Key result
In 80 laparoscopic urologic surgeries monitored by the OR Black Box, 138 clinically significant intraoperative adverse events occurred, with 51% happening during critical operative steps.
Why the study?
To mitigate intraoperative adverse events, the study aimed to characterize intraoperative adverse events and potential distractions occurring during minimally invasive urologic procedures.
What are the characteristics of intraoperative adverse events and distractions during minimally invasive urologic procedures using the OR Black Box?
Cohort (n=80)
No
What are the characteristics of intraoperative adverse events and distractions during minimally invasive urologic procedures using the OR Black Box?
May guide vigilance during critical steps in urologic laparoscopy; leaves open whether OR Black Box monitoring reduces events.
PURPOSE: To mitigate intraoperative adverse events, it is important to understand the context in which these errors occur. The purpose of this study is to characterize the IAEs and potential distractions that occur in minimally invasive urologic procedures. METHODS: We conducted a prospective cohort study in patients undergoing laparoscopic urologic surgery at an academic health center. The OR Black Box, a unique technology system which captures video and audio recordings of the operating room as well as the operative field, was used to collect data regarding procedure type, critical step, IAEs, and distractions. 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). CONCLUSION: Our data demonstrate that IAEs occur frequently during all phases of the operation at hand. Future study will be required to examine the role of distractions and IAE as well as IAE and their relationship to post-operative clinical outcomes.
No takes yet. Share an insight, caveat, or question.
Rai et al. (2021) conducted a cohort in Laparoscopic urologic surgery (n=80). Laparoscopic urologic surgery was evaluated on Intraoperative adverse events (IAEs) and distractions. In 80 laparoscopic urologic surgeries monitored by the OR Black Box, 138 clinically significant intraoperative adverse events occurred, with 51% happening during critical operative steps.
Synapse has enriched 5 closely related papers on similar clinical questions. Consider them for comparative context: