The Operating Room Black Box: Understanding Adherence to Surgical Checklists

Amr I. Al Abbas, Ganesh Sankaranarayanan, Patricio M. Polanco, Jeffrey A. Cadeddu, William Daniel, Vanessa Palter, Teodor Grantcharov, Sonja Bartolome, Priya Dandekar, Kim Evans, Herbert J. Zeh

Research output: Contribution to journalArticlepeer-review


Objective: We report for the first time the use of the Operating Room Black Box (ORBB) to track checklist compliance, engagement, and quality. Background: Implementation of operative checklists is associated with improved outcomes. Compliance is difficult to monitor. Most studies report either no assessment of checklist compliance or deployed in-person short-term assessment. The ORBB a novel artificially intelligence-driven data analytic platform affords the opportunity to assess checklist compliance without disrupting surgical workflow. Methods: This was a retrospective review of prospectively collected ORBB data. Operative cases included elective surgery at a quaternary referral center. Cases were analyzed as prepolicy change (first 9 months) or as a postpolicy change (last 9 months). Measures of checklist compliance, engagement, and quality were assessed. Results: There were 3879 cases that were performed and monitored for checklist compliance between August 15, 2020, and February 20, 2022. The overall scores for compliance, engagement, and quality were 81%, 84%, and 67% respectively. When broken down by phase, the scores for time-out were compliance 100%, engagement 98%, and quality 61%. Scores for the debrief phase were 81% for compliance, 98% for engagement, and 66% for quality. After a hospital policy change, the debrief scores improved significantly (85%; P<0.001 for compliance, 88%; P<0.001 for engagement and 71%; P<0.001 for quality). Conclusions: ORBB provides the unprecedented ability to assess not only compliance with surgical safety checklists but also engagement and quality. Utilization of this technology allows the assessment of compliance in near real time and to accurately address safety threats that may arise from noncompliance.

Original languageEnglish (US)
Pages (from-to)995-1001
Number of pages7
JournalAnnals of surgery
Issue number6
StatePublished - Dec 1 2022


  • checklist
  • compliance
  • robotic surgery
  • safety

ASJC Scopus subject areas

  • Surgery


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