Analyzing and Discussing Human Factors Affecting Surgical Patient Safety Using Innovative Technology: Creating a Safer Operating Culture

Abstract

IntroductionSurgical errors often occur because of human factor–related issues. A medical data recorder (MDR) may be used to analyze human factors in the operating room. The aims of this study were to assess intraoperative safety threats and resilience support events by using an MDR and to identify frequently discussed safety and quality improvement issues during structured postoperative multidisciplinary debriefings using the MDR outcome report.MethodsIn a cross-sectional study, 35 standard laparoscopic procedures were performed and recorded using the MDR. Outcome data were analyzed using the automated Systems Engineering Initiative for Patient Safety model. The video-assisted MDR outcome report reflects on safety threat and resilience support events (categories: person, tasks, tools and technology, psychical and external environment, and organization). Surgeries were debriefed by the entire team using this report. Qualitative data analysis was used to evaluate the debriefings.ResultsA mean (SD) of 52.5 (15.0) relevant events were identified per surgery. Both resilience support and safety threat events were most often related to the interaction between persons (272 of 360 versus 279 of 400). During the debriefings, communication failures (also category person) were the main topic of discussion.ConclusionsPatient safety threats identified by the MDR and discussed by the operating room team were most frequently related to communication, teamwork, and situational awareness. To create an even safer operating culture, educational and quality improvement initiatives should aim at training the entire operating team, as it contributes to a shared mental model of relevant safety issues.

Using the Operating Room Black Box to Assess Surgical Team Member Adaptation Under Uncertainty

“…For example, SASMM skills (which are critical to ensure the team is aware of what happened, what is occurring now, and future plans) were dampened across all team roles during an IAE, suggesting that individuals’ situation awareness may have been compromised while the surgeons focused on IAE rectification. This is consistent with past research, showing that surgeons often mistakenly assume IAEs are irrelevant to others or that team members could hear their conversations with trainees, so no explicit update was needed 31 . While most SASMM research has focused on creating formal pause points/huddles to share information (eg, surgical checklist timeout), SASMM is constantly changing as a case progresses.…”

“…This is consistent with past research, showing that surgeons often mistakenly assume IAEs are irrelevant to others or that team members could hear their conversations with trainees, so no explicit update was needed. 31 While most SASMM research has focused on creating formal pause points/ huddles to share information (eg, surgical checklist timeout), SASMM is constantly changing as a case progresses. Therefore, additional research is needed to elucidate how team roles and skills can be best used to stay abreast of evolving situations (eg, cross-monitoring, call-out) while not overburdening those with the highest workload (eg, surgeon trying to simultaneously rectify an IAE and give updates).…”

The IDEAL framework for surgical robotics: development, comparative evaluation and long-term monitoring

“…have the potential to diffuse responsibility for decisions 33,112,113 . Effective monitoring will require routine recording, storing and analysis of granular data including technical, video, audio and IT data streams, which may be needed in the analysis of adverse events, aligning surgery with other high-risk, high-technology processes 114 .…”

Three-phase video-assisted multidisciplinary team debriefing (VAMTD) in high-fidelity blast simulation through the “advocacy and inquiry” method.

“…23 Emerging technology helps surgical teams reflect on their performance; one example is the multisource video and medical data recorder, also referred to as the black box, which analyzes surgical errors caused by human factors in the operating room with the help of artificial intelligence and machine learning software. 24 A medical data recorder–assisted debriefing may have significant benefits on team performance and surgical outcomes. 5 Another useful tool to monitor intraoperative events in real time is RATE, Remote Analysis of Team Environments, a digital audiovisual data collection and analysis system that can be used for transcription, scoring, accident investigation, certification, team training, and debriefing.…”