Surgical black boxes may not fly in Philadelphia

Could a little black box revolutionize not only the airline industry, but the health-care industry as well?

In an effort to fix health-care problems, airplane analogies have been flown around a lot in recent years -- especially after the Institute of Medicine reported in "To Err is Human" in 1999 that "nearly 100,000 patients die each year from avoidable errors in the hospital" and the subsequent popularity of Why Hospitals Should Fly by John H. Nance. The question became: If the black box on an airplane can help decrease pilot error, then why can't a similarly configured device do the same for surgeons?

According to CNN, researchers in Canada have actually brought this idea to fruition with their version of a surgical black box (actually the color blue) that tracks a surgeon's actions during an operation and records any errors.

Dr. Chethan Sathya, a surgical resident at the University of Toronto and a fellow in global journalism at the Munk School of Global Affairs, described the device: "Inside the operating room, video cameras track every movement. Outside, a small computer-like device analyzes the recordings, identifying when mistakes are made and providing instant feedback to surgeons as they operate. This is the dream of the surgical 'black box.' "

Dr. Teodor Grantcharov, a surgeon at St. Michael's Hospital in Toronto who is leading the device's study, believes that this box could prevent errors. While black boxes in airplanes are used in retrospect to find out what happened before a crash, in the surgical suite, the device's primary goal would be to prevent mistakes from happening in the first place.

The hope is that the data collected will be able to analyze all parts of the surgery including the stitching, handling of organs, and how the surgical team communicates with each other.

So far during the study, the black box has been used in about 40 laparoscopic weight-loss surgeries. Grantcharov said that "at this initial stage, we are analyzing surgeries to determine how many errors occur and which ones lead to bad results for patients."

Being able to better pinpoint surgeons' mistakes brings up the concern of an increase in medical malpractice suits. However, because of the Healthcare Quality Improvement Act here in the United States, the courts cannot access data that doctors use for peer review. For Grantcharov, the purpose of the device is to better train surgeons.

A number of hospitals have shown an interest in Grantchharov's device, including a few in the United States. Can we expect to see the device in our hospitals in the Philadelphia area any time soon?

When asked about the study, Dr. Thane Blinman, attending surgeon at the Children's Hospital of Philadelphia and assistant professor of surgery at the Perelman School of Medicine at the University of Pennsylvania, expressed his concerns that the surgical black box would not be effective in all types of surgeries.

Blinman said that although he is very interested in the safety of patients and excited to see new technology developing that could potentially reduce risks, he has a lot of concerns over the surgical black box.

"This error analysis is very complicated to encode and very unlikely to be used in large hospitals like CHOP," he said. "You would need a panel of experts to analyze the data and it would become very labor intensive."

Blinman's other concern is that each surgical case has its own individual challenges, making it difficult to force one set of procedures to be applied to them all. Making checklists is not as applicable for surgeons as it is for airplane pilots. CHOP sees about 25,000 cases a year, and each case is unique. He doesn't believe that the airplane analogy can be applied to medicine, especially for a children's hospital.

"Every job is a custom job. We use 4,000 different procedure codes for the interventions we perform. We are not making fine machine parts," he said. "This study concentrated mostly on bariatric surgery which is a high-volume procedure, making it a little easier to identify an ideal set of movements."

While the surgical black box might not be a viable tool for CHOP, the surgeons there already have in place a rigorous training program for their residents and fellows. At the William Maul Measey Pediatric Surgical Training Laboratory, they safely practice minimally invasive surgery before they enter the operating room.

"To turn novices into virtuosos in their field, it is important to demystify the equipment," Blinman said. "You can't get good at sewing unless you practice."

In the training laboratory, primarily fake organs are practiced on, along with some animal parts from those that were already deceased. No animals are harmed.

"Versatility and proficiency in the operating room is what we strive for, not tighter control and oversight," he said, "which ironically can lead to de-skilling."

[cnn.com]