Patient Safety Corner: An Interview with Dr. Teodor Grantcharov about St. Michael’s Hospital’s O.R. Black Box Initiative

October 23, 2014

Dr. Teodor Grantcharov is a staff surgeon at St. Michael's Hospital and an Associate Professor at the University of Toronto. He is a Professor in Surgical Simulation at Copenhagen University. He completed his General Surgery residency at the University of Copenhagen, and a doctoral degree in Medical Sciences at the University of Aarhus in Denmark. Following that, he completed a fellowship in Minimally Invasive Surgery at the Western Pennsylvania Hospital, Temple University School of Medicine in Pittsburgh, USA.

Dr. Grantcharov's area of clinical interest is minimally invasive surgery, with a focus on foregut disease including cancer and revisional bariatric surgery. Additionally, his academic interests also include surgical education and patient safety.  He has become internationally recognized as a leader in this area with a focus on curriculum design, assessment of competence and impact of surgical performance on clinical outcomes.

The field of patient safety has often looked to the safety protocols used in the aviation industry as a model for quality and safety improvement efforts in the health care industry. One such improvement effort, the Operating Room (O.R.) Black Box initiative, was invented by Dr. Grantcharov. The O.R. Black Box records both video and audio of all aspects of a surgical procedure. Post-surgery a team of analysts review the recordings where a variety of safety and performance factors, including health care team performance, are assessed. The analysis brings to light any errors and essential learnings that can be used to improve the safety of surgical procedures.  Its creation is part of a pilot study that began with its use in O.R. surgeries performed by Dr. Grantcharov.

The OHA interviewed Dr. Grantcharov on the current state of the pilot project, as well as the support and feedback that this initiative has received.

Q: What has been the level of support and buy-in for this initiative? Have you experienced any push-back or resistance from O.R. colleagues wary of the black box because they feel that their performance will be judged afterwards (e.g. blamed for a mistake or not following a protocol properly) when reviewing the recordings?

A: Surgical teams are not used to this type of initiative. It is natural that some individuals are concerned. Therefore, it is important to have a consensus and clearly communicate the goals of this initiative: to get insight into our performance, and understand what we can do better. Without this information we have very few opportunities to improve. After several educational sessions directed towards our O.R. staff, the vast majority of our colleagues have been very supportive and that made the implementation possible. Since then, we have received massive interest from hospitals in Canada and around the world. We will soon be installing prototypes of the technology at several international sites.

Q: What has been the overall feedback that you have received from patients and the general public who have become aware of this initiative?

A: I have received multiple e-mails from patients asking me to be their surgeon. Patients feel safer when they know that their surgical team takes safety seriously and is willing to constantly improve. The most common reaction I receive when discussing this initiative with my patients is: "I can't believe this isn't the standard practice in modern surgery".

Q: Has there been any discussion of possible legal concerns related to the Black Box initiative and any potential adverse event that may occur?

A: Yes, this is a major concern as it may compromise the wide acceptance of this initiative. In the U.S., the healthcare quality improvement act ensures confidentiality and legal immunity for healthcare peer review processes, like the Black Box initiative.

Q: Can you briefly share any key preliminary findings from this pilot study, such as any trends or patterns in O.R. errors that have become evident after reviewing the video and audio of the surgeries performed? Has the Black Box initiative facilitated any observable improvements in patient safety in the O.R. since its implementation, and if so, what kind of improvements have occurred?

The study is still going on. In the initial pilot we confirmed that this technology can allow us to evaluate individual/team/technology performance; help us identify errors and the way they contribute to adverse events. This information will be of great value when we design educational interventions to make sure errors are not repeated. We are currently in the data collection phase. Once we have completed it, we will focus on quality improvement interventions. At this point we have multiple ideas for such interventions, however, they will be carefully designed and delivered after the data collection/analysis phases have been completed. Moving forward, based on our findings in the study, the aim is to demonstrate that this initiative can contribute to improving patient safety and reducing health care costs.

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