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Distraction-Free Induction Zone: A Quality Improvement Initiative at a Large Academic Children’s Hospital to Improve the Quality and Safety of Anesthetic Care for Our Patients

Crockett, Christy J. MD; Donahue, Brian S. MD, PhD; Vandivier, Deana C. CRNA

doi: 10.1213/ANE.0000000000003879
Pediatric Anesthesiology: Original Clinical Research Report

BACKGROUND: Noise in the operating room may cause distractions during critical periods and impair reliable communication between staff. Even momentary inefficiency while administering anesthesia can lead to errors and serious consequences for the patient. Distractions to an anesthesia provider during critical periods such as induction and emergence are a patient safety issue. Because of concerns regarding unacceptable noise levels and distractions during induction of general anesthesia, our institution developed a quality improvement initiative, the “Distraction-Free Induction Zone.” The specific aim of this project was to decrease the percentage of cases with a distraction, described as music, unnecessary conversations, or loud noises, occurring during induction of general anesthesia in pediatric otolaryngology operating rooms from 61% to 15%.

METHODS: To complete this quality improvement initiative, a multidisciplinary team used improvement science methods, including The Model for Improvement with interventions tested via Plan-Do-Study-Act cycles. We used tools such as the Key Driver Diagram, Pareto Charts, Process Flow Chart, and Plan-Do-Study-Act worksheets. Data were manually collected and entered weekly in an Excel spreadsheet. Statistical process control methods, including a run chart and a P-control chart, were used for data analysis. Our measure was a composite measure in which observation of 1 of the 3 distractions during induction of general anesthesia categorized the case as a case with a distraction.

RESULTS: We tested and implemented several interventions via Plan-Do-Study-Act cycles in which 3 main interventions collectively were associated with an observed decrease in distractions during induction of general anesthesia. These included educating the perioperative staff present in the operating room to help them understand that distractions to anesthesia providers represent a patient safety issue, the operating room circulating nurse taking responsibility to pause any music on arrival to the operating room, and the anesthesiologist reminding the staff in the operating room of induction time and/or asking for quiet during induction if a distraction occurs. The percentage of cases with a distraction during induction of general anesthesia in our pediatric otolaryngology operating rooms decreased from 61% to 15% by April 15, 2017 and to 10% by June 5, 2017.

CONCLUSIONS: Using improvement science methods, we observed a decrease in distractions during induction of general anesthesia, improved a process, and encouraged change in culture at a large academic children’s hospital to enhance the quality and safety of the anesthetic care we provide our patients.

From the Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee.

Published ahead of print 19 September 2018.

Accepted for publication September 19, 2018.

Funding: None.

The authors declare no conflicts of interest.

Reprints will not be available from the authors.

Address correspondence to Christy J. Crockett, MD, Department of Anesthesiology, Vanderbilt University Medical Center, 2200 Children’s Way, Suite 3116, Nashville, TN 37232. Address e-mail to

Copyright © 2018 International Anesthesia Research Society
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