Impact of Teamwork, Patient Safety Culture, and Operating Room Distractions on Patient Safety Management Activities among Perioperative Nurses

Eun Yeong Lee; Eun Kyeung Song

doi:10.34250/jkccn.2026.19.1.48

J Korean Crit Care Nurs > Volume 19(1); 2026 > Article

팀워크, 환자안전인식, 수술실 방해요인이 수술실 간호사의 안전관리활동에 미치는 영향

Original Article

Journal of Korean Critical Care Nursing 2026;19(1):48-63.

Published online: February 28, 2026

DOI: https://doi.org/10.34250/jkccn.2026.19.1.48

팀워크, 환자안전인식, 수술실 방해요인이 수술실 간호사의 안전관리활동에 미치는 영향

이은영¹

, 송은경^2,

¹울산대학교병원 간호부, 울산대학교 의과대학 간호학과

²울산대학교 의과대학 간호학과

Impact of Teamwork, Patient Safety Culture, and Operating Room Distractions on Patient Safety Management Activities among Perioperative Nurses

Eun Yeong Lee¹

, Eun Kyeung Song^2,

¹Department of Nursing, Ulsan University Hospital; Department of Nursing, College of Medicine, University of Ulsan, Ulsan, South Korea

²Department of Nursing, College of Medicine, University of Ulsan, Ulsan, South Korea

Correspondence : Song, Eun Kyeung Department of Nursing, College of Medicine, University of Ulsan, Daehak-ro 93, Nam-gu, Ulsan, 44610, South Korea Tel : 82-52-259-1233, Fax : 82-52-259-1236, E-mail : gracesong@ulsan.ac.kr

Received November 1, 2025 Revised December 3, 2025 Accepted December 19, 2025

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Purpose

Teamwork and perceptions of patient safety culture are positive factors in operating room (OR) nurses’ patient safety management activities. Distractions in the OR may negatively impact OR nurses’ patient safety management activities; however, the relationship between these variables has not yet been explored. This study aimed to determine the relationships among teamwork, perception of patient safety culture, distractions in the OR, and patient safety management activities among OR nurses.

Methods

A descriptive cross-sectional study was conducted with 149 OR nurses from U Metropolitan City. Structured questionnaires were used to assess teamwork, perceptions of patient safety culture, distractions in the OR, and patient safety management activities. T-tests, one-way analysis of variance, Pearson's correlation analysis, and hierarchical linear regression were used for data analysis.

Results

Positive correlations were found among teamwork, perception of the patient safety culture, and patient safety management activities (all p ＜.001). Auditory distractions in the OR were negatively correlated with patient safety management activities (r=-0.21, p = .011). Hierarchical linear regression revealed that teamwork(β=0.28, p=.007), perception of patient safety culture (β=0.24, p=.016), and visual (β=-0.22, p = .023) and communication distractions (β=-0.26, p = .002) were associated with patient safety management activities.

Conclusion

Strategic interventions are thus needed to strengthen teamwork, foster a positive patient safety culture, and minimize distractions in the OR to enhance patient safety management activities among OR nurses.

Key Words: Perioperative nursing, Patient safety, Interprofessional relation

주요어: 수술간호, 환자안전, 전문직 간 협력

I. INTRODUCTION

Patient safety is an important healthcare issue worldwide, defined as preventing errors that could harm patients with healthcare, learning from errors that do occur, and creating a safe healthcare environment for patients [1]. The importance of patients safety has been further emphasized since the Patient Safety Act went into effect on July 29, 2016, in South Korea[2]. Patient safety has been recognized as a key indicator for evaluating healthcare services in hospitals, leading to patient safety management activities [3,4].

In 2008, the World Health Organization(WHO) developed the “Surgical Safety Checklist” to effectively prevent potential patient safety incidents during surgery [5]. Based on this, the National Accreditation Agency for Medical Institutions developed a Korean version of the Surgical Patient Safety Guidelines, which emphasizes the participation of all medical staff involved in surgery to carry out pre-anesthesia, pre-incision, and predischarge confirmation[6]. However, the number of patient safety incidents in the operating room (OR) increased by an average of 1.9% each year, reaching 304 cases in 2023 and 303 cases in 2024 according to the Korea Patient Safety Reporting and Learning System (KOPS) [7]. Also, it was reported that patients safety incidents related to surgery and anesthesia accounted for the highest proportion as 49.9% of all patient safety incidents as a result of data analysis on OR incidents from the KOPS [8]. Patient safety incidents occurring in the OR carried a higher likelihood of resulting in serious harm, including adverse events or sentinel events, and prolonged hospital stays [8,9]. Therefore, for preventing patient safety incidents, healthcare professionals working at the OR need to be alert and aware of patient safety incidents, and furthermore, they need to have patient safety competency, leading to patient safety management activities.

A systematic review of patient safety in South Korea indicated that the majority of studies have primarily addressed nurses’ activities related to patient safety management[10]. A systematic review of nurses’ patient safety management activities in South Korea identified patient safety culture as a positive factor of patient safety management activities at organizational level[11]. Patient safety culture is the shared commitment in a healthcare setting to keep patients safe, openly discuss mistakes, and improve safety together[12]. A meta-path analysis on nurses’ patient safety management activities revealed that patient safety culture at organizational level had indirect effects on patient safety management activities through nurses’ perceptions of the importance of patient safety management and their patient safety competency[13]. Likewise, it was found that the higher the perception of patient safety culture among OR nurses, the more actively patient safety management activities have been conducted [14-16].

