PATIENT SAFETY
Developing a Video-based Multidisciplinary Review Rounds of Critical Events in the OR
Published on
Jan 22, 2026
Journal of Patient Safety
Forrester, Joseph D. MD, MSc; Gostic, William J. MD; Peterson, Ashley MD; Gomez, Britomar MSN, RN; Watt, Dominique RN MBA, MSN, CPHQ, CPPS; Singer, Sara MBA, PhD; Wald, Samuel H. MD, MBA; Bateman, Brian T. MD; Hawn, Mary T.
Overview
In this research, the team developed a standardized Video-based Multidisciplinary Review (VB-MDR) process that uses the OR Black Box® to drive team-level learning and system improvement. A multidisciplinary working group (surgery, anesthesiology, interventional platform and quality leaders) curates short, high-yield clips, sets ground rules that emphasize systems rather than individuals, and prepares facilitated talking points and action items. The format—brief case presentations, facilitated multidisciplinary discussion, and a curated discussion deck—was deliberately designed to be reproducible, non-punitive, and accessible to a broad range of OR staff, with the explicit goal of converting observed safety issues into concrete quality improvement work.
Results
Implementing VB-MDR at a single quaternary academic center produced rapid scale and tangible system changes: meeting attendance rose roughly tenfold (from ~40 to 400+), and the process generated multiple institution-level interventions that improved surgical reliability and resilience. Examples of system changes attributed to VB-MDR include embedding a retained-foreign-object (RFO) protocol as a one-click EMR order, revising blood-scanning workflows, introducing specimen allocation hard stops, establishing a Code Hemorrhage pathway, pushing the Universal Protocol enterprise-wide, and launching closed-loop communication projects. The authors credit these gains to objective, multimedia case review, cross-disciplinary learning, and carefully enforced ground rules that created a safe, action-oriented culture of improvement.
Peer-reviewed Research
