By Don Sadler


If asked whether they would prefer to perform their jobs in a quiet, distraction-free environment or a loud, distracted environment, most people will probably choose the former.

This includes the surgeons and perioperative nurses who perform incredibly complex and detailed tasks upon which lives are dependent. So, it’s somewhat surprising that noise levels in operating rooms frequently exceed the EPA’s recommended level for continuous background noise in hospitals.

Interrupting Patient Care

Excessive noise in the OR can be harmful to patients and OR personnel, says Mary J. Ogg, MSN, RN, CNOR, Senior Perioperative Practice Specialist with the Association of periOperative Registered Nurses (AORN).

“Noise is a distraction that interrupts patient care and potentially increases the risk for error,” says Ogg. “It may minimize the ability of OR team members to communicate effectively, making it difficult to understand content and contributing to miscommunication.”

Noise and distractions in the OR increase the possibility of adverse patient outcomes by “diverting attention from the current task of a team member, which could lead to omissions and mental lapses,” adds Ogg. “This is especially relevant during critical phases of the surgical procedure.”

Such critical phases include time-out periods, critical dissections, surgical counts, confirming and opening of implants, induction and emergence from anesthesia, and care and handling of specimens.

One study evaluating OR noise levels during hernia repairs found that noise levels were substantially higher during wound closure for patients who developed surgical site infections.

Another study found that when the average noise level during OR trauma surgeries is 85 decibels (dBs), distractions and interruptions occurred an average of 60.8 times during the procedure.

And another study determined that the noisiest periods during surgery are associated with induction and emergence of anesthesia. Noise negatively impacts concentration and work among anesthesiologists, the survey found, and hinders the ability to detect signals from monitors and other equipment.

In a lab study simulating OR background noise, there was a 17 percent reduction in the accuracy of anesthesia residents in detecting changes in saturation on a pulse oximeter.

Noise Impacts on OR Staff

Excessive OR noise and distractions can also negatively impact OR staff.

“Noise in the OR is associated with job dissatisfaction, irritability, tachycardia, anxiety, fatigue, illnesses, stress, emotional exhaustion, burnout and injury,” says Ogg.

“High noise levels in the OR can interfere with concentration and make it difficult to hear and discern information and communicate effectively,” says Erin Lawler, MS, CPPS, Human Factors Engineer with the Office of Quality and Patient Safety, Division of Healthcare Improvement, The Joint Commission.

“This not only impacts productivity and efficiency, but it also contributes to adverse patient events,” adds Lawler.

Common Sources of OR Noise

Ogg lists a number of different sources of noise and distractions in the OR, including the following:

  • Medical equipment devices such as radiology equipment, waste management systems, smoke evacuators, powered surgical instruments, monitors, clinical and alert alarms, and dropped metal instruments.
  • Fixed communication devices such as overhead pages and announcements and landline telephones in the OR.
  • Environmental devices such as HVAC systems and pneumatic tube systems.
  • Personal communication and electronic music devices such as cellphones, pagers, personal digital assistants and digital audio players.
  • Behavioral activities by OR personnel such as having non-case relevant conversations and walking in and out of the OR during procedures.
  • Electronic activities by OR staff such as emailing, texting, posting on social media, surfing the Internet and playing games.

According to The Joint Commission, the EPA’s recommended level for continuous background noise in hospitals is 45 decibels (dB). However, one study measuring noise levels in OR trauma procedures found that average noise levels were 85 dB, or almost double this recommendation, and reached as high as 130 dB.

The highest sustained background noise levels tend to occur during orthopedic surgery and neurosurgery procedures. Intermittent peak noise levels exceed 100dB more than 40 percent of the time during these procedures, The Joint Commission notes.

Patient and Surgical Safety Risks

A study published in the Journal of the American College of Surgeons in 2013 was the first to demonstrate the patient and surgical safety risks posed by ambient background noise in the OR.

“The operating room is a very fast-paced, high-demand, all senses running on all cylinders type of environment,” stated study coauthor Matthew Bush, MD, assistant professor of surgery at the University of Kentucky Medical Center, upon the study’s publication.

“To minimize errors of communication, it is essential that we consider very carefully the listening environment we are promoting in the OR,” added Bush.
In this study, researchers created a noise environment similar to that of an OR and tested surgeons with a wide range of surgical experience. It concluded that background noise – and music in particular – resulted in a significant decrease in speech comprehension when the words were unpredictable.

“Our main goal is to increase awareness that operating room noise does affect communication,” said Bush. “The surgical team needs to work diligently to create the safest environment possible.”

“That step may mean either turning the music off or down, or limiting background conversations or other things in the environment that could lead to communication errors and medical mistakes,” added Bush.

How to Reduce Noise and Distractions

Given that miscommunication is one of the most common causes of preventable medical errors, there has been a concerted effort by some health care organizations to limit ambient background noise in the OR.

“The first step is to determine if there is a noise problem in the OR,” says Lawler.

She recommends using a sound level meter or a dosimeter to measure OR noise levels.

“It’s important to identify and understand sources of noise within the environment, including any nuisance sources,” says Lawler. “Then, you can employ a systems-based program to address the sources of noise and foster a culture to decrease noise.”

Lawler and Ogg suggest the following steps for reducing OR noise and distractions:

  • Create a no-interruption zone where nonessential conversation and activities are prohibited during the critical phases of the surgical procedure.
  • Insist that personal communication and electronic music devices like those listed above be placed on vibrate or silent mode during surgical procedures. Better yet, they should be turned off or left outside the OR if they aren’t needed for the procedure.
  • Use fixed communication devices only for essential communication, and make sure they’re turned down to the lowest volume.
  • Evaluate the level of noise generated by medical equipment devices during the purchase evaluation decision and consider equipment alternatives that produce less noise whenever possible.
  • Provide simulation and training to enhance OR staff members’ focused attention skills in the presence of continuous and intermittent noise and distractions.
  • Use care to quietly place metal instruments in trays, instead of loudly dropping instruments in trays.
  • Limit the amount of foot traffic going in and out of the OR during surgical procedures.

“Small adjustments can make a big difference,” says Lawler. “OR staff should practice effective team training and communication to ensure that information has been effectively received.

“And all team members should feel empowered to speak up and ask for silence if they feel like OR noise and distractions are becoming excessive,” Lawler adds.