Particularly in the OR, healthcare professionals collaborate interdependently and perform complex and precise tasks that require a high degree of concentration[17]. As surgical procedures become more complex, with an increasing variety of surgical tools and specialized equipment, the need for effective teamwork in ensuring patient safety has become more critical [18]. The WHO has also emphasized the importance of teamwork and communication among healthcare professionals at the OR, encouraging all involved healthcare professionals to share patient information and surgical process details [19]. Superior teamwork has shown to be one of perioperative patient safety indicators [20] and be associated with a shorter length of hospital stay in patient outcomes [21]. Also, teamwork was a positive factor of patient safety management activities of OR nurses in prior investigations [14,22].

To establish a safe environment for patients in the OR, it is necessary to evaluate the factors that may disrupt surgical flow[23,24]. Healthcare professionals in the OR have been exposed to various types of disruptions, including auditory, visual, equipment-related, and environmental factors [25-28]. Auditory disruptions such as equipment alarms and sound, or phone calls were identified to impair communication [29], and increase the risk of errors during the surgical procedures [30]. Visual disruptions such as higher number of door openings were shown to increase the likelihood of surgical site infections[31]. Equipment-related disruptions such as shortage of equipment or equipment availability increased the job stress of OR nurses[32], which can affect patient safety management activities of OR nurses. Communication disruptions such as case-irrelevant conversation and environmental disruptions including excessive heat/cold or poor physical working condition were also frequently reported among perioperative nurses[25,28]. However, while previous studies have shown the partial link between a disruption factor and patient safety outcomes, research on the relationship between various types of surgical disruption and patient safety management activities of OR nurses are limited. Furthermore, it is necessary to investigate the relationship of the distracting factors in the OR that threaten patient safety to perception of patient safety culture and teamwork which has been positively associated with patient safety management activities of OR nurses.

Therefore, the aims of this study were 1) to identify OR nurses’ perceived distractions; 2) to determine the relationships among teamwork, perception of patient safety culture, distractions in the OR, and patient safety management activities of nurses working in the OR; and 3) to determine whether any type of distractions in the OR were associated with patient safety management activities of OR nurses after controlling for teamwork and perception of patient safety culture.

Ⅱ. METHODS

1. Study Design

A descriptive, cross-sectional study design was used in this study to examine the relationships among teamwork, perception of patient safety culture, distractions in the OR, and patient safety management activity among nurses working in the OR. The study participants were recruited from Ulsan University Hospital, Ulsan, South Korea.

2. Study Subjects

Nurses working at the OR for more than three months as a scrub nurse, a circulating nurse, an anesthesia nurse, or a surgical assistant(SA) nurse in the perioperative process were eligible to participate in this study. Nurses with less than 3 months of clinical experience, new nurses undergoing job training, or nursing managers in the OR were excluded from this study. According to the Position Statement established by the Association of Perioperative Registered Nurses(AORN), the recommended minimum orientation period for perioperative nurses is at least three months. The first 3 months correspond to the institution's perioperative orientation and skill-acquisition period. Therefore, nurses with less than three months of clinical experience were excluded from this study. The G*Power program 3.1.9.7 for Window was used to estimate the sample size with a medium effect size of 0.15 and an expected R² for teamwork, perception of patient safety culture, and distractions in the OR in the multiple linear regressions [33]. A minimum sample size was estimated to be 146 with α of 0.05, 80% power (1-β), and up to 17 independent variables for multiple linear regressions. Considering the 10% dropout rate, a total of 160 participants were recruited, and 11 participants did not complete the questionnaire. Therefore, data from 149 participants were included in the final analysis.

3. Measures

1) General characteristics

General characteristics were obtained through a self-reported questionnaire from the participants including sex, age, type of hospital, education level, clinical career at the OR, working pattern, job position, number of surgical patients per day, experience of patient safety management education, and the most recent date, contents, and methods of patient safety management education. Patient safety management education experience at least once within three months was shown to be positively related to patient safety management activities in previous studies [16,32], and the most recent education date was divided by three months.

2) Teamwork

Teamwork is defined not simply as working together, but as the integration of knowledge, skills, and attitudes necessary for functioning as a team of two or more[34]. In this study, teamwork was measured using a modified version of the TeamSTEPPS Teamwork Perceptions Questionnaire, developed by the Agency for Healthcare Research and Quality [35]. The questionnaire was adapted by An and Lee(2016) for the OR context of Korea and administered to perioperative medical staff [22]. This questionnaire consists of 35 items across five domains: team structure, leadership, situation monitoring, mutual support, and communication. Each item was rated on a scale from 1(not at all) to 5 (very severe), with higher scores indicating better teamwork. In a previous study [36] on the development of a teamwork improvement program for patient safety in the perioperative period, the Cronbach's α coefficient for this questionnaire was .92, while it was .95 in our study.

3) Perception of Patient Safety Culture

The perception of patient safety culture refers to the awareness and understanding of healthcare staff regarding the shared values, beliefs, attitudes, and behaviors within an organization that aim to minimize patient harm during healthcare delivery [12]. The OR nurses’ perceptions of patient safety culture was assessed using a modified version of the Safety Attitudes Questionnaire (SAQ) [12], which is a widely used, validated survey tool designed to assess the safety culture or climate within healthcare organizations. A modified, Korean version of the SAQ consists of a total of 30 items and six domains: safety climate, teamwork climate, working conditions, stress recognition, perception of management, and job satisfaction [37]. Each item was rated on a 5-point Likert scale from 1(strongly disagree) to 5(strongly agree), with a higher score indicating a more positive perception of patient safety culture. The Cronbach's α for the modified Korean version of the SAQ was .92 in previous study [37], and it was .93 in this study.

