Device at Toronto’s St. Michael’s Hospital is being used to identify and proactively minimize OR mistakes

In the event of a plane crash, air transport safety investigators look to the aircraft’s flight recorder — or so-called black box — to review critical flight data and recorded cockpit conversation to find information that may help them piece together what caused the mishap.

In April St. Michael’s Hospital in Toronto began testing its own version of the aviation industry’s black box in order to analyze operating room (OR) procedures and minimize mistakes.

“We want to see where errors happen in surgery so that we can understand how errors lead to adverse events and develop training curricula to prevent these errors from ever happening again,” said Dr. Teodor Grantcharov.

The St. Michael's Hospital OR black box
The St. Michael’s Hospital OR black box

Grantcharov designed the OR black box which he is testing in the operating rooms at St. Michael’s, where he specializes in advanced minimally invasive surgeries, such as gastric bypasses. The device is also being tested at two hospitals in Copenhagen with more international sites to be involved soon.

About the size of a box of tissues or a thick book, it records almost everything that goes on in the OR, such as video of the surgical procedure, conversations among health care workers, room temperature and decibel levels. It works only for laparoscopic, or minimally invasive, surgeries that insert video cameras in thin plastic tubes into small incisions in the body that allow the surgeon to see what’s going on inside the patient.

The goal is to improve patient safety and outcomes by identifying where errors occur in the OR and teach surgeons how to prevent them.

About 7.5 per cent of patients admitted to acute care hospitals in Canada in 2000 experienced one or more adverse events — everything from reactions to wrongly administered medications to bed sores, falls, infections and surgical errors, according to a 2004 paper by Ross Baker, a professor at the University of Toronto’s Institute of Health Policy, Management and Evaluation. Baker’s paper is considered a landmark study in medical errors in Canada.

Most of these events did not result in any serious harm, the study found, but almost 37 per cent were preventable. More recent studies have shown rates of adverse events in hospital between 10 and 14 per cent. Such events cost taxpayers billions of dollars, usually in longer hospital stays.

“It doesn’t mean that we will have perfect surgeries, because we are not perfect. But it means we will learn from our errors, which will make us safer,” Grantcharov said. “We will train future surgeons better because we can show them what are the most critical situations and how to avoid them.”

He is looking at performance issues – something the surgeon did or didn’t do, such as apply enough force when grabbing a bowel, which might make it slip and tear. Less tangible factors that can lead to errors, such as communication and team dynamics, are also being monitored.

The device has helped St. Michael’s determine that 84 per cent of errors in bypass surgery happen during the same two steps, so training has been adapted to help surgeons master those two skills.

Grantcharov also hopes the black box would bring more transparency to the OR for patients and help change the “blame-and-shame” culture that traditionally has made doctors and nurses reluctant to report mistakes.

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