World Journal of Surgery

, Volume 32, Issue 8, pp 1643–1650 | Cite as

Annoyances, Disruptions, and Interruptions in Surgery: The Disruptions in Surgery Index (DiSI)

  • Nick SevdalisEmail author
  • Damien Forrest
  • Shabnam Undre
  • Ara Darzi
  • Charles Vincent



Recent studies have investigated disruptions to surgical process via observation. We developed the Disruptions in Surgery Index (DiSI) to assess operating room professionals’ self-perceptions of disruptions that affect surgical processes.


The DiSI assesses individual issues, operating room environment, communication, coordination/situational awareness, patient-related disruptions, team cohesion, and organizational issues. Sixteen surgeons, 26 nurses, and 20 anesthetists/operating departmental practitioners participated. Participants judged for themselves and for their colleagues how often each disruption occurs, its contribution to error, and obstruction of surgical goals.


We combined the team cohesion and organizational disruptions to improve reliability. All participants judged that individual issues, operating room environment, and communication issues affect others more often and more severely than one’s self. Surgeons reported significantly fewer disruptions than nurses or anesthetists.


Although operating room professionals acknowledged disruptions and their impact, they attributed disruptions related to individual performance and attitudes more to their colleagues than to themselves. The cross-professional discrepancy in perceived disruptions (surgeons perceiving fewer than the other two groups) suggests that attempts to improve the surgical environment should always start with thorough assessment of the views of all its users. DiSI is useful in that it differentiates between the frequency and the severity of disruptions. Further research should explore correlations of DiSI-assessed perceptions and other observable measures.


Operating Room Frequency Estimate Organizational Issue Merge Dimension Specific Disruption 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



The authors thank Ms. Sonal Arora for her useful feedback on previous drafts of the present paper.


