Surgical video analysis: an emerging tool for improving surgeon performance.

To cite: Dimick JB, Varban OA. BMJ Qual Saf Published Online First: [please include Day Month Year] doi:10.1136/bmjqs-2015004439 Consistent with the emphasis on systems’ approaches that have characterised much of the patient safety movement thus far, most existing efforts aimed at improving surgical safety tend to focus almost exclusively on perioperative care. For example, surgical quality committees spend the lion’s share of their time discussing methods of ensuring optimal antibiotic prophylaxis to prevent wound infections or reining in the creative and highly variable ways surgeons use heparin (and its counterparts) to prevent deep venous thrombosis. Unfortunately, many of these initiatives have had only a modest impact on surgical outcomes. As a result, there has been growing enthusiasm for targeting the operation itself for improvement. Surgical procedures are complex, technical in nature and are particularly vulnerable to human error: outcomes may depend on the individual surgeon’s ability to avert or mitigate technical errors. However, very little is known about the impact of surgical skill and technique on patient outcomes. Ironically, this may be attributable to the tendency of patient safety to focus on systems rather than individuals. Two other practical barriers to advancing the study of the contribution of individual technical skill and competence to surgical safety and quality include the following: (1) obtaining data on the details of what happens in the operating room; and (2) the lack of scientific work aimed at systematically evaluating these data to better understand surgical skill and technique. Each of these barriers is currently being addressed and, as a result, the study of surgical intraoperative skill and technique is gaining momentum. One recent study reminded us of the potential importance of surgeon skill as a driver of patient outcomes. This study, from the Michigan Bariatric Surgery Collaborative (MBSC), demonstrated that peer video ratings of surgical skill were strongly correlated with clinical outcomes for practicing surgeons performing laparoscopic gastric bypass procedures. Surgeons from around Michigan submitted ‘typical’ videos and were rated by at least 10 of their peers using a modified version of objective structured assessment of technical skill (OSATS) instrument. This study demonstrated wide variations in surgical skill among practicing surgeons. But perhaps most importantly, it found a strong correlation between these video peer ratings of skill and all of the measured clinical outcomes—including 30-day surgical complications and medical complications. This paper shows that what happens in the operating room matters for safety and has generated great enthusiasm for strategies aimed at improving the intraoperative technical aspects of surgery. Bonrath et al add to our scientific understanding of intraoperative surgeon performance. The investigators reviewed 54 unedited videos of successful (uncomplicated) laparoscopic bariatric procedures to identify near-miss events using the Generic Error Rating Tool (GERT). They found 66 events in 38 of the video recordings, including 25 where the surgeon had to undertake additional measures (eg, haemostasis or suture repair) to address the problem. This study makes several important contributions. First, expanding on the prior work demonstrating the reliability of peer ratings of surgeon skill, this study demonstrates the reliability of the GERT scale for using video review to categorise ‘near-miss’ technical errors. Second, the study provides a proof-of-concept that even videos of uncomplicated cases can yield generalisable teaching points. For example, the majority of the technical EDITORIAL