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‘Black Box’ Tracks Errors In Toronto Operating Room


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‘Black box’ tracks errors in Toronto operating room

Most mistakes made during two steps of surgery, pilot project at Toronto’s St. Michael’s Hospital finds

Wed Jul 09 2014 - Toronto Star
By: Gemma Karstens-Smith - Staff Reporter

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.”

“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,”


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