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"Flying right": Adapting aviation’s ‘sterile cockpit rule’ to improve patient safety in the OR

The "Sterile Cockpit Rule" is a Federal Aviation Administration (FAA) regulation which prohibits crew members from performing any non-essential duties or activities while the aircraft is below 10,000 feet including the use of tablets, smartphones, and laptops for personal use during a flight. 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.

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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 and wrong site surgeries continue to be serious problems in the OR. Patient safety dictates that distractions be limited during 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. 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 multiple distractions that plague OR physicians and staff.

Learn to fly like the pros by following these 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, such as "Safety Silence!", which reminds 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) value communication and teamwork, and do not tolerate intimidating behaviors that cause tension and suppress the escalation of safety concerns.
  3. Tuning Up the Time Out –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 and assigning each team member a brief, but specific task. When the entire team is engaged, the chances of catching an error increase greatly.


Author Kimberly Danebrock, RN, JD, is a Senior Risk Management & Patient Safety Specialist at the Cooperative of American Physicians, Inc. (CAP).


If you have questions about this article, please contact us. This information should not be considered legal advice applicable to a specific situation. Legal guidance for individual matters should be obtained from a retained attorney.