4) Distractions in the OR

Distractions in the OR refer to any stimuli or events that interfere with concentration, communication, and workflow of surgical team [25]. The Korean version of the Distractions in the OR [28] was used to assess distracting factors in OR nurses in this study. This instrument comprises 74 items across 5 domains: auditory, visual, equipment, communication, and environment. Participants were asked whether they considered the following factors to be distracting in the OR. The frequency of experiencing each distraction factor and the degree of bothersomeness in the OR were rated on a 5-point Likert scale from 1 to 5. Higher scores indicated more frequent and more bothersome experiences of distractions. The extent of impact on the flow of surgery was rated on a 5-point Likert scale, with each item scored as follows: 1(negative impact), 2(somewhat negative), 3(no impact), 4(somewhat positive), and 5 (positive impact). In addition, participants were asked to rank the most distracting domain and to explain their reasoning. The extent of impact on surgical flow was reverse-scored so that a higher score indicates a more negative impact on surgical flow. Then, the total score was calculated by adding the frequency, degree of bothersomeness, and extent of impact on surgical flow for each of the 5 domains. A Cronbach's α coefficient was .87 in a previous study [28], and it was .90 in this study.

5) Patient Safety Management Activity

The Patient Safety Management Activity questionnaire was developed to measure the level of patient safety management activities among OR nurses in Korea[37]. The patient safety management activity of OR nurses was assessed across six domains: infection control, specimen management, pre-operative confirmation, medical equipment and accessory management, counting, and injury prevention. The Patient Safety Management Activity questionnaire consists of a total of 35 self-reported items, and each item is rated on a 5-point Likert scale from 1 to 5, with a higher score indicating a better implementation of safety management activities by OR nurses. In previous research [37], Cronbach's α coefficient was .94, and in this study, it was .94.

4. Data Collection

After the primary researcher explained the purpose and procedures of this study to eligible study subjects, written consent was obtained from all participants. Then, questionnaires were provided for participants, and data collection took approximately 20-30 minutes. Each completed questionnaire was returned to the primary researcher in a sealed envelope. When returning the questionnaire, a gift worth approximately 2,500 won was given to all participants. Data collection was conducted from September 1 to September 30, 2024.

5. Ethical considerations

The research proposal was approved by the Institutional Review Board of Ulsan University Hospital to ensure the protection of the rights of human subjects (UUH 2024-08-025), before data collection. Written informed consent was obtained from all participants.

6. Data Analysis

All data analyses were performed using SPSS for Windows 27.0(IBM, Armonk, New York, USA). A p-value of ＜ .05 was considered statistically significant. Descriptive statistics were shown as means with standard deviations and frequencies with numbers. Independent t-tests and one-way analysis of variance(ANOVA) were used to identify differences in patient safety management activities according to the general characteristics. Pearson's correlation coefficient was used to examine the relationships between teamwork, perception of patient safety culture, distractions in the OR, and patient safety management activities.

This study maintained the assumption of no multicollinearity, with tolerance values ranging from 0.48 to 0.69 and variance inflation factors (VIF) between 1.45 and 2.07 (close to 1-2). Hierarchical linear regression analysis was used to determine the relationships of distractions in the OR to patient safety management activities of OR nurses, after controlling for teamwork and perception of patient safety culture, and other variables related to patient safety management activities with a p-value＜.10 in univariate analysis. The p-value cutoff in univariate analysis was set above the conventional p -value of .05 to avoid excluding potentially important predictors and confounders from the multivariate model, which is in line with the purposeful selection strategies recommended in regression modeling [38].

Ⅲ. RESULTS

1. General Characteristics and Patient Safety Management Activities of Participants by general characteristics

The general characteristics of the 149 OR nurses are shown in Table 1. Among the participants, 121 (81%) were female, and the average age was 31.99±6.55 years. Most participants (73.2%) had a bachelor's degree. The average clinical career at the OR was 95.56 ± 84.98 months, with 50% of the participants having more than 72 months of experience. Regarding work patterns, 70 participants (47.0%) worked in 3-shift rotations, and 35 (23.5%) worked in regular day shift with on-call duty. The job positions were as follows: 50(33.6%) staff nurses, 48 (32.2%) surgical assistants, 32 (21.5%) anesthesia nurses, and 19 (12.8%) charge nurses. The average number of surgical patients assigned per day was 3.72 ± 1.40, with 50% of participants caring for 4 or more patients. A total of 110 participants (73.8%) had received education for patient safety management, and 51 (34.2%) had received education within the past 3 months. The most common content of education for patient safety management was infection control, followed by specimen management and preoperative check. Among the general characteristics, there were no variables that showed differences in the patient safety management activities of the study subjects(all p＞.05)(Table 1).

Table 1.

General Characteristics and Patient Safety Management Activities by General Characteristics (N=149)

