Application of the Aviation Black Box Principle in Pediatric Cardiac Surgery: Tracking All Failures in the Pediatric Cardiac Operating Room

Sustained reductions in time to antibiotic delivery in febrile immunocompromised children: results of a quality improvement collaborative

“…The initial key drivers of this process included rapid identification of eligible patients, standardised pre-arrival process, standardised post-arrival process, faculty and staff engagement and buy in, family engagement, preoccupation with failure18 and timely vascular access. These key drivers were categorised as pre-arrival interventions, post-arrival interventions and expanded to include spread to the CBDI clinic.…”

A surgical black box to prevent mistakes

“…At St. Louis Children's Hospital in St. Louis, MO, perioperative personnel implemented a variation of the black box technique, prompting process changes that improved their delivery of care. 6 In their study, events were recorded in real time by the RN circulator who placed a time stamp on an index card along with a brief note about the event; the cards were then placed into a locked black box in the OR for later tabulation and evaluation by a multidisciplinary group to identify recurrent patterns or themes. 6 After refining the process, personnel switched to video recordings to review surgical cases.…”

“…6 In their study, events were recorded in real time by the RN circulator who placed a time stamp on an index card along with a brief note about the event; the cards were then placed into a locked black box in the OR for later tabulation and evaluation by a multidisciplinary group to identify recurrent patterns or themes. 6 After refining the process, personnel switched to video recordings to review surgical cases. The failure event rate increased over the study duration as these monitoring methods identified small errors and minor events that postoperative review and personal recall of serious A surgical black box to prevent mistakes Margaret Wasserman, BSN, RN events did not capture.…”

“…The authors noted that they had no awareness of these failures until they carried out their study and began systematic review of all failures in the OR. 6…”

Implementation of a “threat and error” model in complex neonatal cardiac surgery patients to identify quality improvement opportunities

“…Much work has been done to reduce this vulnerability, yet significant gaps remain. [5][6][7] The Society for Thoracic Surgeons ranks programs based on outcomes with a star rating system, and these rankings are publicly available (https://publicreporting.sts.org/) to promote transparency. Many CHD programs publicly post their own outcomes by surgical complexity on hospital websites.…”