The Sterile Cockpit Rule: How Does it Apply to Medicine?

I spend a lot of my life inside the cardiac operating room. It’s a high-stakes arena with up to nine medical staff assuming different roles for the care of the patient: anesthesiologist, nurse anesthetist, perfusionist, circulating nurse, scrub technician, first assistant, cardiologist, and device rep, not to mention any medical students in training.

As you might imagine, in a situation like this, communication is paramount. If the surgeon assumes that I heard the call to give the heparin, but I never did (and didn’t repeat it back to him), the consequences could be catastrophic.

So, how do we make sure that all moving parts are working together and communicating in these high-stakes scenarios? Let’s borrow a framework used by airplane pilots: the sterile cockpit rule.

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What is the Sterile Cockpit Rule?

Medicine is a high-stakes profession, no doubt, so it’s not surprising doctors like to borrow terminology and process from other high-stakes fields.

Perhaps the greatest example of this is how we’ve adopted terminology used by pilots, who follow what’s known as the “sterile cockpit rule.”

The sterile cockpit rule is a law (originally applying to airplane pilots) that prevents any extraneous conversation or action during crucial moments of takeoff, landing, and taxiing in an effort to decrease distraction and minimize human error.

All communication and duties performed during these times must be necessary for the safe operation of the aircraft.

A bit of background on how this rule came about: after analyzing error-causing human actions during flights, it was discovered that chatter with other cockpit members was a major source of distraction.

Also, flight attendants entering the cockpit to ask questions also led to interruption that pulled the pilots attention away from safely flying the plane.

When Applied to Medicine…

While it’s true doctors and pilots alike have lives in their hands, many would argue that applying such a rule to medical professionals seems draconian. Is it really a good idea to have a law that dictates when and where I can say what I want?

The debate raises understandable concerns. And yet, it’s clear that minimizing intrusions that could cost lives is a good measure to take. 

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When to Apply the Sterile Cockpit Rule in Medicine

So, how do we employ the sterile cockpit rule in medicine? And should we? Let’s take a look at these issues, and see what makes sense when it comes to the safety of our patients.

1. The Pre-Surgery Time-Out

One area where we see a sterile cockpit approach is the time-out before a surgery. This is a time when the team minimizes distractions such as music and cell phones are turned off and put away. Everyone stops performing their tasks, and as a group, the whole OR goes through the process of ensuring we’re performing the correct procedure on the correct part of the correct patient’s body, that they’re receiving the correct medications, that we vocalize any overarching concerns, and all team members agree. 

Unfortunately, depending on the institution and staff, the timeout isn’t always taken as seriously as it should be. Oftentimes music is still playing, operating room staff is organizing instruments, and anesthesia is administering medications. Although awareness is heightened, there isn’t always full devotion to the silence and awareness necessary for a properly sterile time out. 

2. Surgical Emergencies 

Some phases of certain surgeries also employ a sterile cockpit mentality. When a patient goes on circulatory arrest, they’re chilled down to a hypothermic body temperature, and the blood flow in their body completely ceases. Their blood sits in a plastic bucket, a few yards away from their body. It’s one of the most audacious things we do in medicine. 

During that time, every wasted second is one that the patient’s organs aren’t receiving blood flow. Clearly, it’s not a time to catch up with one another and ask how the local football team did last night. Everyone is on the same page: keep your mouth shut unless you have something necessary to say, and get through the circulatory arrest period as quickly and safely as possible. 

Then, after that, you can talk about the book you’re reading or ask your colleague how his son’s birthday was. 

3. Nonsurgical Applications 

There are many examples throughout the literature of how the sterile cockpit rule is being used to decrease errors in medicine. Nurses are employing the rule during medication administration in order to reduce errors in inpatient units. 

The rule has streamlined process and patient safety in the field of extracorporeal life support. Whether it’s being used for routine tasks, or the most emergent tasks in which every second counts, the minimization of distraction has been a boon to patient safety.

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The Sterile Cockpit Rule: Should it Apply to Medicine?

These days, distractions are at an all-time high. Staffing shortages are leading to fewer clinicians taking on more roles and more work. We’re all being pulled in more directions at any given time. 

On top of that, the outside world is demanding more of our attention. How many notifications are popping up on your phone and watch while you’re trying to do your job? Too many.

So what do we do with this information? All in all, whether you petition your group or hospital to employ the sterile cockpit rule for certain tasks, the name of the game is minimizing distraction. It’s being present and giving the totality of your focus to the task at hand.

This is difficult to do every time when you’re relying on mere willpower. But that’s what makes the rule so effective. It mandates what we’re trying to accomplish. Turn off those notifications, save the “How was your weekend?” until lunch time, and ensure that the high-stakes moments of your day at the hospital are distraction-free.

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Further Reading

Looking for more (free!) content to help you in professional practice? Check out these other posts on the Rosh Review blog:

• A Physician’s Guide to Communicating with Your Medical Team
• 3 Nonnegotiables for Patient Care in the OR
• How to Communicate in Medical Consultations: A Case Study

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