Taking a page from the airline industry, hospitals are capturing surgical procedures on video to reduce errors and enhance teamwork. Here’s why one expert thinks black boxes are crucial for improving patient safety.
Editor’s note: The opinions expressed by the author do not necessarily reflect the opinions of the AAMC or its members.
Within seconds, Sarah James* went from having normal vital signs to no signs of life. A middle-aged woman who had long carried excess weight, James elected to undergo gastric bypass surgery last year in the hopes of reducing obesity-related health risks. Instead, she nearly died.
For reasons that still remain unclear, James’ blood pressure plummeted and her heart stopped when the surgical team introduced carbon dioxide into her abdomen — a step necessary to expand the space for the procedure.
What happened next was a blur. The team immediately started heart compressions and administered medications to raise James’ blood pressure, but to no avail. They then quickly called for life support, and the extracorporeal membrane oxygenation team raced into the operating room (OR) with the necessary equipment. Almost as soon as they got her connected to the equipment, James recovered and her vital signs began returning to normal.
What could have been a tragic incident turned into an amazing rescue by more than 20 high-performing health care workers — and all within a matter of minutes.
In the United States, potentially catastrophic events happen in hospitals every day. In fact, 24% of hospital patients experience some type of harm each year, according to a 2023 New England Journal of Medicine study, and 23% of those adverse events were deemed preventable.
After James’ rescue, our team had to ask certain crucial questions: Were we just lucky to have the right people in the right place to save her? Would we be able to save the next patient? Was there something we could have done better?
Fortunately, we had our OR Black Box to help provide answers.
Modeled after the airline industry’s similar tool, the OR Black Box system — which we have in place in four of our operating rooms at Stanford Hospital, in Palo Alto, California — continuously captures video, audio, and patient vital signs data. In this case, it allowed us to review how the team responded, how staff communicated with each other, who called for additional help, when help arrived, and ultimately, how long it took to stabilize James.
But the OR Black Box has many additional — and significant — uses. It can reduce medical errors, increase efficiency, enhance teamwork, and help educate existing and future providers. In fact, given their numerous benefits, it makes sense for hospitals to install such a system not only in their operating rooms but also in intensive care units, emergency departments, and other high-risk areas.
We installed our OR Black Box system in June 2022. Around a dozen other U.S. teaching hospitals have implemented them in the past few years, and additional hospitals are planning to install them. The systems are fairly simple: They use video cameras and microphones attached to the ceiling and to the surgical field’s overhead light to capture all activity 24/7. This recorded information can be merged with data in electronic health records (EHRs) and anesthesia monitoring systems to allow for a complete capture of patients’ vital signs and medications.
[The OR Black Box] can reduce medical errors, increase efficiency, enhance teamwork, and help educate existing and future providers.
Of course, our hospital has for decades employed reviews of patient-safety events like James’, but those usually rely on human memory, which can be blurred by the adrenaline of the moment and the passage of time. We also use in-person audits to monitor compliance with safety measures such as pre-operative timeouts — the crucial moment when staff make sure they are performing the right procedure on the right patient — but the mere presence of an auditor can change staff behavior. And, of course, auditors cannot be everywhere at all times.
Simply put, compared to humans, the OR Black Box provides more complete — and more objective — data.
At our hospital, we get monthly OR Black Box report cards that allow us to monitor progress over time. Using artificial intelligence trained and validated on numerous operating room videos, the reports provide aggregate scores on the use of such safety measures as OR timeouts, appropriate patient positioning, and safety checklists. We can also use the data to compare our ratings to peer institutions in the Surgical Safety Network, a consortium of hospitals that use OR Black Boxes. At Stanford, we assess all this data at our monthly quality-improvement meetings and act on it accordingly.
In addition to these monthly reports, any OR staff can request a more in-depth review of an unexpected event like James’. Because we tape every procedure performed in the monitored rooms, we can pull out selected recordings to help us understand what occurred, whether protocols were followed, and if proper mitigation steps were undertaken.
