From the Lab to the Real World

An Ounce of Prevention: St. Michael’s Takes Page from Aviation, Develops ‘OR Black Box’ to Record Surgical Errors

St. Michael’s develops a ‘black box’ to illuminate human error in the OR in a positive way ‒ that is, without pointing the finger; to prevent future errors; to improve patient safety and outcomes, possibly saving lives; and to preemptively save health care dollars.

Researchers at St. Michael’s Hospital have developed a ‘black box’ to record errors in the operating room (OR) in the same manner as black box flight recorders have done in the airline industry since they were introduced in the 1960s.

The aim of this new device, approximately the size of a laptop, is three-fold: to show exactly where errors take place in the OR for the purpose of addressing problem(s) and educating surgeons; to improve patient safety and outcomes, including saving lives in the most extreme cases; and to save health care dollars by preventing longer hospital stays, which can add up in the billions.

“We, as a surgical team, do our best. But we can always be better. Using the black box we can improve our game,” says the inventor, Dr. Teodor Grantcharov, a specialist in minimally invasive surgery at St. Michael’s and an Associate Professor of Surgery at the University of Toronto. He hopes this new device will help dismantle the “blame-and-shame” culture where health care practitioners are reluctant to report mistakes.

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Dr. Teodor Grantcharov using the black box in the OR. Photographs courtesy of St. Michael’s Hospital.

Errors, defined as “deviations from an optimal course of action,” can and do happen in the OR. One research paper, “The Canadian Adverse Events Study,” by Drs. Ross Baker and Peter Norton, published in the Canadian Medical Association Journal (CMAJ) in 2004, looked at incidents of adverse events ‒ which can range from minor falls or infections to death ‒ among hospital patients in Canada.

This seminal study found that 187,500 out of 2.5 million patients admitted annually to acute care hospitals experience an adverse event. It estimated that between 9,000 to 23,000 Canadians die each year because of preventable adverse events in hospitals, and the largest single source of mistakes is surgery — accounting for 34%.

The OR black box, which began testing last April in St. Michael’s ORs as part of a pilot project, addresses the issue of preventable adverse events in surgery, head on.

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Researcher at St. Michael’s Hospital checking the OR black box monitor during surgery. Photograph courtesy of St. Michael’s Hospital.

“The data from the OR black box will provide surgeons with meaningful feedback about our performance. Using this, we will be able to design educational interventions to practice in a safe environment, so that when we go back to the OR, we can do a better job next time,” Grantcharov explains. “We’ll reduce the risk and complications, for patients, and show how to make the OR more efficient.”

The OR black box records almost everything that goes on in the OR, including a video of the surgery, conversations among health care workers, room temperature and decibel levels.

Grantcharov says that, via the OR black box, it is also possible to examine less tangible factors that can lead to errors, such as communication and team dynamics. “Say a surgeon picked up the wrong instrument. Then he got angry or frustrated and started to make technical errors. The more mistakes he made, the worse communications became,” Grantcharov said in St. Michael’s press release.

In this pilot study, video from the OR black box is analyzed for training and quality improvement, kept for 30 days due to privacy constraints, then destroyed, although it may be kept if there were an official request or court order.

Evidence Shows Black Box Works

There’s already evidence as to the OR black box’s success: The pilot study revealed that 84% of errors in bypass surgery were happening during the same two steps, so training was adapted to help surgeons master those two critical steps.

Looking ahead, Grantcharov imagines a day when the OR black box will be a regular feature of ORs around the world. His team has already been approached by organizations across Europe and North America.

The OR black box pilot study was funded by Innovation Funds from St. Michael’s.

To see a video of the OR black box in use, go here: http://bit.ly/VjfNLH. To read St. Michael’s press release, go here: http://bit.ly/1w5ZwuC. To read “The Canadian Adverse Events Study,” published by CMAJ, go here: http://bit.ly/1nMwztD.