One underutilized patient safety tool that we have recommended for the past decade – video recording – is finally starting to get attention in the literature. Two recent articles have noted some of the potential benefits of video recording in healthcare settings.
First was an editorial in the British Medical Journal (Makary 2015). Makary and colleagues use the analogy of video recording in the OR to that of the “black boxes” in airplanes. They can be used retrospectively to review what actually happened in cases with unwanted outcomes rather than relying simply on the recollection of all involved. But they also note the potential of the “Hawthorne effect” to lead to improvements. They also note that “if concerns about consent, privacy, and data security are dealt with carefully, video data can tell a story that simply cannot be matched by written documentation.”
Makary has written previously about the benefits of video recording (Makary 2013). He noted that North Shore University Hospital was able to improve hand washing compliance from 6.5% to 81.6% after installing cameras to monitor hand washing (see our March 2012 What's New in the Patient Safety World column “Smile...You’re on Candid Camera!”). He also noted that many procedures are already being recorded, noting that colonoscopy performance measures improved considerably once physicians became aware that someone might review the videos of their procedures. He also describes how reviewing videos of procedures can be used in a “coaching” manner to improve performance, similar to a coach reviewing play with players after an athletic contest. Importantly, as we have often discussed, video recording is also a good way to identify and deal with disruptive behavior and other behaviors that interfere with good teamwork. And he also notes that patients generally like the idea of having their procedures recorded, even receiving a copy of some of these videos.
In a series of letters commenting on his 2013 editorial, issues of legal protection and patient privacy were raised (Kels 2013, van der Veldt 2013). Makary’s reply (Makary 2013b) was that improving patient satisfaction by providing video recording may well reduce the threat of malpractice suits and that the patient privacy issues can be dealt with by informed consent and securing the video as securely as the medical record is secured.
The other recent publication was a controlled trial of video monitoring in the OR with real-time feedback (Overdyk 2015). It demonstrated that compliance with the surgical safety checklist improved significantly in those OR’s receiving real-time feedback. In addition, OR efficiency improved in that mean turnover times for scheduled cases was reduced by 14% in the OR’s receiving real-time feedback. The video streams were audited by a 10-person audit team to identify and time OR milestones to the nearest 20 seconds. Real-time feedback metrics were posted to OR display boards or sent as email or text alerts to the OR team. An example of an alert might be “time out failed”, which allowed surgeons, anesthesia providers and nurse managers to intervene.
The Overdyk study goes way beyond what we had envisioned in the utility of video monitoring. While virtually all of our recommendations involved retrospective review of activities recorded, the Overdyk study demonstrates the potential power of using this modality in real-time. That is really exciting! The Overdyk study does include any data on the costs of the system, which appear to be moderate. However, the improved OR efficiencies and the potential savings from prevention of errors may well cover the cost of such extensive systems.
Overdyk and colleagues also discuss how they were able to overcome the two most common barriers to use of video recording: (1) concerns about legal “discoverability” and (2) patient privacy issues. Their study was also designed to measure team performance rather than individual performance and was done in a non-punitive fashion. The researchers felt this was a significant factor in acceptance of use of the technology by the staff.
The Overdyk study utilized only video feeds and did not include audio recording. For most of the uses for which we have recommended recording the audio portion is at least as important (and often more important) than the video portion.
We’ve, of course, advocated for various uses of video recording over the past decade. Constructive review of recorded OR sessions is a great way to enhance teamwork and communication in the OR. Also, in our September 23, 2008 Patient Safety Tip of the Week “Checklists and Wrong Site Surgery” we advocated use of video recording as a way to improve compliance with Universal Protocol, the WHO Surgical Safety Checklist, and other OR activities.
In our March 17, 2015 Patient Safety Tip of the Week “Distractions in the OR” we noted that video recordings could be used to identify distractions in the OR. And in our November 24, 2015 Patient Safety Tip of the Week “Door Opening and Foot Traffic in the OR” we noted that review of video recordings might also be a useful way to determine the reasons for door opening in the OR in attempt to identify and reduce unnecessary door openings and unnecessary foot traffic.
And video recording is not just for the OR. In our November 2011 What's New in the Patient Safety World column “Restricted Housestaff Work Hours and Patient Handoffs” we noted that recording of handoffs is a potential way to improve the quality of handoffs. We noted in that column that doing video/audio recording is preferable to just audio recording since so much of such interactions involve non-verbal behavior. We’ve already noted how video recording can be used to improve hand hygiene compliance. It could also be used to constructively help housestaff perform bedside procedures.
We concur with Makary et al. that the time has come to make better use of video recording technology. And that study by Overdyk et al. takes this technology tool to a whole new level.
Some of our previous columns discussing video recording:
September 23, 2008 “Checklists and Wrong Site Surgery”
December 6, 2010 “More Tips to Prevent Wrong-Site Surgery”
November 2011 “Restricted Housestaff Work Hours and Patient Handoffs”
March 2012 “Smile...You’re on Candid Camera!”
August 27, 2013 “Lessons on Wrong-Site Surgery”
March 17, 2015 “Distractions in the OR”
November 24, 2015 “Door Opening and Foot Traffic in the OR”
Overdyk FJ, Dowling O, Newman S, et al. Remote video auditing with real-time feedback in an academic surgical suite improves safety and efficiency metrics: a cluster randomised study. BMJ Qual Saf 2015; Published Online First 11 December 2015
Makary MA, Xu T, Pawlik TM. Can video recording revolutionise medical quality? BMJ 2015; 351 (Published 21 October 2015)
Makary MA. The power of video recording: taking quality to the next level. JAMA 2013; 309(15): 1591-1592
Kels CG. Video Recording of Medical Procedures. JAMA. 2013; 310(9): 979-980
van der Veldt AAM, Kleijn SA, Nanayakkara PW. Video Recording of Medical Procedures. JAMA. 2013; 310(9): 979-980
Makary M. In reply: video recording of medical procedures. JAMA 2013; 310(9): 979-980