Anne van Dalen

134 I Chapter 4 threats in debriefing in itself may be considered of value to patient safety, if done in a structured manner. Secondly, theoperatingteammemberswerethefocusofthisqualityimprovement pilot study. 28 The patient data and post-operative outcomes were therefore not included as outcome parameter of this study. This, also to protect the privacy and safety of all study participants, according to the latest data and privacy protection regulations. 29 As such, no correlations between number of safety threats or resilience support events and patient outcomes or clinical endpoints were made. Now that a baseline has been set, future studies are needed to assess (in)direct positive impact of a possible reduction of safety threats on patient outcomes. Thirdly, even though the events were labelled according to a validated framework, it may still be biased by subjectivity. As example, ‘substandard technique’, may have been labelled incorrectly, as surgical techniques may differ amongst surgeons and centers. Hence, the term ‘substandard’ may be disputable. Nevertheless, machine learning and AI software is currently being used to continuously improve and optimize the analysis of the MDR, customized per centre. 31 68 Lastly, results may have been influenced by the Hawthorne effect, meaning unintentional change of behavior or productivity in response to the presence of an ‘observer’. 69 70 Yet, the video recordings were made with surveillance cameras that were already mounted into the OR ceilings. This non-obstructive set-up for observation is likely not to attribute much to a possible Hawthorne effect, as one usually forgets a camera not when it is not disturbing one’s activities. 28 71 To date, the OR Black Box® user network has grown to various other medical centers world-wide. 72 Our center intends to install the new OR Black Box system -updated with improved AI andmachine learning software- inmultiple operating rooms to continuously record and analyze surgeries. 35 New research lines will be started and focus on change of safety behavior (i.e team debriefing and training), how to build stronger teams based on the identified safety threats (e.g. human factors, distractions, equipment failure), and its impact on patient outcomes. Indeed, scheduling the multidisciplinary debriefings, with an independent facilitator, for such an amount of consecutive surgical