Variables	Categories	n (%) or Mean±SD	Patient safety management activities	t/F or r (p)
Variables	Categories	n (%) or Mean±SD	Mean±SD	t/F or r (p)
Sex	Male	28(18.8)	4.37±0.45	0.37(.715)
	Female	121(81.2)	4.34±0.41
Age (years)		31.99±6.55		0.03(.730)
	＜30	59(39.6)	4.41±0.43	1.57(.212)
	30∼39	66(44.3)	4.48±040
	≥ 40	24(16.1)	4.37±0.43
Type of hospital	Tertiary medical center	130(87.2)	4.33±0.42	-1.34(.182)
	General hospital	19(12.8)	4.46±0.41
Education	College degree	26(17.4)	4.35±0.38	0.15(.863)
	Bachelor's degree	109(73.2)	4.33±0.44
	In Master's program or higher	14(09.4)	4.40±0.37
Clinical career at operating room (months)		95.56±84.98		0.02(.847)
	＜72	74(49.7)	4.40±0.43	1.66(.100)
	≥72	75(50.3)	4.29±0.40
Working pattern	Three shift	70(47.0)	4.30±0.39	0.65(.585)
	Two shift	10(06.7)	4.49±0.48
	None shift	34(22.8)	4.36±0.44
	Rugular day shift with on-call duty	35(23.5)	4.37±0.44
Job position	Staff nurse^†	50(33.6)	4.38±0.39	0.83(.482)
	Charge nurse^‡	19(12.8)	4.43±0.33
	Surgical assistant^§	48(32.2)	4.28±0.46
	Anesthesia nurse^∥	32(21.5)	4.33±0.44
Average number of surgical patients per day		3.72±1.40		0.07(.399)
	＜4	74(49.7)	4.31±0.42	-0.84(.403)
	≥4	75(50.3)	4.37±0.42
Experience of education for patient safety management				2.60(.077)
	No	39(26.2)	4.30±0.45
	Completion within 3 months	51(34.2)	4.44±0.41
	Completion ≥ 3 months	59(39.6)	4.27±0.39
Contents of recent patient safety management education^*
	Infection control	63(24.8)
	Specimen management	50(19.7)
	Preoperative check	50(19.7)
	Equipment and item management	41(16.1)
	Count (Gauze, Needle, etc.)	33(13.0)
	Injury prevention	15(5.9)
	Other	2(0.8)
Methods of recent patient safety management education^*
	Face to face education	50(33.6)
	Written education	41(27.5)
	Internet video education	19(12.8)

SD: Standard deviation,

^* multiple responses The roles of the four job positions are as follows:

^† prepares the operating room, assists during surgery by passing instruments, and monitors patient vitals;

^‡ oversees OR team coordination, ensures efficient workflow, and manages resources and staffing;

^§ directly aids surgeon during procedures with tasks like retracting tissues, suturing, and instrument handling;

^∥ administers anesthesia, monitors patient during procedure, and manages airway and vital signs.

2. Teamwork, Perception of Patient Safety Culture, and Patient Safety Management Activities of Participants

The teamwork of the subjects of this study was 3.97±0.44 on average, and the team structure was the highest among the five domains. The perception of patient safety culture was 3.53±0.47 on average, and teamwork climate and safety climate were the highest among the six domains. The patient safety management activity was 4.34 ±0.42 on average, and the preoperative check was the highest among the six domains, followed by the injury prevention (Table 2).

Table 2.

Teamwork, Perception of Patient Safety Culture, and Patient Safety Management Activities of Subjects (N=149)

Variables	Categories	Mean±SD
Teamwork	Total	3.97±0.44
	Team structure	4.06±0.49
	Mutual support	4.02±0.45
	Situation monitoring	4.00±0.52
	Communication	3.95±0.54
	Leadership	3.79±0.62
Perception of patient safety culture	Total	3.53±0.47
	Teamwork climate	3.91±0.58
	Safety climate	3.91±0.48
	Working conditions	3.70±0.60
	Job satisfaction	3.54±0.67
	Perception of management	3.46±0.66
	Stress recognition	3.16±0.75
Patient safety management activities	Total	4.34±0.42
	Preoperative check	4.58±0.48
	Injury prevention	4.51±0.48
	Count	4.39±0.54
	Specimen management	4.29±0.56
	Equipment and item management	4.15±0.74
	Infection control	3.99±0.58

SD: Standard deviation

3. Distractions in the OR

In terms of experience with distracting factors in the OR, 122 subjects(81.9%) experienced equipment shortages among the equipment domain and poor physical working condition among the environment domain the most, followed by equipment availability among the equipment domain and excessive heat/cold among the environment domain with 115 subjects (77.2%). Among all distracting factors in the OR, the most frequent was the door opening during the case, followed by phone calls/pagers/beepers, and case relevant conversations. Participants responded that poor physical working conditions, such as standing for long time or being in a fixed position, was the most bothersome factor. The factor that had the most negative impact on the surgical flow was the poor physical working conditions, followed by the equipment shortage. Lastly, the largest proportion of OR nurses (35.6%) identified the environment domain as the most distracting domain among five domains, followed in order by equipment, communication, auditory, and visual (Table 3).

Table 3.

Distractions in the Operating Room (N=149)

Distraction domains	Sub-factors	A distracted experience	Frequency of experience	Degree of bothersomeness	Extent of impact	The most distracting	Total score
Distraction domains	Sub-factors	n (%)	Mean±SD	Mean±SD	Mean±SD	n (%)	Mean±SD
Auditory	Music	51(34.2)	2.36±1.19	1.79±0.90	2.46±0.98	17(11.4)	34.71±9.49
	News	49(32.9)	2.11±1.12	1.88±0.98	2.70±0.84
	Phone calls/pagers/beepers	73(49.0)	2.58±1.07	2.62±1.22	3.58±0.76
	Equipment alarm	78(52.3)	2.42±1.07	2.40±1.05	3.41±0.81
Visual	Door opening during case	74(49.7)	2.64±0.94	2.36±1.05	3.38±0.62	7(04.7)	34.37±9.26
	Movement around the monitor	52(34.9)	1.95±1.03	2.13±1.00	3.36±0.65
	Increasing in room traffic during case	76(51.0)	2.04±0.98	2.46 ± 1.17	3.50±0.69
	Staff changeover	61(40.9)	2.03 ± 1.06	2.17 ± 1.03	3.28±0.61
Equipment	Equipment availability	115(77.2)	1.81±0.87	3.45 ± 1.20	4.05±0.75	49(32.9)	20.02±5.10
	Shortage of equipment	122(81.9)	1.68±0.89	3.38 ± 1.26	4.06±0.77
Communication	Case relevant conversation	34(22.8)	2.58 ± 1.23	1.60±0.87	2.20±0.96	23(15.4)	28.93±6.72
	Case irrelevant conversation	88(59.1)	2.17 ± 1.03	2.68±1.23	3.57±0.86
	Consultation	38(25.5)	1.78±0.98	1.87±0.94	2.74±0.79
	Teaching or training	39(26.2)	1.85±0.96	1.88±0.99	2.68±0.81
Environment	Excessive heat/cold	115(77.2)	2.23 ± 1.08	3.45 ± 1.26	3.88±0.89	53(35.6)	41.26±9.39
	Team member's unavailability	111(74.5)	1.77±0.96	3.47 ± 1.21	4.05±0.78
	Poor physical working condition	122(81.9)	2.53 ± 1.13	3.73 ± 1.13	4.10±0.75
	Appropriate room assignment	105(70.5)	1.91 ± 1.07	3.29 ± 1.10	3.81±0.77

