While most algorithms operate near perfectly on their own, Peter Grantcharov explains that the OR black box is still not fully autonomous. For example, it’s difficult to capture audio through ceiling mikes and thus get a reliable transcript to document whether every element of the surgical safety checklist was completed; he estimates that this algorithm has a 15% error rate. So before the output from each procedure is finalized, one of the Toronto analysts manually verifies adherence to the questionnaire. “It will require a human in the loop,” Peter Grantcharov says, but he gauges that the AI model has made the process of confirming checklist compliance 80% to 90% more efficient. He also emphasizes that the models are constantly being improved.
In all, the OR black box can cost about $100,000 to install, and analytics expenses run $25,000 annually, according to Janet Donovan, an OR nurse who shared with MIT Technology Review an estimate given to staff at Brigham and Women’s Faulkner Hospital in Massachusetts. (Peter Grantcharov declined to comment on these numbers, writing in an email: “We don’t share specific pricing; however, we can say that it’s based on the product mix and the total number of rooms, with inherent volume-based discounting built into our pricing models.”)
“Big brother is watching”
Long Island Jewish Medical Center in New York, part of the Northwell Health system, was the first hospital to pilot OR black boxes, back in February 2019. The rollout was far from seamless, though not necessarily because of the tech.
“In the colorectal room, the cameras were sabotaged,” recalls Northwell’s chair of urology, Louis Kavoussi—they were turned around and deliberately unplugged. In his own OR, the staff fell silent while working, worried they’d say the wrong thing. “Unless you’re taking a golf or tennis lesson, you don’t want someone staring there watching everything you do,” says Kavoussi, who has since joined the scientific advisory board for Surgical Safety Technologies.
Grantcharov’s promises about not using the system to punish individuals have offered little comfort to some OR staff. When two black boxes were installed at Faulkner Hospital in November 2023, they threw the department of surgery into crisis. “Everybody was pretty freaked out about it,” says one surgical tech who asked not to be identified by name since she wasn’t authorized to speak publicly. “We were being watched, and we felt like if we did something wrong, our jobs were going to be on the line.”
It wasn’t that she was doing anything illegal or spewing hate speech; she just wanted to joke with her friends, complain about the boss, and be herself without the fear of administrators peeking over her shoulder. “You’re very aware that you’re being watched; it’s not subtle at all,” she says. The early days were particularly challenging, with surgeons refusing to work in the black-box-equipped rooms and OR staff boycotting those operations: “It was definitely a fight every morning.”
“In the colorectal room, the cameras were sabotaged,” recalls Louis Kavoussi. “Unless you’re taking a golf or tennis lesson, you don’t want someone staring there watching everything you do.”
At some level, the identity protections are only half measures. Before 30-day-old recordings are automatically deleted, Grantcharov acknowledges, hospital administrators can still see the OR number, the time of operation, and the patient’s medical record number, so even if OR personnel are technically de-identified, they aren’t truly anonymous. The result is a sense that “Big Brother is watching,” says Christopher Mantyh, vice chair of clinical operations at Duke University Hospital, which has black boxes in seven ORs. He will draw on aggregate data to talk generally about quality improvement at departmental meetings, but when specific issues arise, like breaks in sterility or a cluster of infections, he will look to the recordings and “go to the surgeons directly.”
In many ways, that’s what worries Donovan, the Faulkner Hospital nurse. She’s not convinced the hospital will protect staff members’ identities and is worried that these recordings will be used against them—whether through internal disciplinary actions or in a patient’s malpractice suit. In February 2023, she and almost 60 others sent a letter to the hospital’s chief of surgery objecting to the black box. She’s since filed a grievance with the state, with arbitration proceedings scheduled for October.
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