QUALITY IMPROVEMENT
OR Black Box Technology to Mitigate Local Anesthetic Systemic Toxicity Risk
Published on
Dec 1, 2025
Journal of PeriAnesthesia Nursing
Gyuhyun Lee, Barbara S. Turner, Jessica D. Szydlowski, Virginia C. Simmons
Overview
This quality improvement study evaluated the use of OR Black Box® to assess adherence to institutional protocols for administering liposomal bupivacaine (LB), with the goal of mitigating the risk of local anesthetic systemic toxicity (LAST). Conducted in two robotic operating rooms at a tertiary academic medical center, the project used retrospective OR Black Box video/audio recordings and electronic medical record review to identify barriers to protocol compliance. Key safety practices assessed included completion of LB-specific time-outs, application and verification of LB alert wristbands, discontinuation of lidocaine infusions, and adherence to the recommended 2:1 admixture ratio of LB with bupivacaine hydrochloride.
Results
Among 39 surgical cases involving intraoperative LB administration, protocol adherence was variable: 64% completed an LB time-out, 62% applied an LB alert wristband, 59% documented a wristband check, and 36% incorporated lidocaine infusion checks during the time-out. One case did not discontinue a lidocaine infusion, and three cases failed to follow the correct admixture ratio; however, no episodes of LAST occurred during the study period. The findings suggest that the OR Black Box can effectively identify safety gaps and support improvements in protocol adherence, while also highlighting limitations such as incomplete visual coverage, potential behavioral changes due to observation (Hawthorne effect), and medicolegal concerns.
Peer-reviewed Research