SD: Standard deviation

4. Correlation between Teamwork, Perception of Patient Safety Culture, Distractions, and Patient Safety Management Activities

Teamwork(r=0.32, p＜.001) and perception of patient safety culture(r=0.36, p＜.001) had a positive correlation with patient safety management activities. Auditory domain of distractions in the OR showed significantly negative correlation with patient safety management activities (r=-0.21, p =.011) (Table 4).

Table 4.

Correlation among Teamwork, Perception of Patient Safety Culture, Distractions In the Operating Room, and Patient Safety Management Activities (N=149)

Variables		Teamwork	Perception of patient safety culture	Distractions in the operating room					Patient safety management activities
		Teamwork	Perception of patient safety culture	Auditory	Visual	Equipment	Communication	Environment	Patient safety management activities
		r(P)
Teamwork		1
Perception of patient safety culture		0.69 (<.001)	1
	Auditory	-0.31(<.001)	-0.28(.001)	1
	Visual	-0.32(<.001)	-0.29(<.001)	0.62(<.001)	1
Distractions in the operating room	Equipment	-0.15(.079)	-0.28(.001)	0.44(<.001)	0.51(<.001)	1
	Communication	-0.21(.011)	-0.18(.028)	0.47(<.001)	0.51(<.001)	0.38(<.001)	1
	Environment	-0.33(<.001)	-0.43(<.001)	0.42(<.001)	0.52(<.001)	0.60(<.001)	0.31(<.001)	1
Patient safety management activities		0.32(<.001)	0.36(<.001)	-0.21(.011)	-0.14(.079)	-0.00(.957)	-0.15(.061)	0.20(.149)	1

5. Factors Associated with Patient Safety Management Activities of OR nurses

The hierarchical multiple linear regression analysis to determine factors associated with patient safety management activities was presented in Table 5. Experience of education for patient safety management with a p -value ＜.10 in univariate analysis, teamwork, and perception of patient safety culture were included in step 1, and then, auditory, visual, and communication domains of distractions in the OR were added in step 2. Teamwork(β=0.28, p=.007), perception of patient safety culture(β=0.24, p=.016), visual distractions (β=-0.22, p=.023), and communication distraction (β=-0.26, p = .002) were associated with patient safety management activities. In step 1, teamwork and perception of patient safety culture explained about 22% of patient safety management activities of OR nurses(F=11.32, p＜.001). In step 2, visual and communication distractions contributed an additional 4% to explaining patient safety management activities (F = 8.52, p ＜.001) (Table 5).

Table 5.

Factors Associated with Patient Safety Management Activities in the Hierarchical Linear Regressions (N=149)

Variables		Patient safety management activities
Variables		β	t	p	β	t	p
Step 1	Completed education within 3 months (versus. no education experience)	- 0.23	-0.25	.801	0.00	0.05	.965
	Completed education for 3 months or more (versus. no education experience)	0.88	0.97	.334	0.07	0.82	.416
	Teamwork	0.27	2.62	.010	0.28	2.76	.007
	Perception of patient safety culture	0.23	2.29	.024	0.24	2.43	.016
Step 2	Auditory distractions				-0.02	-0.19	.853
	Visual distractions				-0.22	-2.31	.023
	Communication distractions				-0.26	-3.10	.002
	Overall	Adjusted R² = 0.22, F=11.32, p＜.001			Adjusted R² = 0.26, change in adjusted R² = 0.04, F=8.52, p＜.001

Ⅳ. DISCUSSIOS

This study focused on the relationships among teamwork, perception of the patient safety culture, distracting factors in the OR and patient safety management activities of OR nurses, exploring strategies for ensuring patient safety in the OR. The major findings of this study indicate that visual and communication distractions in the OR were associated with patient safety management activities of OR nurses after controlling for teamwork and perceptions of the patient safety culture.

In this study, it was determined that visual domain including door openings, increased room traffic, and staff changeovers during cases was the least distracting domain among the five domains, and door opening during cases emerged as the most frequent distracting factor. These findings were similar to those of previous studies about distractions in the OR [25,28]. A recent individual-patient data meta-analysis demonstrated that frequent intraoperative door openings have been linked to a marginally increased risk of surgical site infection[39]. Also, staff changeover during cases was associated with prolonged OR time [40], and increased room traffic within case appeared to have more incidence of postoperative complications [41]. These findings, together with ours, support the importance of implementing strategies to reduce door openings and OR traffic during cases to enhance patient safety in the OR. A visual feedback using electronic door counters [42] or door alarms [43] could be recommended to reduce unnecessary door openings and OR traffic. In addition, it is recommended that protocols should be established to minimize traffic into and out of the OR during procedures. Furthermore, comprehensive education would be provided for all staff regarding the detrimental impact of visual distractions and the critical importance of maintaining concentration throughout cases.

