Organized chaos or well-oiled machine? Optimizing safety & efficiency in an OR

Organized chaos or well-oiled machine? Optimizing safety & efficiency in an OR

Posted by Wilant van Giessen on Mon 18 May. 2020 - 3 minute read

Hospital operating rooms (OR) are spaces in which medical personnel performs often complex surgeries and tasks with many interactions between humans and equipment. Even though to the casual observer an operating room may come across as organized chaos, it’s meant to be a well-choreographed sequence of procedures. Any issues with regard to teamwork, communication, workflow, and equipment design are known to lead to complications and increased mortality.

Dr. Anjali Joseph and her team use a Portable Noldus Observation Lab, behavioral coding with The Observer XT, and computer modeling to qualify and quantify the goings on during surgeries in real operating rooms, not simulated versions of one. Their goal is to identify flow disruptions, determine what’s causing them, and come up with solutions to minimize them and make ORs as safe and efficient as possible.

Are you ready to kick start your research? Want better insights and faster results? Contact us now to learn how we can help you!

Direct observation and behavioral coding

Joseph et al. (2019) used a Portable Noldus Observation Lab (with 4 cameras and microphones) to record activity during 28 surgeries in 3 operating rooms. The locations, roles, and activities of all medical personnel, along with any flow disruptions (FD), were then coded in detail with The Observer XT software. Across all surgeries a total of 2504 FDs were observed, 26% of which were major ones. 

Video recording in an Operating Room

The researchers found that the rate of major FDs increases with the rate of minor FDs, especially when they are related to particular equipment and its positioning in the room, and certain specific locations in the OR. More FDs were observed in the anesthesia zone than any other zones. 

Floorplan Operating Room

The central role of the circulating nurse

The role of the circulating nurse (CN) was studied in more detail by Neyens et al. (2018) and Bayramzadeh et al. (2018). Across 25 surgeries, in 3 different ORs, the CN spent 34 hours performing 1471 tasks, each categorized as patient, equipment, material, and information related. CNs were more likely to be involved in layout and environmental hazard FDs when involved in patient, material, or equipment-related tasks compared to information tasks, while the latter tasks involve the least movement. 

The OR was divided up in multiple zones, each of which was categorized as functional (work stations, preparation zones, surgery, etc.) or transitional. The CN traveled through multiple zones during the vast majority of activities. Of all flow disruptions, 58% happened in the transitional zones, while behavioral coding revealed that even though the layout of the 3 ORs varied, the flow disruption patterns were quite similar: certain zones will always be adjacent to each other.

Flow disruptions and movements in the OR.

Digging deeper: Simulation modelling to analyze traffic flow in the OR

To dig deeper into what all is going on in an operating room, Taaffe et al. (2020) used the behavioral data set generated with The Observer XT to model the traffic flow during surgery. They looked at the effect of the size and shape of the room, the orientation of the surgery table, and the location of the workstation of the circulating nurse. 

A larger room reduced the number of contacts and transitions, even though it required more movement. Positioning the table at an angle into the center of the room with the workstation at the foot of the table resulted in a reduction of undesired contacts among medical personnel. 

Future work: Adapting the OR to COVID-19 conditions

Dr. Joseph and her team are presently using the Noldus Portable lab and The Observer XT to observe and code telemedicine sessions for stroke patients conducted in an ambulance. They also just finished coding a set of videos from 25 additional surgeries in new, optimized ORs that were finished in January 2020. Plans are now underway to use the Portable Lab and The Observer XT to study adaptation of operating rooms for use during COVID-19. 

FREE TRIAL: Try The Observer XT yourself!

Request a free trial and see for yourself how easy behavioral research can be!

  • Work faster
  • Reduce costs
  • Get better data


Joseph, A.; Khoshkenar, A.; Taaffe, K.M.; Catchpole, K.; Machry, M.; Bayramzadeh, S. & RIPCHD.OR study group. (2019). Minor flow disruptions, traffic-related factors and their effect on major flow disruptions in the operating room. BMJ Quality & Safety. 

Bayramzadeh, S.; Joseph, A.; San, D.; Khoshkenar, A.; Taaffe, K.; Jafarifiroozabadi, R.; Neyens, D.M. & RIPCHD.OR Study Group (2018). The Impact of Operating Room Layout on Circulating Nurse’s Work Patterns and Flow Disruptions: A Behavioral Mapping Study. Health Environments Research & Design Journal, 11, 124-138.

Neyens, D.M.; Bayramzadehb, S.; Catchpole, K.; Joseph, A.; Taaffe, K.; Jurewicza, K.; Khoshkenara, A.; San, D.; RIPCHD. OR Study Group (2019). Using a systems approach to evaluate a circulating nurse's work patterns and workflow disruptions. Applied Ergonomics, 78, 293-300. 

Taaffe, K.; Joseph, A.; Khoshkenar, A.; Machry, H.; Allison, D.; Reeves, S.T. & RIPCHD.OR Study Group (2020). Proactive Evaluation of an Operating Room Prototype: A Simulation-Based Modeling Approach. Journal of Patient Safety.

Image Credit: Dr. A. Joseph

Don't miss out on the latest blog posts
Share this post
Relevant Blogs

The role of explicit bias in working with depressed cardiac patients

Using simulated medical encounters, Dr. Crapanzano and her team measured the influence of bias in the medical students' diagnosis and treatment plans for a patient presenting as mildly depressed.

Clinical interviews – analyzing verbal and non-verbal behavior

In general, researchers choose the methods and techniques that best suit their research objectives. That’s no different when researching doctor-patient communication or any other clinical interview setting.

Exploring learning experiences of undergraduate nursing students

Simulation-based training sessions are essential in healthcare education. How do nursing students experience the use of a virtual interactive digital simulator compared to a human patient simulation?