While the following story doesn’t originate from the United States, it still provides critical information about medical mistakes and surgical mishaps that could happen in any country and under any circumstances. This story is about a series of cameras and microphones being setup in an operating room to track the surgical team’s movements, communication and, ultimately, errors.
It is being dubbed a “black box” for surgeries, but of course that isn’t exactly accurate. Instead, the system is meant to be a training and learning guide for medical staff to see the mistakes they have made — however minute they may be — so that they can improve and protect patients from potential harm. As our source article put it, it is very difficult for surgeons to notice the tiny mistakes they make during surgery. During the procedure they are so focused that they likely think they have done everything correctly.
It’s also important to realize that a surgical “mistake” in this context means something that most patients won’t even realize as a mistake. For example, the “black box” counts a surgeon looking away from his instrument for a moment while suturing to be a “mistake.” Is the look away ideal? Of course not. But is it truly a mistake on par with nicking an organ or causing a serious medical complication? The answer, again, is “of course not.”
But this black box program still provided some important lessons for medical personnel. They found that 86 percent of the mistakes they were making during gastric bypass surgeries happened during one of two steps: grafting and suturing. They can use this information to improve themselves and their medical facility.
Source: Brampton Guardian, “‘Black box’ tracks errors in Toronto operating room,” Gemma Karstens-Smith, July 9, 2014
