Grant: Project Grant

Surgical errors are a leading contributor to patient harm and death. Safety threats leading to such errors (e.g. surgical instrument left in body) result from the many system factors (e.g. technology and environment design, interruptions) that impact health care providers ability to work safely. We must identify these safety threats so that we can design interventions to address them. In addition to studying the conditions surrounding surgical threats, it is equally important that we identify the factors that support resilience in the system. Resilience supports (e.g. access to back-up equipment) enable workers to respond to unexpected disturbances to resume safe operations with a minimum negative impact. By studying what we do right and wrong, we can find opportunities to improve performance. The main goal of this study is to improve surgical safety in our Canadian hospitals. First, we will identify safety threats and resilience supports across multiple sites by analyzing operating room (OR) video recordings of surgeries in 4 Canadian hospitals. This is made possible thanks to an innovative technology, called OR Black Box, that extracts information from surgical procedures through audio-visual data, physiological data and data from devices and sensors. Experts then analyze this data and make suggestions for improvements. Second, we will design and distribute an online pan-Canadian risk-assessment survey, to be completed by operating room clinicians, to assess their perceptions of safety threats and resilience supports in their operating rooms. This will provide a national data source about the type, range, and amount of safety threats and resilience supports. Third, we will provide a quick reference guide (QRG) containing evidence-based intervention recommendations. Finally, we will engage key health system stakeholders to strategize how best to implement the intervention recommendations to improve surgical safety.