A “black box” installed in a Toronto operating room earlier this year has found that surgical teams are making the vast majority of their errors during the same two steps surgery after surgery.

Now researchers are looking at how to reduce those mistakes and prevent similar slips in the future.

Dr. Teodor Grantcharov, who developed the operating room black box compares using the technology to learning how to golf.
“Usually we can’t appreciate our performance while we’re in the middle of the operation,” said Grantcharov, a surgeon at St. Michael’s Hospital. “You swing and you think you’ve done a great job and someone video records it and shows you how you’ve done and obviously there are so many things to improve.”

Three microphones and three cameras began recording all of Grantcharov’s surgeries at the end of April as part of the black box project. Two of the cameras film the operating room, while a third internal camera records what’s happening inside the patient’s body while the surgeon and his team perform minimally invasive surgeries. The video and audio collected is then analyzed by a team, who look at surgical techniques, the surgical team’s communication and how they work together, and what kind of hazards exist in the operating room.

An initial pilot recorded about 80 Gastric bypass surgeries and found that 86 per cent of the errors were made during just two steps: suturing and grafting the bowel.

That information was very valuable, Grantcharov said, and a team is now working on creating educational tools based on the data.

“If we know where the errors happen, then we will know what to do to avoid them in the future.”

There are small errors in every surgery, but that doesn’t mean that a patient’s safety is compromised, Grantcharov said. An error could be something as simple as a surgeon losing sight for a split second of a needle while suturing.

“Error, for us, is minimal, the smallest deviation from the perfect course,” he explained. “In the vast majority of cases, it is nothing. The patient will recover perfectly and nobody will ever know that there has been an error.”

Traditionally, however, error hasn’t been discussed in surgical culture, Grantcharov said. He’s hoping having black boxes in operating rooms will help promote a safety culture similar to that of the aviation industry, where people can speak freely about mistakes and point out things they believe could be done better.

“I think it’s acceptable, it’s just human, that we make errors,” he said. “It’s not acceptable not to do anything about it.”

Reducing slips in the operating room will not only make surgery safer for patients, but it will help cut costs, too, said Grantcharov. If surgeons make fewer errors, they’ll be able to operate more quickly and do more surgeries in a given time period. Preventing errors will also cut back on adverse events — injuries that need to be fixed — which also saves money, he explained.

Currently St. Michael’s is the only hospital with the black box technology, but other hospitals have said they, too, want to try out the cameras and microphones. Grantcharov hopes black boxes will be installed in some European hospitals soon, and wants the technology to eventually spread to a wide variety of procedures in operating rooms around the world.

So far, surgical teams at St. Michael’s have been open to the black box project, and they see the potential learning and safety benefits, Grantcharov said. But there is potential for the technology to be used in less positive ways, such as recording evidence for use in malpractice lawsuits.

“If we choose to use it as a tool to place blame and to point fingers at surgeons for litigation, I think this will never take off,” Grantcharov said.

“It’s important that we use this constructively, that we use this to improve our selves, to become better surgeons and safer surgeons and improve the outcome for out patients. If we use it in this direction, I think this will change the way we practice.”