European Journal of Cardiovascular Medicine

The operating room (OR) represents a highly complex and cognitively demanding environment requiring sustained attention, precise motor coordination, and seamless communication among multidisciplinary team members. Optimal surgical performance depends on minimizing external disruptions while maintaining effective intraoperative communication. However, modern operating rooms are increasingly exposed to multiple sources of auditory stimuli, including equipment alarms, verbal communication, background music, and mobile phone notifications, all of which may act as potential distractions.¹–³

Human-generated auditory stimuli have been identified as one of the most frequent contributors to OR noise. Brommelsiek et al. demonstrated that non-essential conversations and phone-related interruptions significantly affect surgical workflow and team dynamics.¹ Similarly, survey-based studies have shown that healthcare professionals frequently perceive auditory interruptions as detrimental to concentration, situational awareness, and communication efficiency.²

Noise levels in contemporary operating rooms often exceed recommended hospital acoustic standards due to the widespread use of electronic monitoring devices and alarm systems.³,⁴ Engelmann and Fischer reported that the combination of continuous background noise and intermittent alarms contributes to elevated acoustic exposure during surgical procedures.⁸ Such environments may impair verbal communication, increase the likelihood of misinterpretation, and delay critical responses.¹²

From a human-factors perspective, excessive auditory stimuli can increase cognitive load. Cognitive load theory suggests that the human working memory has limited capacity, and excessive external inputs may reduce task performance and situational awareness during complex procedures.⁹,¹⁰ Prior studies have shown that intraoperative distractions may increase technical errors, prolong operative time, and negatively impact decision-making.⁶,⁷,¹⁶

Importantly, the impact of auditory distractions extends beyond surgeons. Nurses, anaesthesiologists, and other OR personnel also experience increased stress and communication challenges in noisy environments.⁴ Mixed-method studies have demonstrated that persistent acoustic disturbances contribute to fatigue, reduced focus, and decreased team efficiency.⁴

Various strategies have been proposed to mitigate OR noise, including alarm management protocols, staff education, and architectural acoustic modifications.⁵ Human-factors–based interventions have shown promise in reducing environmental distractions and improving surgical workflow.¹⁷ Prospective observational studies further suggest that distractions occur frequently even during routine procedures and may be particularly critical during minimally invasive surgeries requiring sustained visuomotor coordination.¹¹,¹⁵

Despite growing recognition of this issue, there remains limited prospective data evaluating the frequency, sources, and perceived impact of auditory distractions across different surgical specialties, particularly in real-world clinical settings.

Therefore, the present study aimed to:

1. Assess the prevalence of auditory distractions in the operating room
2. Identify the most common sources of these distractions

Evaluate their perceived impact on surgical performance across different types of procedures

Study Design and Setting This was a prospective observational study conducted in the operating rooms of a tertiary care center. The study focused on subjective assessment of auditory distractions, without direct measurement of sound intensity (decibel levels). Study Population A total of 370 surgical procedures were observed over the study period, including: • Laparoscopic abdominal surgeries • Open abdominal surgeries • Breast surgeries • Thyroid surgeries • Perineal procedures • Hernia repairs • Limb surgeries Both elective and emergency procedures were included. Data Collection Auditory distraction events were recorded in real time during surgical procedures. Each event was categorized into one of the following groups: • Phone ringtones • Verbal communication (non-essential conversations) • Equipment alarms • Background music For each procedure, the following were documented: • Number of distraction events • Type of surgery • Type of distraction • Personnel affected (primary surgeon, assistant, scrub nurse, anaesthesiology team) • Nature of procedure (elective vs emergency) Outcome Measures Primary outcomes included: • Frequency of auditory distractions per surgery • Distribution of distraction sources • Perceived impact on different OR personnel Secondary outcomes included: • Comparison across surgical types • Association between distraction source and surgeon distraction risk Statistical Analysis Descriptive statistics were used to summarize frequencies and proportions. • Chi-square test was applied to compare distraction sources across surgical types • Logistic regression analysis was performed to assess the association between noise sources and surgeon distraction • Multivariate analysis was used to identify independent predictors A p-value <0.05 was considered statistically significant.

