Sterile Cockpit Rules Come to the O.R.
Sterile Cockpit Rules have been in effect for 34 years. They require pilots to focus strict attention during critical stages of the flight when below 10,000 feet altitude.  
This means no non-flight conversations and no interruptions.
Should surgical teams use the same method during critical phases of a procedure?
The need for Sterile Cockpit Rules became apparent when jet airliners replaced propeller planes. Modern aircraft made flying easier.
Pilots didn’t need to personally monitor aspects of the flight and depended more on technology to help fly the plane.
The new technologies created a less busy cockpit and allowed for more opportunities for non-flight related conversations and interruptions.
The FAA imposed the Sterile Cockpit Rules in 1981 after reviewing a series of accidents caused by flight crews who were distracted from their flying duties by engaging in non-essential conversations during crucial parts of the flight. One notable accident was Eastern Air Lines Flight 212, which crashed 3 miles short of the runway. The crew was making an instrument landing in heavy fog. The voice transcript showed the probable cause of the accident was distraction due to non-flight conversations among the flight crew during the approach phase of the flight.
The Sterile Cockpit Rule has only 3 parts:
  • No flight crewmember may perform any duties during a critical phase of flight except those duties required for the safe operation of the flight. Ordering galley supplies, pointing out sights of interest and filling out payroll records are not required for the safe operation of the aircraft.
  • No flight crewmember may engage in, nor may any pilot in command permit, any activity during a critical phase of flight which could distract any flight crewmember from the performance of his or her duties or which could interfere in any way with the proper conduct of those duties. Eating, engaging in non-essential conversations and reading publications not related to the proper conduct of the flight are not required for the safe operation of the aircraft.
  • Critical phases of flight includes all ground operations involving taxi, takeoff and landing, and all other flight operations conducted below 10,000 feet.
Should surgical teams use the same method during critical phases of a procedure? The statistics certainly suggest a need.

Several malpractice studies show that surgical ‘Never Events’, errors that should never happen, occur at least 4,000 times per year.

These are preventable errors of inattention and distraction.
  • Wrong Procedure – 1000+ times per year
  • Wrong Side/Site – 1000+ times per year
  • Retained Items – 2000+ times per year
Preparing for and conducting surgery is as equally complicated as aircraft operations involving taxi, takeoff and landing.  Shouldn’t there be a Time-Out before, during, and after surgical procedures to consult checklists and ensure they are complete and correct?
Shouldn’t there be Sterile Table Rules, in which there are no non-case related conversations, no non-case related interruptions and no distractions?

Here is a sample of Sterile Table Rules:
  • Sterile Table Rules can be in effect 60 seconds per minute while the patient is in the operating room
  • Or, during the Time-Out checklist confirmations before, during, and after the procedure
  • And during crucial stages of the procedure
Restrictions When Sterile Table Rules are in effect:
  • Silence, other than case-related conversations
  • No non-case related conversations
  • No Music
  • No Personal Electronics
  • No non-case related interruptions from inside or outside O.R.
  • At all times: No incivility, joking, sarcasm, passive aggression, bullying, verbal violence
  • At all times: Activate your maturity, courtesy, and professionalism
  • Compliance is not optional.
  • All staff are empowered to ‘Call a Safety Stop’
Should the Sterile Table Rules come with a strong message for surgical team members to see before entering the O.R.? For example:
  • Sterile Table Rules are in effect
  • Many people are depending on you to be alert, sober and serious for the duration of this procedure
  • 4,000 will be injured or worse this year from surgical inattention
  • This patient will not be one of them
  • Activate your maturity, courtesy, and professionalism
The Sterile Cockpit Rules work well for the airline industry and have developed into a culture of safety. The same is possible for surgical teams that observe Sterile Table Rules during every procedure. They are practicing safer surgery and a reduction of surgical ‘Never Events’ will be realized.

Aircraft Accident Report Eastern Air Lines Flight 212: http://www.airdisaster.com/reports/ntsb/AAR75-09.pdf
Maintaining a Sterile Cockpit: http://www.safetystanddown.com/maintaining-a-sterile-cockpit-an-essential-attention-control-technique/
Operating Room Distractions: http://www.aaos.org/news/aaosnow/may12/clinical5.asp
80,000 Surgical ‘Never Events’ Charted Over 20 Years: http://healthleadersmedia.com/page-1/QUA-287732/80000-Surgical-Never-Events-Charted-Over-20-Years
Share This Posting
Hospitals use checklists to reduce errors