  1. 1.
    Calland J, Guerlain S, Adams R et al (2002) A systems approach to surgical safety. Surg Endosc 16:1005–1014PubMedCrossRefGoogle Scholar
  2. 2.
    Vincent C, Moorthy K, Sarker SK et al (2004) Systems approaches to surgical quality and safety: from concept to measurement. Ann Surg 239:475–482PubMedCrossRefGoogle Scholar
  3. 3.
    Martin JA, Regehr G, Reznick R et al (1997) Objective structured assessment of technical skill (OSATS) for surgical residents. Br J Surg 84:273–278PubMedCrossRefGoogle Scholar
  4. 4.
    Moorthy K, Munz Y, Sarker SK et al (2003) Objective assessment of technical skills in surgery. Br Med J 327:1032–1037CrossRefGoogle Scholar
  5. 5.
    Fried GM, Feldman LS (2008) Objective assessment of technical performance. World J Surg 32:156–160PubMedCrossRefGoogle Scholar
  6. 6.
    Fletcher G, Flin R, McGeorge P et al (2003) Anaesthetists’ Non-Technical Skills (ANTS): evaluation of a behavioural marker system. Br J Anaesth 90:580–588PubMedCrossRefGoogle Scholar
  7. 7.
    Yule S, Flin R, Paterson-Brown S et al (2006) Non-technical skills for surgeons. A review of the literature. Surgery 139:140–149PubMedCrossRefGoogle Scholar
  8. 8.
    Yule S, Flin R, Paterson-Brown S et al (2006) Development of a rating system for surgeons’ non-technical skills. Med Educ 40:1098–1104PubMedCrossRefGoogle Scholar
  9. 9.
    Saegert S, Winkel GH (1990) Environmental psychology. Ann Rev Psychol 41:441–477CrossRefGoogle Scholar
  10. 10.
    Sundstrom E, Bell PA, Busby PL et al (1996) Environmental psychology 1989–1994. Ann Rev Psychol 47:485–512CrossRefGoogle Scholar
  11. 11.
    Healey AN, Sevdalis N, Vincent CA (2006) Measuring intraoperative interference from distraction and interruption observed in the operating theatre. Ergonomics 49:589–604PubMedCrossRefGoogle Scholar
  12. 12.
    Sevdalis N, Healey AN, Vincent CA (2007) Distracting communications in the operating theatre. J Eval Clin Practice 13:390–394CrossRefGoogle Scholar
  13. 13.
    Healey AN, Primus CP, Koutantji M (2007) Quantifying distraction and interruption in urological surgery. Qual Saf Health Care 16:135–139PubMedCrossRefGoogle Scholar
  14. 14.
    Alvarez G, Coiera E (2005) Interruptive communication patterns in the intensive care unit ward round. Int J Med Inform 74:791–796PubMedCrossRefGoogle Scholar
  15. 15.
    Chisholm CD, Dornfeld AM, Nelson DR, Cordell WH (2001) Work interrupted: a comparison of workplace interruptions in emergency departments and primary care offices. Ann Emerg Med 38:146–151PubMedCrossRefGoogle Scholar
  16. 16.
    Woloshynowych M, Davis R, Brown R, Vincent CA (2007) Communication patterns in a UK emergency department. Ann Emerg Med 50:407–413PubMedCrossRefGoogle Scholar
  17. 17.
    Brixey JJ, Tang Z, Robinson DJ et al (2008) Interruptions in a level one trauma center: a case study. Int J Med Inform 77:235–241PubMedCrossRefGoogle Scholar
  18. 18.
    Undre S, Sevdalis N, Healey AN et al (2006) Teamwork in the operating theatre: cohesion or confusion? J Eval Clin Pract 12:182–189PubMedCrossRefGoogle Scholar
  19. 19.
    Makary MA, Sexton JB, Freischlag JA et al (2006) Operating room teamwork among physicians and nurses: teamwork in the eye of the beholder. J Am Coll Surg 202:746–752PubMedCrossRefGoogle Scholar
  20. 20.
    Lingard L, Espin S, Whyte S et al (2004) Communication failures in the operating room: an observational classification of recurrent types and effects. Qual Saf Health Care 13:330–334PubMedCrossRefGoogle Scholar
  21. 21.
    Lingard L, Garwood S, Poenaru D (2004) Tensions influencing operating room team function: does institutional context make a difference? Med Educ 38:691–699PubMedCrossRefGoogle Scholar
  22. 22.
    Katz JD (2007) Conflict and its resolution in the operating room. J Clin Anesth 19:152–158PubMedCrossRefGoogle Scholar
  23. 23.
    Undre S, Healey AN, Darzi A et al (2006) Observational assessment of surgical teamwork: a feasibility study. World J Surg 30:1774–1783PubMedCrossRefGoogle Scholar
  24. 24.
    Undre S, Sevdalis N, Healey AN et al (2007) Observational assessment of surgical teamwork: refinement and application to urological surgery. World J Surg 31:1373–1381PubMedCrossRefGoogle Scholar
  25. 25.
    Sevdalis N, Davis R, Koutantji M et al (2008) Reliability of a revised NOTECHS scale for use in surgical teams. Am J Surg (in press)Google Scholar
  26. 26.
    Eby LT, Dobbins GH (1997) Collectivistic orientation in teams: an individual and group-level analysis. J Organ Behav 18:275–295CrossRefGoogle Scholar
  27. 27.
    Dukes KA (2005) Cronbach’s Alpha. Encyclopedia of biostatistics, 2nd edn. Wiley InterScience. Available at:
  28. 28.
    Wetzel CM, Kneebone RL, Woloshynowych M et al (2006) The effects of stress on surgical performance. Am J Surg 191:5–10PubMedCrossRefGoogle Scholar
  29. 29.
    Arora S, Sevdalis N, Nestel D et al (2008) Managing intra-operative stress: what do surgeons want from a crisis training programme? Am J Surg (in press)Google Scholar

Copyright information

© Société Internationale de Chirurgie 2008

Authors and Affiliations

  • Nick Sevdalis
    • 1
    • 2
    Email author
  • Damien Forrest
    • 1
  • Shabnam Undre
    • 1
  • Ara Darzi
    • 1
  • Charles Vincent
    • 1
  1. 1.Clinical Safety Research Unit, Department of Bio-Surgery & Surgical TechnologyImperial CollegeLondonUK
  2. 2.National Patient Safety Agency LondonUK

Personalised recommendations