The Journal of mHealth Vol 1 Issue 6 (Dec 2014) | Page 39

Canadian Researchers Create 'Black Box' for Use in Operating Rooms

bypass surgery happen during the same two steps, so training
has been adapted to help surgeons master those two skills.
Dr. Grantcharov said he’s 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.
But he’s also looking at less tangible factors that can lead to
errors, such as communication and team dynamics.
Dr. Grantcharov’s team has done extensive research on surgical
error analysis. According to this framework, an error is a minor
deviation from an optimal course of action. Errors happen during each procedure; however very few lead to adverse events and
therefore go unnoticed by the surgical team.
A 2004 paper by Ross Baker, a professor at the University of
Toronto's Institute of Health Policy, Management and Evaluation, found that 7.5 percent of patients admitted to acute care
hospitals in Canada in 2000 experienced one or more adverse
events, which can include everything from reactions to wrongly
administered medications to bed sores, falls, infections and surgical errors.
The study found that most of these events did not result in
any serious harm, but that almost 37 percent were preventable.
More recent studies have shown rates of adverse events in hospital of between 10 and 14 percent. Such events cost taxpayers
billions of dollars, usually in longer hospital stays.
Dr. Grantcharov noted that professional athletes have coaches
who point out their wrong moves and help them improve their
performance.
“For surgeons, we will have data that will allow better coaching
and improvements and therefore better patient care,” he said.
“We will reduce the risk and complications and show how to
make the operating room more efficient, which will also allow
us to save money and do more cases.”

Dr. Grantcharov said he also hoped his black box would bring
more transparency to the operating room for patients and help
change the “blame-and-shame” culture that traditionally has
made doctors and nurses reluctant to report mistakes.
Recording Mistakes
Many surgeons, however, might be uncomfortable with using
a black box in the operating room, says Dr. Teodoro Forcht
Dagi with the American College of Surgeons Perioperative Care
Committee.
"If there was a legal requirement to record every operation,
then many sur