What’s covered in this post?

  • Black boxes record video, audio, and data from multiple sources in the operating room (OR), such as cameras, microphones, patient monitoring equipment, and medical devices.
  • By offering transparency on the multiple simultaneous processes in the OR, black box data can be used to improve safety and efficiency, train staff, and onboard new nurses.
  • The data can be used for retrospective analysis of specific events or aggregate analysis to detect patterns and variations in practice over time.
  • Black box data has been used to improve and standardize OR processes such as handling tissue samples, handoff communication during shift changes, and pre-surgical patient positioning.
  • The data is de-identified and is normally deleted within 30 days.
  • Finding what went right and learning from it is the goal, not pointing fingers.

Figures in the OR as recorded and de-identified by an OR Black Box. Image courtesy Surgical Safety Technologies.

Rebecca McKenzie, DNP, MBA, MSN, RN, assistant vice president of perioperative services at Duke University Hospital, recently spoke with AJN about her hospital’s use of black boxes in operating rooms (ORs) to standardize key processes to improve safety and efficiency, train current staff, and onboard new nurses.

OR Black Boxes, made by a Canadian company called Surgical Safety Technologies (SST), are modeled on the concept of black boxes used in airplane cockpits to record flight data and have so far been adopted by a small number of hospitals in the United States, Canada, and Europe.

The black boxes record video and audio from four cameras and multiple surface-mounted microphones, as well as data from patient monitoring equipment and medical devices such as laparoscopic cameras and the anesthesia machine.

“Any data point that’s being captured by medical devices in the operating room can be incorporated into the algorithm for the data analysis,” says McKenzie. Given the richness and variety of the data collected by the black box, there are clearly many ways to make use of it to improve safety and standardize work and team communication in the OR.

While it can be invaluable for a retrospective analysis of an aspect of a particular event, the data is just as often analyzed in the aggregate to detect pattern and variation in practice over time, with the goal of using quality improvement tools to improve patient care.

Improving analysis of complex processes.

In health care, says McKenzie, “we often learn retrospectively, relying on recall and perception. We know that recall is fraught with error and incomplete information—impacted by lack of timeliness, inaccuracies, implicit bias, unawareness of contributing factors. . . The OR is a very complex environment like an orchestra, with parallel processing and multitasking among multiple team members.”

Black boxes provide what McKenzie refers to as transparency, using video, audio, and data analytics to give a more objective window on the simultaneous tasks being performed by different team members.

It’s not “about pointing fingers” or assigning blame, she says, a message that she has reiterated to physicians, nurses, and other staff, but instead about team members retrospectively “looking at the whole environment” to gain insight into how to improve patient care. Patients and staff members are de-identified, their faces and torsos blurred out, their voices altered. The data is erased after 30 days except as used, still de-identified, for aggregate analysis.

Quality improvement through transparency.

Says McKenzie, “The goals here are for the team members to look at the de-identifed video and data for informed decision-making and insights into how to effectively manage and develop best practices.” From this wealth of data, it’s possible to zero in on one small step and get a more objective view of what’s really happening and where there are variations.

For example, information from the black boxes has helped clarify the steps of team members involved in handling tissue samples so that the right specimens are sent to the right destinations. It has also been used to study communication when nurses change over between shifts during a procedure or if, for example, a staff member is taking a meal period during a procedure and somebody else replaces them.

“We’ve done observations and we have a checklist of things that we are looking at for information that was covered as part of that handoff. And then we have identified a tool to use and we’ve educated people on that tool.” Staff, she says, have welcomed the introduction of a standardized handoff tool as a way to reduce variations in practice that can lead to gaps in sharing crucial information.

In another example, information collected by the black box is being used for standardizing the process of pre-procedure patient positioning according to evidence-based standards to avoid skin injuries or nerve damage that can debilitate the patient while prolonging their care and length of stay. The goal, says McKenzie, “is to do everything possible to make sure that we adhere to [the standards] . . . or if there’s variation, to understand why.”

Black box video as a nurse training and onboarding tool.

The possible gains in efficiency from such quality improvement projects seem obvious, and are still being measured at Duke. Such data-informed examination of key processes in the OR, says McKenzie, is also invaluable when it comes to onboarding nurses new to the OR.

“It’s a unique specialty and nurses [who are interested in it] don’t have experience in the operating room and nursing schools anymore. Many colleges have eliminated that from their curriculum…They didn’t get any rotations clinically in school, so we have to become creative in how we train new people and how we onboard people efficiently and in a standardized way.”

To this end, black box videos have provided teachable examples of the steps involved in surgical timeouts for patient positioning, the handover of specimens, and surgical site prep as well as regarding surgical safety checklists and debriefings at the conclusion of the OR procedure.

Finding examples of best practices to learn from.

“Often when we think about a black box scenario,” says McKenzie, “we think about something that didn’t go the way we expected. The reverse is also true. Sometimes we find that . . . our response to a particular situation was exactly the way it should be, everything was done done correctly, and the right people had the right response. . . . The black box data can be used as a tool to share best practices in the OR when teaching and onboarding new staff.”

While there’s a significant initial time investment in incorporating black boxes in operating rooms, McKenzie says that evidence of their value and new ideas for their use in clinical practice will continue to emerge as their increased use among other hospitals creates a larger database.