Black Boxes in the O.R.

By Joseph J. Wang

Many questions are raised following an airplane crash. First and foremost is what caused the crash. The answer is not easily ascertained because the best witnesses, the pilots themselves, do not always survive the crash. The answer, however, could lie within a little black box.

In the aviation context, "black boxes" refer to the cockpit voice and flight data recorders, both of which are located within the aircraft. The cockpit voice recorder records the voices and verbal communications of the flight crew via several microphones built into the cockpit. The flight data recorder records information about the flight: time, airspeed, air pressure, altitude, fuel flow, magnetic heading, and many other parameters. Taken together, these black boxes provide the National Transportation Safety Board, the primary investigators of aviation accidents in the United States, a technical picture of events leading up to an airplane accident. Knowing why an accident occurred helps aircraft manufacturers and the Federal Aviation Administration better ensure safety in air travel.

If black boxes have proven to be invaluable in improving safety in aviation, could not black boxes prove to be invaluable in ensuring safety in medicine? Researchers in London think so. See Black Box for Operating Rooms, available at

In the context of surgery, a black box similar in purpose to a flight data recorder could be used to record patient vital signs and process both clinical and physiological data throughout the surgery. Also, a black box similar in purpose to a cockpit voice recorder could be used to record conversations among the surgical staff via microphones set up in the operating room. In fact, this black box could go further and visually record events during surgery via small video cameras. Operating room black boxes, also known as Clinical Data Recorders (CDRs), could provide a wealth of information concerning the favorable and adverse results of a medical or surgical procedure. Like the information recorded in aviation black boxes, the information from CDRs could be studied and used ultimately to improve the quality and safety of medical practice. Further, since CDRs are recording medical activities, physicians and other health care professionals would be more inclined to report anomalies, regardless of the integrity of confidential reporting systems. CDRs have great potential for purposes of quality assurance and patient safety. But are they a good idea?

One potential problem with the widespread use of CDRs is that the information collected could be used for purposes other than improving medical quality and assuring patient safety. The information collected could be used to promote medical malpractice suits. Patients who are not satisfied with a surgical outcome could potentially build a lawsuit around the information contained in CDRs. Consequently, hospital and other health care entities would be less inclined to utilize CDRs, regardless of the benefits advanced by this technology.

Another problem with the widespread implementation of CDRs is that progress involving novel, experimental, medical and surgical techniques could be stymied. The threat of malpractice could force physicians to lean toward being excessively conservative following rigidly established medical protocol. Physicians would be less likely to engage in more risky maneuvers, even if experience and sound judgment dictate these maneuvers, because every hand motion and heartbeat will be recorded and could be used against them.

Finally, protecting the confidentiality and security of information collected by CDRs could be tedious and expensive, especially for smaller health care entities. Within the gamut of information collected by CDRs, a subset of that information could be considered "protected health information" under the Health Insurance Portability and Accountability Act of 1996. A health care entity holding protected health information would have a legal duty to protect the confidentiality and security of that information or be in violation of federal law.

For more information on patient safety, see Health Law News, March 2000, available at