Anne van Dalen

3 Implementing structured team debriefing using a Black Box in the operating room I 85 INTRODUCTION Despite various efforts aiming to improve surgical safety, the incidence of surgical adverse events remains high to date. 1–3 Studies have estimated one-third of surgical adverse events to be potentially preventable. 1, 2, 4, 5 Adverse events are usually not the result of individual failure, but the consequence of an uninterrupted chain of events and decisions, spanning multiple phases of surgical care. An important number of these adverse events occur within the operating room (OR) and aremost often unnoticed by the team. 2, 6, 7 Therefore, a suggested approach towards error reduction could focus on finding and implementing mechanisms to facilitate the awareness of such unnoticed events. 8 Subsequently, steps should be undertaken to acknowledge, analyse and understand common error-event patterns. 7, 8 Several studies have highlighted the importance of non-technical skills in the OR to avoid error. Skills associated with error reduction or prevention are teamwork, situational awareness and communication. 9–11 Therefore, interventions to improve surgical quality and safety should involve all members of the operating team. 11–13 A Medical Data Recorder (MDR) is similar to a system better known in aviation as a ‘Black Box’ or a ‘Flight Data Recorder’. It may have the potential to look back upon joint performance jointly to improve quality and safety in the OR. The outcome of using an MDR may be used for purposes of multidisciplinary debriefing in a privacy-protected environment if it is well constructed for this purpose. This may provide surgical teams with the opportunity to assess unnoticed events and look back upon their actual performance to learn and improve. Hence, it may avoid future adverse events that possibly compromise surgical safety. Despite aforementioned insights and currently available technology, reported surgical safety improvement initiatives using an MDR are still limited. Moreover, an actual multidisciplinary debriefing culture for teams performing surgery is lacking. 14–17 The aim of this study was to investigate the participants’ satisfaction with an MDR, the OR Black Box® and its subsequent performance report used as a tool for structured postoperative multidisciplinary debriefing. 18