What Really Makes Surgery Safer 

When something goes wrong on a plane, investigators turn to the black box. Now, a similar tool is being tested in operating rooms – where researchers review synchronized video, audio and physiological data to gain a better understanding of what happens during surgery.  

Patricia Trbovich, an associate professor at the Institute of Health Policy, Management and Evaluation at the Dalla Lana School of Public Health, is using this “OR black box” not just to analyze failures, but to study what goes right. Her research shows that outcomes often hinge on small, overlooked details – how a surgical team communicates, where equipment is placed or how an operating room is laid out. 

The system captures video and audio from the operating room, patient vital signs and even the heart rates – and heart-rate variability – of clinicians, recorded through wearable devices. Originally developed by Dr. Teodor Grantcharov to improve surgical training and patient safety, the OR black box now allows researchers like Trbovich to examine how subtle factors – from team dynamics to the space around the operating table – influence how an operation unfolds. 

More than two million surgeries are performed in Canada each year. Yet national data doesn’t fully capture the challenges in operating rooms. Researchers have noted that surgical patients account for the highest rates of safety incidents among hospitalized patients, but many priorities identified by health-care experts – including outcomes that matter most to patients – are not well captured in existing data. 

That’s where black box research can help. By reviewing 195 surgeries across hospitals in Toronto and Palo Alto, California, Trbovich and her colleagues are identifying patterns that traditional reporting systems overlook. She emphasizes: poor surgical outcomes are not necessarily due to failure by clinicians. They are often rooted in system design.

“Our black box data reveals again and again that it’s not a lack of skill,” she says, “but rather a lack of design leading to most of the errors we see. I notice practitioners’ resilience – their ability to make small adjustments when the unexpected happens – much more than practitioner error.” 

Human Factors

Rather than focusing solely on human mistakes, Trbovich asks broader questions: How was the operating room designed? Was someone interrupted at a critical moment? Was the equipment where it should have been? This approach – known as human factors – examines how people interact with their environment. 

Trbovich, the Badeau Family Research Chair in Patient Safety and Quality Improvement at North York General Hospital, has identified distractions, unclear communications and missing or poorly designed equipment as key safety concerns. Different members of the surgical team need to focus at different points in a procedure, she says. When colleagues understand those moments, they can avoid unnecessary disruptions and protect each other’s concentration.

Just as important are the often invisible adjustments teams make to prevent problems from escalating. A lead surgeon may switch roles with a surgical trainee. A nurse may anticipate the need for an extra instrument. The team may call in an expert to advise. These actions rarely appear in incident reports, but they are essential to keep patients safe. “Success often leaves no trace,” Trbovich says. “We’re trying to make those invisible moments visible.”

Changing outcomes 

As Trbovich’s team studies OR black box data, they are developing ideas for operating room improvements. Some fixes are straightforward. For instance, hospitals often add items to the World Health Organization’s surgical safety checklist. Over time, some checklists become so long and densely printed that they are difficult to read from the operating table. Trbovich worked with hospitals to condense their lists and improve their visibility. 

Her team is also studying how to strengthen psychological safety in operating rooms. Rather than focusing only on individual behaviour, they are testing cultural changes such as adding names to surgical caps, offering opportunities for confidential feedback and creating structured pauses during surgery for team input – small adjustments that make speaking up easier and more routine.

Looking ahead, Trbovich is leading a project to develop predictive tools that could flag safety threats as surgeries proceed. The goal is to use AI to analyze black box data and provide timely alerts to clinical teams. The system is being designed with clinicians to ensure it augments – rather than replaces – human judgment. It is also being tested to minimize unnecessary warnings and avoid “alert fatigue,” says Trbovich.

Whether the solution involves redesigning a checklist or developing AI-driven insights, the principle is the same: better systems support better care. Trbovich compares it to Formula 1 racing. “F1 drivers aren’t superhuman,” she says. “They’re fast because every part of the system – the car, the track, the data – is engineered around performance.” Likewise, in the operating room, success depends on more than individual expertise. It depends on an environment designed to help skilled teams do their best work – even when the unexpected happens.