Intraoperative Events Are Critical Signals for Patient Safety

SSN highlighted the importance of measuring intraoperative events such as bleeding, thermal injury, and mechanical injury. Presentations described the SEVERE framework for analyzing event type, severity, and rectification, including whether an event was fully corrected during the case.

The key insight was that intraoperative events are not isolated moments. They sit at the intersection of technical skills, non-technical skills, human factors, patient-level variables, safety threats, and resilience supports. Measuring these events creates a more complete picture of surgical safety than postoperative outcomes alone.

Non-Technical Skills Remained a Key Open Question

The conference acknowledged that technical performance was becoming increasingly measurable, but that important questions remained about non-technical skills. The materials asked what aspects of non-technical skill influence outcomes and noted that OR Black Box® provides a vehicle to study this while controlling for technical skill.

This insight foreshadowed later SSN themes around teamwork, psychological safety, communication, and system performance. In 2019, the conference was already identifying the need to understand how human factors and team behaviors shape surgical outcomes.

The Network Was Defining the Questions That Data Should Answer

The 2020 agenda included breakout sessions asking what types of insights and analytics were needed, and how they would be used by hospital administration, perioperative teams, and researchers. This made SSN 2019 an early “question-defining” year: participants were not only reviewing available analytics, but also shaping the clinical, operational, and research questions that OR Black Box® data could help answer.