Anne van Dalen

Six Sigma in surgery I 243 9 The Black Box to improve safety culture Implementation of a platform such as an Operating Room Black Box is an important tool to facilitate transparency, carefully balancing legal restrictions whilst respecting patient interests. 17 Use of such a system may be very valuable in creating a sustainable culture managing error responsibly. 4,7,13 Use of a data monitoring system such as the Operating RoomBlack Box in the operating theatre following the Six Sigma approach is summarised in Figure 1. All healthcare professionals working in the operating theatre should be involved to define what the purpose of a safety improvement initiative really is; ‘what is in it for them?’. Indeed, healthcare professionals need the chance to develop a more proactive and progressive attitude towards safety culture and improvement. 22 Changing safety culture in healthcare can only be achieved by those working in it. They need and deserve the tools to do so. Proactive and progressive healthcare organisations prioritise safety, actively invest in safety improvement initiatives, and staff raising safety-related issues are rewarded, not blamed. 22 Changing an established working culture in the operating theatre is perceived as being difficult, and therefore a basis of trust, responsibility, and accountability is essential. 1,9 The Operating Room Black Box precisely measures and analyses how the team interacts and responds to unexpected events, by collecting and analysing objective multisource data from within the operating theatre, which offers a vast new field of data concerning systemfactors affecting surgical safety. 6,11 Usingmultisource big data, relevant safety threats, which are often unforeseen, are now identified whilst focusing on resilience and support. In multidisciplinary debriefings, safety threats are proactively discussed in a blame-free atmosphere of trust, where the conventional hierarchical mode is flattened. Solutions are introduced, and the team verifies that the proposed improvements are able to solve the issue at hand. This exchange of data may help foster trust, more responsible attitudes, and enhance risk awareness to increase safety. Next, these teams report more errors, allowing them to talk about errors, in turn increasing timely error detection and correction. These highly performing teams will indeed have a proactive attitude towards error reporting, management, and prevention. Suggested safety improvement solutions