Airline-inspired black box to help surgeons improve O.R. performance

WATCH ABOVE: A surgical team led by Dr. Teodor Grantcharov at St. Michael’s Hospital uses a “black box” in the operating room, similar to those used in the airline industry.

TORONTO – Ever thought of your surgeon as a professional athlete in need of coaching? How about as an airline pilot who could use a record of events to determine what went wrong or how to fly better?

Toronto Dr. Teodor Grantcharov draws on both analogies to explain why he’s eager to make “black boxes”—recording devices known for their use in the aviation industry—part of standard operating room procedure in hospitals.

READ MORE: What is a black box and how does it work?

“Usually while you operate—while you’re in action—you don’t notice your weaknesses. You don’t notice what you’ve done wrong or what you can improve,” said Grantcharov, a minimally invasive surgeon at St. Michael’s Hospital and the leader of the research team that developed and implemented the O.R. (operating room) black box.
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“It’s the same in professional sports, when a player is in the game they usually don’t notice what they do wrong. They have the video coaches for video-analyzing and usually providing feedback and tell them what they can improve on the next time.”

So his idea has taken the shape of a box the size of a thick book that will record almost everything that happens in the O.R.: Video of the procedure, conversations of health care staff in the room, temperature and decibel levels.

The black box used in St. Michael’s Hospital pilot project is actually blue. St. Michael's Hospital handout

One black box (that’s actually blue) has been installed at Toronto’s St. Michael’s Hospital for about a month, and though he’s the only one being recorded so far, Grantcharov said he has partners in the U.S., Europe, and South America who will receive prototypes in the next few months.

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St. Michael’s said patients must consent to be part of the pilot but they “don’t experience anything different than if there were no black box there” when asked for comment from someone who’d undergone surgery recorded by the device.

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Grantcharov is hopeful the technology will improve patient care and decrease costs in the “high-performance, high-risk industry” of health care. The doctor, also an associate professor of surgery at the University of Toronto, said currently these types of records aren’t kept, which means a significant loss of information.

The black box data may also improve training protocol.

“We don’t teach our residents how to recognize and fix errors; usually we show them perfect technique, and we want them to do it.”

He added the pilot project has already given him ideas of how to develop training interventions specifically designed to address weaknesses, such as keeping the suturing needle in your visual field at all times during a laparoscopic surgery.

The hospital referenced a 2004 study that suggested 9,200 to 23,000 Canadians die each year because of preventable adverse events in hospitals, with surgery accounting for the largest source of mistakes at 34 per cent of the total.

Grantcharov said significant gains have been made in the aviation industry, where pilots have reduced adverse events based on studying data recorded by the black boxes. He wants hospitals to record the performance as a team, then look back together in a “relaxed environment,” potentially calling on experts from around the world to give feedback and help surgeons “improve their game” to try to reach the “unbelievable safety record” seen in the aviation industry—an industry he says shares some protocols with health care.

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“The similarities are that there is a human performance and there is a technology (devices or aircrafts) and we need to really understand how these two interact and how we can create teaching or training interventions, or safety-enhancing interventions to predict risks proactively, and find ways to mitigate all these risks.”

Watch below: Dr. Grantcharov explains the O.R. black box on Global’s The Morning Show:

The O.R. black box made headlines in September 2013, when the technology was finalized (with help from Air Canada) and Grantcharov obtained approvals for the pilot study.

Concerns that any mistakes found would be used to “shame and blame” surgeons or other health care workers were outweighed by the potential for improved performance for past present of the Canadian Association of General Surgeons Dr. Garth Warnock, who told the National Post he’d be the “first” to offer up his operating room at the time. A request to the CAGS Tuesday was not immediately answered.

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“We have to sacrifice some of our privacy and open our operating rooms for observers, which we’re not used to. So every time we change practice, especially such an invasive change, there are concerns,” acknowledged Grantcharov. “But I think here we need to keep focused on the big benefit. …All of us want to be as safe as we can be and be the best doctors we can be for our patients.”

He said video from the black box is analyzed quickly, kept for 30 days, then destroyed so it’s used strictly for training and quality improvement (though if there was an official request or court order, the video would be provided).

“If this turns out to be a way to blame individuals, or use it for something destructive like that, I think this would kill the purpose and this idea will not survive.”

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