Frequency of Auditory Distractions

Table 1. Frequency of Auditory Distraction Sources

A total of 728 auditory distraction events were recorded, corresponding to a mean of 1.97 distractions per surgery.

• Phone ringtones: 256 (35.2%)
• Verbal communication: 212 (29.1%)
• Equipment alarms: 164 (22.5%)
• Background music: 96 (13.2%)

Phone ringtones were the most frequent source of distraction, followed by verbal interactions among staff.

Figure 1 demonstrates the frequency distribution of auditory distractions.

Distribution by Surgical Type

Table 2. Distribution of Surgical Procedures (n = 370)

Laparoscopic abdominal surgeries demonstrated the highest number of distraction events, followed by open abdominal surgeries.

• Laparoscopic abdominal: 400 events (mean 2.38/case)
• Open abdominal: 222 events (mean 1.79/case)
• Other procedures: 106 events (mean 1.36/case)

Figure 3 shows the negative impact of auditory distractions across surgical types.

Personnel Affected

Table 3. Personnel Most Affected by Distractions

The primary surgeon was most affected:

• Primary surgeon: 39.0%
• Assistant: 22.3%
• Scrub nurse: 20.3%
• Anaesthesiology team: 18.4%

Elective vs Emergency Surgery

Table 4. Elective vs Emergency Surgery Distraction Perception

Elective procedures showed higher perceived distraction levels:

• Elective: 2.23 distractions/case
• Emergency: 1.62 distractions/case

Logistic Regression Analysis

Table 5. Logistic Regression Analysis: Noise Source and Surgeon Distraction Risk

Chi-Square Analysis

Table 6. Chi-Square Comparison of Auditory Distraction Sources Across Surgical Types (n = 370)

A statistically significant association was observed between type of surgery and source of distraction:

• Laparoscopic surgeries: χ² = 18.7, p < 0.001
• Open surgeries: χ² = 12.4, p = 0.002

Overall model: χ² = 21.3, p < 0.001

Phone ringtones and verbal communication significantly increased surgeon distraction risk:

• Phone ringtones: OR 2.48 (p < 0.001)
• Verbal communication: OR 1.89 (p = 0.001)
• Equipment alarms: borderline significance
• Background music: not significant

Multivariate Analysis

Table 7. Multivariate Predictors of Surgeon Distraction in the Operating Room (n = 370 procedures)

Independent predictors of surgeon distraction included:

• Phone ringtones: OR 2.61 (p < 0.001)
• Verbal communication: OR 2.08 (p < 0.001)
• Equipment alarms: OR 1.53 (p = 0.039)
• Laparoscopic surgery: OR 1.84 (p = 0.002)
• Elective surgery: OR 1.67 (p = 0.011)

Model Statistics

Model performance:

• χ² = 28.6
• p < 0.001

Nagelkerke R² = 0.34

This prospective observational study of 370 surgical procedures demonstrates that auditory distractions are frequent in the operating room and are predominantly driven by human-generated sound sources, particularly mobile phone notifications and nonessential verbal communication. These findings reinforce the growing recognition of operating room noise as a critical human-factors issue with potential implications for surgical performance, team dynamics, and patient safety.

Our findings are consistent with contemporary literature. Brommelsiek M et al. demonstrated that human-caused auditory distractors significantly impair operating room team function and workflow efficiency.¹ Similarly, Nasri BN et al. reported that healthcare professionals frequently identify mobile phone alerts and nonessential conversations as the most disruptive intraoperative stimuli.² These observations underscore that a substantial proportion of operating room noise arises from modifiable behavioural sources, highlighting an important target for intervention.

Technological contributors to noise were also evident in our study. Brunker LB et al. described the operating room as an acoustically complex environment, where monitoring devices and alarms generate both continuous background noise and intermittent high-intensity signals.³ Engelmann C and Fischer further demonstrated that sound levels in modern operating theatres frequently exceed recommended hospital thresholds, particularly during technologically intensive procedures.⁸,¹³ Although the present study did not quantify noise in decibels, it focused on clinically meaningful distraction events, which may more directly correlate with cognitive disruption than absolute sound intensity.

In addition to surgeons, operating room noise has been shown to affect other team members. Liu W et al., in a mixed-methods study, reported that excessive noise contributes to increased stress, fatigue, and impaired communication among nurses.⁴ These findings align with our observation that multiple members of the surgical team experience distraction, although the primary surgeon remains the most affected, likely due to the central cognitive demands of operative decision-making.

