Inspired by aviation disasters, a Canadian research team is pulling back the curtain on a secretive high-risk environment by putting "black boxes" in operating rooms.
The "OR Black Box," which has been installed in about a dozen hospitals throughout Canada, the U.S. and Europe, is producing data that its lead developer says could make surgeries safer.
The walls of Dr. Teodor Grantcharov's operating room at St. Michael's Hospital in Toronto are equipped with cameras and microphones, monitoring every move made and every word uttered.
"Distraction leads to poor performance and errors. Errors lead to adverse events that could impact patient safety," he told CTV News, noting complications like bleeding and tissue injuries.
"In a bus, we don't distract the driver. We don't distract the pilot during takeoff and landing. But we [surgeons] get distracted all the time."
New data could help change that. Black box recordings are sent to a server and analyzed by the International Centre for Surgical Safety (ICSS) in Toronto. . Faces are blurred and voices are disguised, but the boxes pick up crucial information -- namely distractions like loud noises and irrelevant conversation.
In a recent study presented by the developers, surgeons reported being distracted in some 44 per cent of cases. They also reported distracting noises from alarms, bells and telephones an average of 95 times per surgical case. The black boxes also pick up device malfunctions in the operating room, which occurred 35 per cent of the time, according to the new research.
The most "shocking" item for Grantcharov's teammate, nurse Katie Hogan, was how often OR doors open and close. The research showed that doors open and close as often as 41 times per procedure and sometimes remain open for as long as three minutes at a time, allowing outside air to get in and increasing the risk of infectious agents crossing into the sterile environment. Years ago, said Hogan, there were more measures in place to keep operating rooms quiet. Doors were often locked for many surgeries, and silence was key. Now, conversation is common inside an OR theatre.
"The accumulative noise that is in a room is unbelievable at times," she said. "When I started my nursing career in New Brunswick you did not have speaking in an operating room. It was to be quiet. Over the years, things have changed dramatically. A social conversation is a normal thing. It's about team building and cohesiveness in the theatre, which is important. It's like distractions -- phones and pagers -- out in the real world. People are playing with their phones all the time and they're walking into traffic."
The team is working on protocol now for how to address the doors dilemma, said Hogan. And they've already been implementing procedures for addressing distractions, including calling a "time out." Anyone in the room can request a time out and all are required to stop talking once it is called.
"Everybody in the room has to respond to it and stop," she said. "The person who calls it can say what they need at that moment. 'I need the bells to stop ringing off that phone.' Or 'I need you to be quiet for a few minutes.'"
That's where Grantcharov would like to see protocol go a step further in line with the aviation industry, which initially inspired his OR Black Box. Aviation industries have implemented a "sterile cockpit" rule: no non-operational conversation is permitted during takeoff and landing periods where the plane is flying under 10,000 feet.
Though surgeons aren't getting off the ground, Grantcharov wants a similar practice implemented in hospitals. "We want to introduce the same thing in our operating room," he said, adding that the focus should be on execution and the task at hand, rather than non-essential conversation.
"We want to, when things are on autopilot, to talk about our plans for next weekend and what happened last week," he said. "At the same time we want to make it very clear that during important critical steps where the patient safety is at risk, there is no room for conversations that are not related to the patient."
While surgery is often complex, many solutions for minimizing distraction in the operating room are simple, despite the fact that fixes haven't been implemented broadly still today, said Grantcharov.
"We still answer the phone during critical steps, we still engage in conversation during critical steps. We still miss a team member because they are outside looking for an instrument during a critical step," he said. "These are not individual failures. These are systematic issues which are easy to fix."
The data gathered from the OR Black Boxes may help contribute to improved protocol around the world, which may have been hindered from decades of what Grantcharov called a "secretive environment."
"[This is] the first time that we get access to one of the most secretive environments in modern society," he said of the OR Black Box data. "Secrecy, mystification are not a good thing in a high-risk industry. In a high-risk industry, the principles that should guide us are openness, transparency, accountability and continuous improvement."
