Quiet ORs Better for Patient Safety

This article appears in HealthLeaders Media, May 16, 2013

Music at loud decibels can contribute to miscues among surgeons and nurses in the operating room, raising the risk of medical error, researchers say.

Operating rooms are noisy places. There’s mechanical noise from whirring drills, beeping and humming from vital sign monitors, and whooshing sounds from fans and suction devices. Those sounds are largely unavoidable.

But then there’s human noise, from conversations, doors opening and closing, the clanging of team members handling instruments and equipment, and, of course, the sound of whatever songs the team wants to hear.

Now, a study is suggesting that all that noise could contribute to miscommunication that leads to errors or issues in patient safety, says Matthew Bush, MD, and colleagues from the University of Kentucky, Lexington.

Their project, described in an article this week in the Journal of the American College of Surgeons, exposed 15 volunteering surgeons to varying levels of noise from conversations, machinery and other operating room sounds. They found that the louder the noise, the less the surgeons were able to discern sentences accurately. When the doctors were asked to complete tasks simultaneously, their ability to hear accurately declined even further.

The music—Beatles tunes played at 74.2 decibels—was louder than normal conversational sound of about 60 db. But, Bush says, it was loud enough that “you’d have to raise your voice to be heard over this environment.”

Factor in that auditory ranges for operating room staff may be diminished by age or damage from occupational or environmental exposure, and the risk for miscommunication increases.

In fact, study results show that variances in comprehension levels were statistically significant, and should prompt hospital OR teams to think through their practices.

“We’re not advocating a completely silent operating room that is devoid of music, [or] devoid of social conversations or communication, because these are environments in which people can naturally work well together,” Bush emphasizes. “We certainly don’t want to create a workforce of silent drones.”

“What we do advocate as a result of our study is that each surgical team, and perhaps each institution, consider very carefully what’s being done, and what happens acoustically in their operating room settings.”

If members of the team are having difficulty hearing or communicating, if comments or requests must be repeated, “that all must be weighed by the surgical team, and people should say, ‘You know, I’m having difficulty communicating. Can we address this? Can we turn that monitor down? Could we stop for a minute and make sure we’re not making a mistake?”

In their experiment, which was conducted in an audiology lab not an operating room, surgeons were asked if they understood sentences. Some of the sentences were highly predictable—that is, if someone didn’t hear some of the words he or she could pretty well figure out what they might be from the context.

But other sentences used in the experiment were not highly predictable. When noise levels were high, and when the surgeons were asked to perform tasks in the lab, their ability to figure out the words in the sentence declined.

Bush, an otolaryngologist and audiology researcher, says that in his training experience in medical school, residency, and now in practice, he’s “seen a diverse array of operating room environments, with lots of different music styles and volumes.

“And I know from communicating with my colleagues and the co-authors of this paper that they have been exposed to music or loud conversations and distractions in the background that make it difficult to communicate. Every person who has worked in the operating room can think of times or situations where they weren’t able to communicate as well or hear what is being said because of loud music.”

Bush is quick to acknowledge that his study uses a very small sample, and has major limitations. For example, the surgeons were not tested for their ability to communicate with other members of their surgical team such as nurses or techs. “We need a study with more subjects and which involves more disciplines. But this is a dialogue starter, and that’s what it’s done at our institution.”

At the University of Kentucky’s outpatient surgery center, there’s now a hallway decibel monitor that signals green, yellow and red when noise levels rise.

“We’re trying to raise awareness that the volume of the sound in an environment matters, especially to patients who are scared and nervous as they travel into the operating room, and it’s also important for what happens in the operating room itself.”

Bush says that ongoing research by his team is looking at the impact of noise in the operating room on the ability of hearing-impaired surgeons, nursing and anesthesiology team members to understand what is being said. It may be, he acknowledged, that OR team members’ ability to hear may come under more routine scrutiny as well.

Bush emphasizes that it’s too early to recommend that institutions make policy changes. “There’s no basis to say, ‘No you can’t listen to this or you can’t do this.’ We’re not policy makers; we’re researchers We want to use scientific methods to ask a question and in an unbiased way, answer that question.”

He says, however, that “in medicine, as a culture, we realize that communication among providers is vital, and we’re going to have to look carefully at these factors. There are unavoidable elements, but we may be able to modulate and decrease the volume of some of the things we use in providing care, and minimize other distractions.”