A key finding of this study is the higher frequency of distractions during laparoscopic abdominal procedures. This is consistent with evidence suggesting that minimally invasive surgery imposes greater cognitive and perceptual demands. Arora S et al. highlighted that increased cognitive load during complex surgical tasks reduces the capacity to filter external stimuli.¹⁰ Similarly, Healey AN and Sevdalis demonstrated that intraoperative distractions can impair technical performance and increase the risk of errors.⁷ These findings support the concept that task complexity amplifies vulnerability to environmental disturbances.

Communication within the surgical team is particularly susceptible to noise-related disruption. Yamada T and Nishimura reported that environmental noise contributes to communication errors and delayed responses in the operating room.¹¹ Given that effective communication is fundamental to patient safety, such disruptions may have clinically significant consequences. Patel VM and Ahmed further emphasized that minimizing distractions is a key component of improving surgical safety through human-factors–based interventions.¹²

Interestingly, our study demonstrated higher perceived distraction levels during elective procedures compared with emergency surgeries. This may be explained by differences in baseline environmental conditions. Elective procedures are typically conducted in more controlled and quieter settings, making sudden auditory interruptions more perceptible. In contrast, emergency surgeries often involve inherently elevated baseline activity, potentially reducing the relative impact of additional noise. This observation reflects the contextual nature of distraction and aligns with human-factors research emphasizing the interaction between environment and cognitive workload. ⁹

Our statistical analysis further strengthens these findings. The chi-square test demonstrated a significant association between surgical type and source of distraction (χ² = 21.3, p < 0.001). Logistic regression analysis showed that phone ringtones increased the likelihood of surgeon distraction by approximately 2.5-fold, while verbal communication increased the risk by nearly twofold. These findings are consistent with earlier observational work by Weld LR and Stringer, who reported that environmental distractions occur frequently during routine procedures and may significantly disrupt workflow. ¹⁵ Foundational work by Healey AN et al. further quantified intraoperative interruptions and demonstrated their measurable impact on surgical performance. ¹⁶

Not all auditory stimuli were equally disruptive. Background music did not show a statistically significant association with distraction in our study. This is consistent with previous reports suggesting that structured or low-intensity background music may have minimal or even neutral effects on performance when compared to unpredictable or sudden noise sources. ³,¹⁴

Clinical Implications

The findings of this study emphasize that a significant proportion of operating room noise is preventable. Dağcı M et al. highlighted that both active and passive noise control strategies can improve patient care by optimizing the acoustic environment.⁵

Practical interventions include:

•             Implementation of “sterile cockpit” principles during critical surgical phases

•             Restriction or silencing of mobile phones

•             Structured communication protocols

•             Optimization of alarm systems

•             Acoustic environmental modifications

Such strategies are supported by human-factors research, which emphasizes minimizing unnecessary cognitive load to improve performance and safety.⁹,¹²

Strengths and Limitations

Strengths

This study has several strengths. It represents a prospective observational analysis with a relatively large sample size and includes a broad spectrum of surgical procedures, enhancing generalizability. The use of multivariate regression analysis strengthens the validity of identified associations. Furthermore, the study provides procedure-specific insights, particularly highlighting laparoscopic surgery as a high-risk setting for distraction.

Limitations

Several limitations should be acknowledged. First, this was a single-centre study, which may limit external validity. Second, distraction assessment was subjective and observer-based, introducing potential bias despite standardized recording methods. Third, objective sound measurements (decibel levels) were not performed, limiting comparison with acoustic standards. However, the study intentionally focused on clinically relevant distraction events rather than absolute noise intensity. Finally, the observational design precludes establishing causality, and direct patient outcomes were not assessed.

Auditory distractions are common in modern operating rooms and are predominantly driven by human-generated sounds, particularly mobile phone notifications and nonessential conversations. Laparoscopic abdominal procedures appear especially vulnerable, and the primary surgeon is most affected. These findings underscore the importance of implementing structured noise-reduction strategies. Targeted behavioural and system-level interventions may enhance concentration, improve communication, and ultimately contribute to safer surgical practice and improved patient outcomes.

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