.1
Data collection
Data were collected from the time the patient was wheeled in the operating room to the time the patient was wheeled out of the operating room. To systematically identify and classify flow disruptions, researchers utilized the RIPCHORD-TWA taxonomy (Realizing Improved Patient Care through Human-Centered Operating Room Design for Threat Windows Analysis). Researchers observed and recorded flow disruptions during the time the patient was in the operating room. Flow disruptions were operationally defined as those events that resulted in a delay or disturbance to a team member’s progress.
3.2
Data coding and classification
Disruptions were categorized using the RIPCHORD-TWA (Realizing Improved Patient Care through Human-Centered Operating Room Design for Threat Windows Analysis) human factors taxonomy. This framework includes six primary categories for classifying disruptions related to human factors: communication, coordination, equipment issues, interruptions, layout, and usability. The observer reached a consensus to classify each observation within the RIPCHORD-TWA framework. Descriptive statistics, such as the frequency and percentage of disruptions by category and the time taken, were calculated.
The RIPCHORD framework consists of six major categories for classifying functional disturbances: communication, coordination, equipment issues, interruptions, layout, and usability. Each major category can be further divided into minor categories, allowing for a detailed analysis of specific disruptions occurring in a particular setting (see Table 1 ).
| Communication (verbal and non-verbal) | Interruptions |
|---|---|
| Confusion | Alerts |
| Environmental noise | Distractions |
| Ineffective communication | Equipment/supplies |
| Lack of response | Interaction with biohazards |
| Lack of sharing | Searching activity |
| Nonessential communication | Spilling/dropping |
| Simultaneous communication | Task deviation |
| Teaching moments | |
| Coordination | Layout |
| Charting/documentation | Connector positioning |
| Personnel not available | Equipment positioning |
| Personnel rotation | Furniture positioning |
| Planning/preparation | Inadequate space |
| Protocol failure | Permanent structure positioning |
| Unknown information | Wires/tubing |
| Equipment issues | Usability |
| Anesthesia equipment | Barrier design |
| General equipment | Computer design |
| Perfusion equipment | Data entry (non-computer) design |
| Surgeon equipment | Equipment design |
| Packaging design | |
| Surface design |
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