Since the 1950s, airplane black boxes -flight data recorders and cockpit voice recorders- have played a key role in helping the aviation industry figure out why planes crash. Consequently, commercial air travel is safer than ever. This remarkable innovation has revolutionized aircraft safety, and is now being used to improve surgical safety. Preventable events such as surgical object being accidentally left in a body cavity following a procedure, or surgery performed on the wrong side of the body, continue to be a challenge. When such events occur, there are usually many unanswered questions and there is often difficulty in determining the exact sequence of event that led up to the error.
NYGH has implemented the Operating Room Black Box (ORBB), which creates an audio/video record of surgical procedures over time, allowing a team of human factors researchers led by Dr. Patricia Trbovich (NYGH Badeau Family Research Chair in Quality Improvement and Patient Safety) to rigorously study how errors come about, and how they are prevented. By observing how teams communicate, how equipment is selected and used, and how the layout of the physical operating room itself influences care, her team can begin to identify what factors are associated with the presence or absence of errors. Ultimately, her research helps identify the precursors to errors, and proposes stopgaps that can break the chain of events that cause patient harm.
Thesis students are needed to observe and analyze videos for specific safety or resilience factors. For example, projects on team communication, uncertainty, resilience, surgical checklist use, etc. are possible.