CLOSE WATCH Any high-risk industry monitors the performance of the frontline workers. Surgery should be no different.

Flight data recorders embedded on airliners retrace the events that led to mid-air disasters. I've developed the same "black box" technology for the OR to find out why adverse events happen and what can be done in the future to improve patient safety. But the technology has broader applications. My goal is place a black box in every OR, including yours, to enhance surgical outcomes, improve case efficiencies and lower healthcare costs.

Moments in time
The black box platform, which is about the size of a tissue box or thick book, records almost everything that happens in the OR during laparoscopic surgeries. It captures video from the surgeon's imaging equipment and from a camera mounted in the operating room. It also captures audio recordings of surgical team interactions, tracks physiological data from the anesthesia monitor and records the room's decibel levels and air temperature, as well as potential distractions: how often the OR door is opened and how many times phones ring or ping.

Surgical teams can use the black box to zero in on specific moments during cases to check the patient's vital signs, listen in on what the surgical team was discussing and watch the surgeon's technique. Yes, they can use the technology to determine what led to a surgical error, but they can also analyze the captured moments of time to assess how procedures could have been performed better or more efficiently.

Proprietary software syncs the inputs to timestamp every event that occurs during a procedure, allowing for post-op analysis of the many different factors that contribute to outcomes, successful or otherwise. Currently, most of the analysis is automated, but our goal is to automate the entire information-gathering process and send the data to a central database designed for tracking trends that help predict risk of future hazards and quantify surgeon performance in order to develop effective coaching interventions. Surgeons will have the clinical data they need for better coaching and technique improvement, to reduce the risks of surgery and sidestep avoidable complications, to ultimately provide better patient care. The surgical team will notice the little things they can do to improve overall procedural efficiencies, which will save facilities money and allow them to schedule more cases.

WIRED FOR SOUND Strategically placed mics listen in to what the surgical team discusses

Demystifying the OR
Some surgical professionals have expressed reservations about having Big Brother looking over their shoulders during procedures, watching their every move. They're also fearful that the data captured could be used during medical malpractice cases, especially in the litigious society in which we all operate. Those are valid concerns and I understand why surgeons might feel that way, but in the vast majority of cases, the information captured by the black box will help surgical teams in court by showing they performed to the best of their abilities.

In addition, demystifying the operating room will benefit our profession and keep patients better informed about the care they receive. Patients are more interested in healthcare transparency, from the true cost of procedures to the quality of the care involved.

The OR remains a high-risk environment. Errors will continue to happen, despite our best efforts to prevent them, although the black box will reduce the likelihood that surgical teams keep repeating the same mistakes. But I also believe the technology has a greater purpose if it's used constructively to improve surgical care for patients and enhance how surgical teams interact and perform procedures. Beyond error analysis, the black box will be used to analyze adverse events or assess new procedures, technology and techniques.

Every surgeon wants to improve professionally. They spend a great deal of time developing skills in clinical workshops and learning about new techniques at educational conferences and in peer-reviewed journals. But there's a problem with the culture of expectation in surgery. Surgeons have the unfair expectation of perfection ingrained into them early on in their careers. It's a false hope reinforced by patients who expect their surgeons to be infallible and all surgeries to result in successful outcomes. But that misguided belief limits opportunities to develop skills, because surgeons won't take the risks needed to innovate techniques out of fear of making mistakes.

During my surgical residency more than 15 years ago, I often felt great driving home after surgery, confident after another successful day in the OR. But then I watched a video of myself in action, and it was embarrassing. I noticed numerous things I needed to improve upon, and saw incredible amounts of wasted effort and time. That's human nature. It's very difficult to be self-critical about your performance while you're in the middle of the action.

That's where the black box comes in. It provides a good opportunity to reflect back on the individual performance of surgeons as well as our processes to compare it to other ORs down the hall or in other surgical facilities. Beyond error analysis, the black box can be used to analyze adverse events or assess new procedures, technology and techniques.

EYE IN THE SKY Cameras positioned throughout the OR capture all the action.

Preventing future harm
Black box technology has been a positive development in preventing human suffering in aviation, and there's no reason the tracking of time-stamped data can't do the same in surgery.

I've used the black box to review elements of procedures I had never experienced and have turned them into teaching opportunities. There's no doubt that even the most proficient surgeon can do the same to improve upon their skills in order to operate as optimally and as safely as possible.

That doesn't mean that we will have perfect surgeries. But it means we will learn from our errors, which will make us safer. We will train future surgeons better because we can show them the most critical situations in surgery and how to avoid them.

WATCH AND LEARN
Identifying Room for Improvement

My research using "black box" technology in the OR has involved capturing data from cases, analyzing it within 24 hours and assessing patient conditions at 30 days post-op to determine what impact surgical performance had on outcomes.

The number of correctible errors we noticed was eye-opening. For example, we saw that a majority of errors taking place during bypass surgery occurred during the same 2 steps of the procedure. Realizing that let us design teachable steps for surgeons to practice in order to master the technique in question.

Our research team also looked at not-so-obvious sources of potential errors, such as how hard a surgeon grips a bowel, which might lead to slips and tears, and less tangible factors, such as how surgeon frustration can lead to communication breakdowns that change the dynamics of the surgical team.

We're not only looking at errors, we're also looking at how to improve time management in the OR. For example, we can track how efficiently a room was used throughout a day by tracking how much time was allotted to turning it over between cases or was spent waiting for instruments to return from central sterile.

— Teodor Grantcharov, MD, PhD