The OR Black Box also is quite beneficial in medical training. For example, a resident can watch — and rewatch — a video of themselves to get a better sense of how well they performed a surgical procedure, much like an athlete reviewing a game tape.
We can pull out selected recordings to help us understand what occurred, whether protocols were followed, and if proper mitigation steps were undertaken.
For Stanford, and many other hospitals where OR Black Boxes are installed, a key goal is helping prevent “never events” — serious, avoidable incidents such as wrong-site surgery. Never events can be costly, impair a hospital’s reputation, and above all, harm the patients who are entrusted to our care.
Our hospital recently used our Black Box video and audio clips to review a possible never event: the retention of a foreign object inside a patient.
Based on the nurses’ record of packages opened during the procedure, a surgical needle was missing. We searched the operating table, the drapes, the floor — everywhere appropriate — and could not find it. We closed the patient’s incisions only after we did an X-ray to ensure that the needle was not inside her. Later, data from the OR Black Box clarified what had occurred: a needle package was opened during a shift change and nurses from both shifts added it to the record, resulting in one extra needle in the official count. The ability to review the data with our nursing and surgical staff yielded numerous benefits, including the implementation of steps to make clear who is recording additions to the count and reviews of hospital policies to prevent and address retained foreign objects.
We also use our OR Black Box system to reduce waste and increase efficiency. For example, our videos clearly and accurately capture time spent waiting for staff to prepare a surgical room. Also, in the past, if we wanted to track the duration of certain parts of a procedure, we needed to record timestamps in EHRs. Now, our OR Black Box system does that automatically and produces easy-to-access data.
Though some argue that these systems could hinder communication as staff worry about being recorded, I believe it mostly can help with communication and collaboration.
Usually, hospitals use simulations to practice critical scenarios like a patient code and then review simulation recordings to assess and improve teamwork. These are useful tools, but because everyone knows that, in these practice scenarios, an untoward event will occur, they are not as powerful as OR Black Box recordings that capture a team’s performance during a real scenario. Instead, this data provides insights into the actual dynamics and availability of critical staff and equipment. Because of that, we shared the video of James’ rescue with anesthesia, surgery, and nursing teams at quality-improvement meetings, and we are working to create multidisciplinary quality forums where additional relevant staff can review such cases together.
Looking ahead, numerous other advances may be possible using OR Black Boxes. For example, perhaps someday data could be used in real time to predict and then alert teams to an impending safety issue — before it even happens.
All recordings are de-identified for patient and provider privacy — faces are blurred and voices are distorted — and erased after 30 days.
Despite the current and potential benefits of OR Black Boxes, not all staff members have been on board.
At Stanford, as at other institutions, we implemented a thorough process to introduce the platform to all OR team members. We held town halls and attended department meetings to share the project’s goals and to address concerns. Among other steps, we made sure to inform staff that recordings would not be used for human resources actions or to compare individuals’ performance. In addition, all recordings are de-identified for patient and provider privacy — faces are blurred and voices are distorted — and erased after 30 days. We also believe that because they’re part of a quality-improvement initiative, there are federal protections that prevent using the recordings in potential lawsuits. The data has not been used in litigation to date, and to my knowledge it has not been requested for admission as evidence.
Of course, as with any new technology, some thorny issues remain. We are working, for example, to determine how to handle serious behavioral lapses captured in recordings, such as a staff member caught speaking inappropriately to a colleague.
Despite such concerns, we are excited about this innovative technology. If hospitals are going to improve safety, we need to develop appropriate systems and cultures that work to prevent errors before they occur, or to minimize the effects on the patient. OR Black Boxes offer crucial data never before available that can help foster those necessary changes. Let’s use the data to understand what’s truly happening on the front lines of the care we are delivering. Doing so will save time, money, energy, and most importantly, patients’ lives.
*The patient’s name and some identifying details have been changed in the interest of patient privacy.