First-year analysis of OR Black Box study

Editor's Note

In this first-year analysis of a data capture system called the OR Black Box, frequent intraoperative errors, events, variation in surgeons’ technical skills, and a high amount of environmental distractions were identified.

In 132 patients having elective laparoscopic general surgery:

• auditory distractions occurred a median of 138 times per case
• medians of 20 errors and 8 events were identified per case
• errors and events occurred often in dissection and reconstruction phases of the procedures
• technical skills of residents were lower than attending surgeons.

Though intraoperative data analysis and transparent disclosure have been advocated to better understand how to improve surgical safety, they have rarely been done, the authors say.