Doctor Uses Black Box To Catch Surgical Negligence

Every year, 9,200 to 23,000 Canadians die as a result of preventable hospital adverse events. About 34% of these events involve surgery errors. Now a doctor at St. Michael’s Hospital in Toronto is attempting to change all of that with a ground-breaking invention that could change operating room culture entirely and hopefully prevent incidents of surgical negligence.

Toronto surgeon discovers a way to catch surgery errors early

Dr. Teodor Grantcharov has been a long-time aviation enthusiast, which gave him the idea: “What if there were a ‘black box’ in the operating room — like what pilots use to determine the cause of a crash?”

The device would record what goes on both inside and outside the patient during a surgery, allowing for a thorough review of the procedure. His invention is currently being tested at St. Michael’s Hospital where he practices, as well as the Hvidovre Hospital in Copenhagen, but the implications are huge.

Medical community supports greater transparency

“I believe this has the potential to change the way we practice surgery,” he told the National Post. “I’m sure some people will feel threatened, like pilots felt threatened when the black box was first introduced, but… we are a high-risk, high performance industry and all of us can be patients one day, and we would like to make sure everybody performs to the standard.”

Others in the medical community have expressed enthusiasm for the new device aimed at curbing surgical negligence. “I think it will improve the outcomes and find pitfalls before accidents happen,” said Dr. Svend Schulze, chief of surgery at Copenhagen’s Hvidore Hospital.

Dr. Garth Warnock, president of the Canadian Association of General Surgeons, said he supports the use of the operating room black box tool for educational purposes, as long as it’s not used to “shame and blame.” He adds that he’d be the first to offer up his operating room.

Surgery errors, including “near-misses” can now be documented

So far, Grantcharov and his colleagues have been studying tapes from the OR black box. Some surgery errors include moving the needle outside the view of the laparoscopic surgery camera, which could lead to a bowel perforation, or breakdowns in communication among team members.

Black box may help victims prove surgical negligence

The Toronto doctor believes his product could have never launched in the “litigious world of American health care,” although there are plenty of people who would love to see such technology make its way over the border.

The product was not intended to aid in personal injury lawsuits, but Grantcharov concedes that it could be used for that purpose. “It’s a free country, if people feel something was done inappropriately, they have the right to take action,” he explains.

Yet, it’s his hope that the very presence of the camera will make more surgeons pause and reflect upon all the little choices they make during a surgery. Procedural changes can be made that will improve the safety in operating rooms as well.

It seems crazy that tiny black boxes detail the path to airline crashes, even though so few happen each year — and yet, the medical community with its hundreds of adverse incidents, deaths and lawsuits has very little transparency.

Resources Resources