Another distraction associated with patient safety management activities of OR nurses was the communication domain in this study. Case-irrelevant conversations occurred more frequently than case-relevant conversations, patient-related consultations, and surgical training or teaching within the communication domain, and were perceived as more disruptive, adversely affecting the surgical flow in this study, aligning with previous investigations of distractions in the OR [25,28,44,45]. After implementation of behavioral guidelines to limit case-irrelevant conversations as a strategy for noise reduction program, case-irrelevant conversations and responses indicating that noise affected the task significantly decreased (46), and postoperative complication rate was significantly lower[47]. Accordingly, it is essential to establish an organizational culture in which perioperative team members consistently refrain from engaging in unnecessary patient-unrelated conversations. Such efforts are expected to enhance patient safety management activities and contribute to a reduction in preventable adverse events.

Aside from disruptive factors, one of the key facilitators of patient safety management activities of perioperative nurses was identified as teamwork in this study. Also, it was previously reported that teamwork was positively associated with patient safety management activities of OR nurses [13,21]. Effective teamwork has been emphasized as a critical factor in reducing the patient safety incidents and improving the efficiency of healthcare professionals’ performance[18]. As a result of implementing a teamwork training program in the OR, work efficiency among intraoperative staffs was improved and patient safety issues were reduced [48]. In our study, leadership was the lowest among the subdomains of teamwork, which is consistent with the findings of a previous study [22], as the primary surgeon usually has played the role of the team leader in the surgical team. The leadership training program for perioperative nurses, particularly in relation to ensuring the consistent completion of the Surgical Safety Checklist, would be implemented at an organizational level [49].

Another key facilitator of patient safety management activities of OR nurses was identified as perception of patient safety culture in this study. The higher the perception of patient safety culture among OR nurses, the more actively they engage in patient safety management activities, which are aligned with previous studies[14-16]. Additionally, it was found that teamwork climate and safety climate were the highest among six domains of perception of patient safety culture in this study. Similarly, in a recent scoping review examining the association between patient safety culture and adverse events, teamwork climate and safety climate consistently emerged as the most frequently identified dimensions linked to lower rates of adverse events[50]. Therefore, the development and implementation of programs aimed at fostering teamwork culture and enhancing safety culture are warranted at the organizational level to cultivate an environment where medical errors are openly discussed, improvements are collaboratively pursued, and mutual support is actively promoted.

This study has several limitations to be addressed. Our study was a cross-sectional study, and all variables were assessed at once, which could not indicate the causal relationship among teamwork, perception of patient safety culture, distraction factors, and patient safety management activities of OR nurses. In addition, our study focused on OR nurses in a general hospital and a tertiary medical center in South Korea. Therefore, our findings warrant further research to determine the relationships among teamwork, perception of patient safety culture, distraction factors, and patient safety management activities of all medical staff working in the OR and would be extended to other clinical settings. Furthermore, future work would be required to evaluate the effects of a training program that fosters the patient safety environment on patient clinical outcomes through randomized controlled trials.

Ⅴ. CONCLUSIONS

Our study determined that OR nurses with higher levels of teamwork and greater perception of patient safety culture engaged more actively in patient safety management activities. On the other side, among the disruption factors examined, visual distractions and communication factors were determined to have a negative impact on patient safety management activities of OR nurses. It is essential to prioritize initiatives that strengthen teamwork and enhance awareness of patient safety culture among OR nurses, as well as to eliminate distractions within the OR environment, for optimizing patient safety management activities.

Notes

Conflict of interest

The authors declare no conflict of interest.

Funding

This study received no external funding.

Data availability statement

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restriction.

REFERENCES

1.World Health Organization. Patient safety incident reporting and learning systems: technical report and guidance [Internet]. Geneva: World Health Organization; 2020. [cited 2024 May 5]. Available from:, https://iris.who.int/handle/10665/334323

2.Korean Law Information Center. Patient Safety Act [Internet]. Sejong: Korea Ministry of Government Legislation; 2016. [cited 2025 August 1]. Available from:, https://www.law.go.kr/%EB%B2%95%EB%A0%B9/%ED%99%98%EC%9E%90%EC%95%88%EC%A0%84%EB%B2%95/(13113,20150128)

3.Joint Commission on Accreditation of Healthcare Organizations. Joint Commission International accreditation standards for hospitals.. 3rd ed.Oakbrook Terrace (IL): 2007. p. 1–240.

4.Korea Institute for Healthcare Accreditation. Accreditation Program for Healthcare Organizations [Internet] [cited 2025 August 1]. Available from:, https://www.koiha.or.kr/web/en/assessment/accStandard.do

5.World Health Organization. WHO Patient safety. Surgical Safety Checklist. 2009.

6.Ministry of Health and Welfare. Safety Guideline for Surgical Patient. Seoul: Korea Institute for Healthcare Accreditation; 2020.

