Anne Sophie van Dalen1, Teodor Grantcharov, MD, PhD2, Marlies P Schijven, MD, PhD, MHSc1. 1Department of Surgery, Amsterdam Gastroenterology and Metabolism, Amsterdam UMC, University of Amsterdam, The Netherlands, 2International Centre for Surgical Safety, Li Ka Shing Knowledge Institute of St. Michael’s Hospital
OBJECTIVE Intraoperative adverse events are a major safety threat in modern surgery. A significant number of these adverse events are preventable, however their true incidence is still unknown and they are not systematically reported and studied. The objective was to use the OR Black Box®, a medical data recorder in the operating room, to analyse safety threats and resilience events in elective laparoscopic abdominal procedures. We compared the events registered by the system with the instances observed and reported by the team during a multi-disciplinary post-operative debriefing.
PROJECT DESCRIPTION AND METHODS The Surgical Team Assessment Record (STAR) post-operative questionnaire was used. Recordings were analysed by a combination of Artificial Intelligence algorithms and trained analysis team of surgeons and human factor specialists. Validated measurement instruments were used, namely the Systems Engineering Initiative for Patient Safety (SEIPS) framework, Non-Technical Skills for Surgeons (NOTSS) and Scrub Practitioners' List of Intraoperative Non-Technical Skills (SPLINTS) system. According to the SEIPS model, the observed events were classified into 6 sociotechnical, human-centered interacting components that influence performance; person(s), tasks, tools and technologies, organization, internal environment, and external environment. Procedures were debriefed using the OR Black Box® standardized performance report, which included a video clip summarizing all relevant positive and negative observed events. A standardized debrief model was developed. The participating team members, which included the surgeons, anaesthesiologists, residents, nurses and medical students, were asked to fill out a questionnaire after the debriefing as well, to measure their satisfaction with the use of a Black Box and its performance report, used as a tool for structured team debriefing.
RESULTS Thirty-five procedures were included. In total, 404 threats were identified and described in the Black Box performance report. A mean number of 52.5 (SD 15.0) relevant positive and negative events per surgical procedure were identified, of which on average 11.5 (SD 4.2) were rated as safety threats. According to the answers of the STAR questionnaire (N=234), in only 26.5% (n=65) of times the operating team members indicated that they had noticed aberrations during the surgical case. During the debriefings, the majority of the discussed adverse events and lessons-learned were concerning (mis)communication and teamwork. In 98% of times, the participating operating theatre staff (N=81), would recommend the Black Box team debriefings to their colleagues.
CONCLUSION: The use of the OR Black Box® and its performance report for postoperative team debriefing was highly recommended. Team debriefing may help the team to recognize, understand and learn from clinically relevant but unnoticed or unreported safety threats and resilience support events. Postoperative structured team debriefing may also be important for resolving incorrect assumptions between theatre staff members to avoid future unnecessary miscommunication.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 98632
Program Number: ET011
Presentation Session: Emerging Technology Session
Presentation Type: Podium