PATIENT SAFETY
Patient Safety in the Operating Room During Urologic Surgery: The OR Black Box Experience
Published on
November 1, 2021
World Journal of Surgery
Overview
This study aimed to characterize intraoperative adverse events (IAEs) and potential distractions during minimally invasive urologic procedures using the OR Black Box®. The prospective cohort study analyzed 80 cases, primarily consisting of partial nephrectomy, radical nephrectomy, and adrenalectomy. The researchers recorded a total of 138 clinically significant IAEs, with 10 of these being of the highest severity. Notably, 51% of the IAEs occurred during critical steps of the operations.
The study also found that distractions were common during surgeries. On average, there were 16 external communication events per case and 4 per critical step. Room traffic was also significant, with a median of 65 entries/exits per case and 17 per critical step. These findings highlight the frequency of IAEs and distractions during all phases of minimally invasive urologic procedures. The researchers conclude that further investigation is needed to understand the relationship between distractions, IAEs, and post-operative clinical outcomes.
Results
Of a total of 80 cases analyzed, the majority of these cases were partial nephrectomy (n = 36; 45%), radical nephrectomy (n = 20; 25%), and adrenalectomy (n = 4; 5%). Across all cases, there were a total of 138 clinically significant IAEs, 10 of which (14%) were of the highest severity (five on the SEVerity of intraoperative Events and Rectification Tool (SEVERE) matrix). Of these, 70 (51%) occurred during an a priori defined critical step of the operation. Distractions were common across all cases. The median rate of external communication per case was 16 events (IQR 11-22); and per critical step was 4 (IQR 2.75-8), while median room traffic per case was 65 entries/exits (IQR 42-76); and per critical step was 17 (IQR 10-65).