7.Korea Institute for Healthcare Accreditation. 2024 Patient safety annual report [Internet]. Seoul: Central Patient Safety Center, Korea Institute for Healthcare Accreditation; 2025. [cited 2025 August 1]. Available from:, https://www.kops.or.kr/kops/ebook/1/30/index.html

8.Kim NY, Ryu H, Kwak S. Patient safety incidents in operating rooms reported in the past five years (2017-2021) in Korea. Risk Management and Healthcare Policy. 2024;17, 1639–46. https://doi.org/10.2147/RMHP.S462485

9.Kim MJ, Seo HJ, Koo HM, Ock M, Hwang JI, Lee SI. The Korea national patient safety incidents inquiry survey: Characteristics of adverse events identified through medical records review in regional public hospitals. Journal of Patient Safety. 2022;18(5):382–8. https://doi.org/10.1097/PTS.0000000000000944

10.Cho HA, Shin H. A systematic review of published studies on patient safety in Korea. Journal of Korean Academy of Dental Administration. 2014;2(1):61–82. https://doi.org/10.22671/JKADA.2014.2.1.61

11.Baek SM, Jeon S-H. A review of patient safety activietes of nurses in Korea. The Journal of Learner-Centered Curriculum and Instruction. 2021;21(6):657–67. https://doi.org/10.22251/jlcci.2021.21.6.657

12.Sexton JB, Helmreich RL, Neilands TB, Rowan K, Vella K, Boyden J, et al. The safety attitudes questionnaire: Psychometric properties, benchmarking data, and emerging research. BMC Health Services Research. 2006;6, 44.https://doi.org/10.1186/1472-6963-6-44

13.Jeong S, Jeong SH. Patient safety management activities of Korean nurses: A meta-analytic path analysis. Journal of Korean Academy of Nursing. 2022;52(4):363–77. https://doi.org/10.4040/jkan.22022

14.Kim S, Choi S. Influences of teamwork and patient safety culture awareness on patient safety management activities among operating room nurses in general hospitals. Journal of Business Convergence. 2024;9(2):161–6. http://dx.doi.org/10.31152/JB.2024.04.9.2.161

15.Kim SM, Kwon SH. Factors influencing patient safety management activities among general hospital operating room nurses. Journal of Korean Academy of Nursing Administration. 2023;29(2):89–98. https://doi.org/10.11111/jkana.2023.29.2.89

16.Kwon KN, Hwang SY. Impact of perception of patient Ssfety culture and safety control on patient safetymManagement activities among perioperative nurses in university hospitals. Journal of Korean Academy of Nursing Administration. 2022;28(3):285–96. https://doi.org/10.11111/jkana.2022.28.3.285

17.Weaver SJ, Benishek LE, Leeds I, Wick EC. The relationship between teamwork and patient safety. In: Sanchez JA, Barach P, Johnson JK, Jacobs JP, editors. Surgical Patient Care. Cham: Springer International Publishing; 2017. p. 51–66.

18.Weller J, Boyd M, Cumin D. Teams, tribes and patient safety: Overcoming barriers to effective teamwork in healthcare. Postgraduate Medical Journal. 2014;90(1061):149–54. https://doi.org/10.1136/postgradmedj-2012-131168

19.Erestam S, Haglind E, Bock D, Andersson AE, Angenete E. Changes in safety climate and teamwork in the operating room after implementation of a revised WHO checklist: A prospective interventional study. Patient Safety in Surgery. 2017;11, 4.https://doi.org/10.1186/s13037-017-0120-6

20.Nyberg A, Jirwe M, Fagerdahl A, Otten V, Haney M, Olofsson B. Perioperative patient safety indicators-A Delphi study. Journal of Clinical Nursing. 2025;34(4):1351–63. https://doi.org/10.1111/jocn.17212

21.Witmer HDD, Morris-Levenson JA, Keceli C, Godley FAt, Dhiman A, Adelman D, et al. Novel application of a dynamic, in-room survey platform to measure surgical team satisfaction. Annals of Surgery. 2024;279(1):71–6. https://doi.org/10.1097/SLA.0000000000005993

22.Ahn S-A, Lee N-J. The effect of operating room nursing and medical staff teamwork and perception of patient safety culture on the performance of surgical patient safety protocol. Journal of Korean Critical Care Nursing. 2016;9(1):27–39.

23.Roberts ER, Hider PN, Wells JM, Beasley SW. The frequency and effects of distractions in operating theatres. ANZ Journal of Surgery. 2021;91(5):841–6. https://doi.org/10.1111/ans.16799

24.Murji A, Luketic L, Sobel ML, Kulasegaram KM, Leyland N, Posner G. Evaluating the effect of distractions in the operating room on clinical decision-making and patient safety. Surgical Endoscopy. 2016;30, 4499–504. https://doi.org/10.1007/s00464-016-4782-4

25.Nasri B-N, Mitchell JD, Jackson C, Nakamoto K, Guglielmi C, Jones DB. Distractions in the operating room: A survey of the healthcare team. Surgical Endoscopy. 2023;37, 2316–25. https://doi.org/10.1007/s00464-022-09553-8

26.Sevdalis N, Forrest D, Undre S, Darzi A, Vincent C. Annoyances, disruptions, and interruptions in surgery: The Disruptions in Surgery Index (DiSI). World Journal of Surgery. 2008;32(8):1643–50. https://doi.org/10.1007/s00268-008-9624-7

27.Sevdalis N, Undre S, McDermott J, Giddie J, Diner L, Smith G. Impact of intraoperative distractions on patient safety: A prospective descriptive study using validated instruments. World Journal of Surgery. 2014;38(4):751–8. https://doi.org/10.1007/s00268-013-2315-z

28.Kang J, Lee S, Jung J, Sim Y, Lee Y, Park B, et al. A survey on factors distracting operating theatre staff during surgery in Korea. Journal of Perioperative Practice. 2026;36(1-2):68–82. https://doi.org/10.1177/17504589251340153

29.Hasfeldt D, Laerkner E, Birkelund R. Noise in the operating room-What do we know? A review of the literature. Journal of PeriAnesthesia Nursing. 2010;25(6):380–6. https://doi.org/10.1016/j.jopan.2010.10.001

