Black boxes in operating rooms are systems that record the course of surgeries second by second, monitor health parameters, and monitor surgeons' work via cameras and microphones. Currently used in large university hospitals, they are expected to reduce medical errors. Will they soon become a comprehensive part of every OR?
Surgeries with no secrets
Black boxes are commonly used in aviation. They record all flight parameters, including data from onboard equipment and conversations in the cockpit. After an accident or a failure, analyzing the collected data helps determine the causes and develop new safety standards to prevent similar incidents in the future.
In this approach, safety is paramount and stands above the crew's privacy in the cockpit. All procedures, commands, and activities are recorded to ensure transparency in the pilots' actions. A similar philosophy applies to black boxes in operating rooms. Currently, doctors do not have access to operating room protocols, which could help analyze the workflows and decision-making processes to investigate the causes of medical errors—not to punish anyone but to improve medical procedures and increase patient safety.
A study published in the New England Journal of Medicine found that 24% of hospitalized patients suffer various forms of injury in the hospital, 23% of which are preventable.
Breaking down the surgery into elementary components
After an operation with unexpected complications, objectively analyzing what went wrong is not easy. In critical situations—when the patient’s health and life are at stake—doctors are forced to make quick decisions under stress. Recalling each step of the operation after it’s finished, using just a memory, is impossible.
However, when something goes wrong, many questions arise: Could something have been done better? How can we improve communication or cooperation at the OR? If a procedure went perfectly, could this golden standard be applied to similar medical procedures in the future? The black box can provide the answers. By reviewing the recorded data—patient parameters, camera, and microphone recordings—the surgery team analyzes all activities step by step: decision-making, workflows, timing, and the sequence of procedures.
Black boxes can also have broader applications, such as tracking compliance with pre-surgery procedures. Advances in this field are significant, as more medical devices are digital and can transmit data to the black box system. Smart cameras—similar to those installed on autonomous cars—can recognize tools, individual team members' movements, and voices to create detailed feedback reports.
In addition to patient safety, black boxes—by recording the duration of each step and time stamps—allow for improving workflows and efficiency. Black boxes can also have great educational value. For example, data collected from procedures can be used to train residents. Young doctors can carefully analyze and improve surgical techniques, decision-making processes, and team cooperation. They can also learn from recordings of procedures performed by experienced surgeons.
Doubts regarding privacy
Cameras in the operating room? But what about the privacy of patients and doctors? Applying black boxes poses several challenges regarding data protection and culture change. Operating rooms have always been shared solely by the clinical teams and no one else, and certainly not by cameras and microphones.
However, these can be easily solved, as black box systems have options for anonymization (de-identification of patients and staff), facial blurring, and voice distortion. Hospitals can also decide in advance how the recordings will be used. A common practice is to limit the availability of recordings for lawsuits. For example, recordings can be erased after the operation is evaluated. This approach dramatically increases staff confidence and is legal, as recordings are not part of the patient's records.
Since the technology is relatively new, a common barrier is a prejudice against continuous work monitoring. To address this, management must be transparent about what cameras can be used. As usual, transparent communication is critical to introducing every novel technology.
Real-time feedback in the OR
Black boxes in operating rooms can significantly improve the safety and efficiency of surgical procedures, making it easier for hospitals to introduce the concept of evidence-based surgeries. University hospitals will most likely benefit from them, as they can use the data from black boxes to train staff and residents.
According to MIT Technology Review, about 40 hospitals in the US are already using the system. The technology is less prevalent in Europe, but the first hospitals, such as Rigshospitalet in Denmark and Amsterdam University Medical Center, are already implementing it. The main barrier—besides legal issues and human acceptance—is cost. For example, the OR Black Box costs around $100,000, with an additional $25,000 per year for the data analytics system.
New generation OR black boxes will apply AI to ongoing data analysis so the operations team can access real-time guidance. In the future, experts hope AI will be powerful enough to predict adverse events based on Big Data analysis developed from connected black box systems.
