The "Sterile Cockpit Rule" is a Federal Aviation Administration (FAA) regulation that was enacted in 1981 after a series of accidents were found to be caused by flight crew distraction from non-essential conversations during the most critical time of the flight takeoff and landing.
Under this regulation, crew members are prohibited from any non-essential duties or activities while the aircraft is below 10,000 feet. The FAA has recently expanded the rule by prohibiting pilots from using their personal tablets, smartphones, and laptops for personal use at any time during the entire flight. Distractions have caused pilots to forget to set the flaps before takeoff, extend the landing gear in preparation for landing, and to misinterpret the instrument information. Are these omissions any less significant than those found in operating rooms across the country, where distractions result in failing to conduct a proper airway history and assessment, failing to complete the "Time Out" correctly, and failing to correctly count sponges? Distractions threaten performance and jeopardize patient safety.
According to the American Society of Anesthesiologists Closed Claims Project 2011, the majority (68 percent) of difficult airway claims arise during the induction phase (analogous to takeoff). Retained foreign objects (sponges and instruments) and wrong site surgeries continue to be serious problems in the OR. Patient safety dictates that distractions be limited during specific critical times including the beginning of a case when the patient's airway is being secured; during the equipment and sponge count; and when the surgical site is being prepped. Individuals who work in the high risk industries of aviation and medicine have a substantial responsibility for ensuring the safety of the people they serve. Understanding that distractions increase the chance of error, the FAA has taken enormous steps to eliminate activities that could contribute to accidents. Hopefully, medicine will look to other high risk industries with improved safety records and adopt best practices or rigorously enforce its own regulations to eliminate the multiple distractions that plague OR physicians and staff. The safety of our patients demands our full attention.
Flying Like the Pros– Proactive Tips for Converting the OR into a Cockpit
1. Standardize the "Call for Quiet"– Implement a phrase that all staff will use during the critical times of starting and ending a case. A phrase such as "Safety Silence!" reminds all physicians and staff to cease all non-essential activity and conversation to create an environment that is entirely patient-centered.
2. De-ice the OR– Create an Atmosphere of Psychological Safety and Teamwork. Highly Reliable Healthcare Organizations (HROs) do not tolerate intimidating behaviors that cause tension and suppress the escalation of safety concerns. HROs value communication, teamwork, and the psychosocial climate that make both possible. Before starting the case, create an atmosphere of teamwork in service of patient safety by asking each team member to introduce themselves and by inviting anyone to escalate a patient safety concern at any time during the case.
3. Tuning Up the Time Out– Researchers from the Joint Commission cited team inattention during the Time-Out as a predominant risk for wrong site surgery. To improve team attention, consider structuring the Time-Out checklist as a series of questions, so that team members are forced to evaluate information before responding. Additionally, to increase engagement, assign each team member a brief, but specific task. When the entire team is engaged, the chances of catching an error increase greatly.
Kimberly Danebrock, RN, JD, is a professional risk management and patient safety executive with 30 years of combined experience in nursing, medical-legal, and risk management and patient safety. Ms. Danebrock develops and conducts risk management and patient safety educational presentations for physicians, residents, and office staff.
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