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Associations of workflow disruptions in the operating room with surgical outcomes: a systematic review and narrative synthesis
  1. Amelie Koch1,
  2. Jacob Burns2,3,
  3. Ken Catchpole4,
  4. Matthias Weigl1,5
  1. 1 Institute and Clinic for Occupational, Social and Environmental Medicine, LMU University Hospital, Munich, Germany
  2. 2 Institute for Medical Information Processing, Biometry, and Epidemiology - IBE, Munich, Germany
  3. 3 Pettenkofer School of Public Health, Munich, Germany
  4. 4 Department of Anesthesia and Perioperative Medicine, Medical University of South Carolina (MUSC), Charleston, South Carolina, USA
  5. 5 Division of Surgery and Cancer, Imperial College, London, UK
  1. Correspondence to Amelie Koch, Institute and Outpatient Clinic for Occupational, Social and Environmental Medicine, Ludwig Maximilians University Munich Faculty of Medicine, Munich, Germany; amelie.koch{at}


Background Performance in the operating room is an important determinant of surgical safety. Flow disruptions (FDs) represent system-related performance problems that affect the efficiency of the surgical team and have been associated with a risk to patient safety. Despite the growing evidence base on FDs, a systematic synthesis has not yet been published.

Objective Our aim was to identify, evaluate and summarise the evidence on relationships between intraoperative FD events and provider, surgical process and patient outcomes.

Methods We systematically searched databases MEDLINE, Embase and PsycINFO (last update: September 2019). Two reviewers independently screened the resulting studies at the title/abstract and full text stage in duplicate, and all inconsistencies were resolved through discussion. We assessed the risk of bias of included studies using established and validated tools. We summarised effects from included studies through a narrative synthesis, stratified based on predefined surgical outcome categories, including surgical process, provider and patient outcomes.

Results We screened a total of 20 481 studies. 38 studies were found to be eligible. Included studies were highly heterogeneous in terms of methodology, medical specialty and context. Across studies, 20.5% of operating time was attributed to FDs. Various other process, patient and provider outcomes were reported. Most studies reported negative or non-significant associations of FDs with surgical outcomes.

Conclusion Apart from the identified relationship of FDs with procedure duration, the evidence base concerning the impact of FDs on provider, surgical process and patient outcomes is limited and heterogeneous. We further provide recommendations concerning use of methods, relevant outcomes and avenues for future research on associated effects of FDs in surgery.

  • interruptions
  • surgery
  • patient safety
  • teamwork

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  • Contributors AK and MW developed study objectives, design, conception and planning. AK and MW carried out studies search and selection, data extraction, analysis and interpretation. JB and KC contributed to data analyses, data presentation and interpretation. AK and MW were responsible for the first draft of the publication. All authors were involved equally in writing and shaping the final version of the manuscript.

  • Funding This study was funded by Munich Centre for Health Sciences (MC Health).

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available on reasonable request. The datasets generated during and analysed during the current study are available from the corresponding author on reasonable request.