30.Mentis HM, Chellali A, Manser K, Cao CG, Schwaitzberg SD. A systematic review of the effect of distraction on surgeon performance: Directions for operating room policy and surgical training. Surgical Endosccopy. 2016;30, 1713–24. https://doi.org/10.1007/s00464-015-4443-z

31.Lansing SS, Moley JP, McGrath MS, Stoodley P, Chaudhari AMW, Quatman CE. High number of door openings increases the bacterial load of the operating room. Surgical Infections. 2021;22(7):684–9. https://doi.org/10.1089/sur.2020.361

32.Kang H, Choi S-K, Kim I-S. Factors influencing on patient safety management activities in operating room nurses. Journal of the Korea Academia-Industrial cooperation Society. 2016;17(9):329–39. http://dx.doi.org/10.5762/KAIS.2016.17.9.329

33.Faul F, Erdfelder E, Lang AG, Buchner A. G*Power 3: A flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behavior Research Methods. 2007;39, 175–91. https://doi.org/10.3758/bf03193146

34.Manser T. Teamwork and patient safety in dynamic domains of healthcare: A review of the literature. Acta Anaesthesiologica Scandinavica. 2009;53(2):143–51. https://doi.org/10.1111/j.1399-6576.2008.01717.x

35.Battles J, King HB. Teamstepps teamwork perceptions questionnaire(t-tpq) manual. Washington, DC: American Institute for Research; 2010.

36.Ahn S, Lee N-J. Development and evaluation of a teamwork improvement program for perioperative patient safety. Journal of Nursing Research. 2021;29(6):e181.https://doi.org/10.1097/JNR.0000000000000460

37.Jeong HJ. Safety culture awareness and safety management activities of operating room nurse [master's thesis]. Seoul: Kyung Hee University; 2013.

38.Ullmann T, Heinze G, Hafermann L, Schilhart-Wallisch C, Dunkler D. TGotSi. Evaluating variable selection methods for multivariable regression models: A simulation study protocol. PLoS One. 2024;19(8):e0308543.https://doi.org/10.1371/journal.pone.0308543

39.Groenen H, Jalalzadeh H, Bontekoning N, Bediako-Bowan AAA, Buis DR, Dreissen YEM, et al. Effect of the number of door openings in the operating room on surgical site infections: Individual-patient data meta-analysis. BJS Open. 2025;9(3):https://doi.org/10.1093/bjsopen/zraf044

40.Giugale LE, Sears S, Lavelle ES, Carter-Brooks CM, Bonidie M, Shepherd JP. Evaluating the impact of intraoperative surgical team handoffs on patient outcomes. Female Pelvic Medicine and Reconstructive Surgery. 2017;23(5):288–92. https://doi.org/10.1097/SPV.0000000000000370

41.Talsma A, Anderson C, Geun H, Guo Y, Campbell DA. Evaluation of OR staffing and postoperative patient outcomes. AORN Journal. 2013;97(2):230–42. https://doi.org/10.1016/j.aorn.2012.11.020

42.DiBartola AC, Barron C, Smith S, Quatman-Yates C, Chaudhari AMW, Scharschmidt TJ, et al. Decreasing room traffic in orthopedic surgery: A quality improvement initiative. American Journal of Medical Quality. 2019;34(6):561–8. https://doi.org/10.1177/1062860618821180

43.Eskildsen SM, Moskal PT, Laux J, Del Gaizo DJ. The effect of a door alarm on operating room traffic during total joint arthroplasty. Orthopedics. 2017;40(6):e1081–5.

44.Sevdalis N, Healey AN, Vincent CA. Distracting communications in the operating theatre. Journal of Evaluation in Clinical Practice. 2007;13(3):390–4. https://doi.org/10.1111/j.1365-2753.2006.00712.x

45.McLeod R, Myint-Wilks L, Davies SE, Elhassan HA. The impact of noise in the operating theatre: A review of the evidence. Annals of the Royal College of Surgeons of England. 2021;103(2):83–7. https://doi.org/10.1308/rcsann.2020.7001

46.Yu CV, Foglia J, Yen P, Montemurro T, Schwarz SKW, MacDonell SY. Noise in the operating room during induction of anesthesia: Impact of a quality improvement initiative. Canadian Journal of Anesthesia. 2022;69, 494–503. https://doi.org/10.1007/s12630-021-02187-9

47.Engelmann CR, Neis JP, Kirschbaum C, Grote G, Ure BM. A noise-reduction program in a pediatric operation theatre is associated with surgeon's benefits and a reduced rate of complications: A prospective controlled clinical trial. Annals of Surgery. 2014;259(5):1025–33. https://doi.org/10.1097/SLA.0000000000000253

48.Weld LR, Stringer MT, Ebertowski JS, Baumgartner TS, Kasprenski MC, Kelley JC, et al. TeamSTEPPS improves operating room efficiency and patient safety. American Journal of Medical Quality. 2016;31(5):408–14. https://doi.org/10.1177/1062860615583671

49.Penataro-Pintado E, Rodriguez E, Castillo J, Martin-Ferreres ML, De Juan MA, Diaz Agea JL. Perioperative nurses’ experiences in relation to surgical patient safety: A qualitative study. Nursing Inquiry. 2021;28(2):e12390.https://doi.org/10.1111/nin.12390

50.Vikan M, Haugen AS, Bjornnes AK, Valeberg BT, Deilkas ECT, Danielsen SO. The association between patient safety culture and adverse events - a scoping review. BMC Health Services Research. 2023;23, 300.https://doi.org/10.1186/s12913-023-09332-8