Dr. Teodor Grantcharov completed his surgical training at the University of Copenhagen, and a doctoral degree in Medical Sciences at the University of Aarhus in Denmark.
Dr. Grantcharov is a Professor of Surgery at Stanford University and Associate Chief Quality Officer for Innovation and Safety at Stanford Healthcare.
Prior to joining Stanford, Dr. Grantcharov was a Professor of Surgery at the University of Toronto and Keenan Chair in Surgery at St. Michael’s Hospital in Toronto. He was the Founder of the International Centre for Surgical Safety – a multidisciplinary group of visionary scientists with expertise in design, human factors, computer- and data science, and healthcare research. He previously held Canada Research Chair in Simulation and Surgical Safety and was awarded the Queen Elizabeth II diamond jubilee medal for his contributions to clinical research and patient safety in Canada. Dr. Grantcharov was awarded the honorary fellowship of the Imperial College in London, the honorary fellowships of the Bulgarian, Danish and Brazilian surgical societies, the Spinoza Chair in Surgery from the University of Amsterdam and multiple national and international awards for his contributions to surgical education and surgical safety.
Dr. Grantcharov’s clinical interest is the area of minimally invasive surgery, while his academic focus is in the field of surgical innovation and patient safety. He has become internationally recognized as a leader in this area with his work on curriculum design, assessment of competence and impact of surgical performance on clinical outcomes. Dr. Grantcharov developed the surgical Black Box concept, which aims to transform the safety culture in medicine and introduce modern safety management systems in the high-risk operating room environment.
Dr. Grantcharov has more than 220 peer-reviewed publications and more than 200 invited presentations in Europe, South- and North America. He holds several patents and is the Founder of Surgical Safety Technologies Inc – an academic startup that commercializes the OR Black Box platform. He sits on numerous committees with Surgical Professional Societies in North America and Europe.
- General Surgery
Professor - University Medical Line, Surgery - General Surgery
Fellowship: Temple University Hospital Dept of Surgery (2006) PA
Residency: Copenhagen University Rigshospitalet (2005) Denmark
Internship: Copenhagen University Rigshospitalet (1997) Denmark
Medical Education: Medical University of Plovdiv (1996) Bulgaria
- Navigating a Path Towards Routine Recording in the Operating Room. Annals of surgery 2023
Surgeon's Leadership Style and Team Behavior in the Hybrid Operating Room
MOSBY-ELSEVIER. 2023: 54S-55S
View details for Web of Science ID 000994639100121
Automated Capture of Intraoperative Adverse Events Using Artificial Intelligence: A Systematic Review and Meta-Analysis.
Journal of clinical medicine
2023; 12 (4)
Intraoperative adverse events (iAEs) impact the outcomes of surgery, and yet are not routinely collected, graded, and reported. Advancements in artificial intelligence (AI) have the potential to power real-time, automatic detection of these events and disrupt the landscape of surgical safety through the prediction and mitigation of iAEs. We sought to understand the current implementation of AI in this space. A literature review was performed to PRISMA-DTA standards. Included articles were from all surgical specialties and reported the automatic identification of iAEs in real-time. Details on surgical specialty, adverse events, technology used for detecting iAEs, AI algorithm/validation, and reference standards/conventional parameters were extracted. A meta-analysis of algorithms with available data was conducted using a hierarchical summary receiver operating characteristic curve (ROC). The QUADAS-2 tool was used to assess the article risk of bias and clinical applicability. A total of 2982 studies were identified by searching PubMed, Scopus, Web of Science, and IEEE Xplore, with 13 articles included for data extraction. The AI algorithms detected bleeding (n = 7), vessel injury (n = 1), perfusion deficiencies (n = 1), thermal damage (n = 1), and EMG abnormalities (n = 1), among other iAEs. Nine of the thirteen articles described at least one validation method for the detection system; five explained using cross-validation and seven divided the dataset into training and validation cohorts. Meta-analysis showed the algorithms were both sensitive and specific across included iAEs (detection OR 14.74, CI 4.7-46.2). There was heterogeneity in reported outcome statistics and article bias risk. There is a need for standardization of iAE definitions, detection, and reporting to enhance surgical care for all patients. The heterogeneous applications of AI in the literature highlights the pluripotent nature of this technology. Applications of these algorithms across a breadth of urologic procedures should be investigated to assess the generalizability of these data.
View details for DOI 10.3390/jcm12041687
View details for PubMedID 36836223
Cognitive biases in surgery: systematic review.
The British journal of surgery
Although numerous studies have established cognitive biases as contributors to surgical adverse events, their prevalence and impact in surgery are unknown. This review aimed to describe types of cognitive bias in surgery, their impact on surgical performance and patient outcomes, their source, and the mitigation strategies used to reduce their effect.A literature search was conducted on 9 April and 6 December 2021 using MEDLINE, Embase, PsycINFO, Scopus, Web of Science, Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews. Included studies investigated how cognitive biases affect surgery and the mitigation strategies used to combat their impact. The National Institutes of Health tools were used to assess study quality. Inductive thematic analysis was used to identify themes of cognitive bias impact on surgical performance.Thirty-nine studies were included, comprising 6514 surgeons and over 200 000 patients. Thirty-one types of cognitive bias were identified, with overconfidence, anchoring, and confirmation bias the most common. Cognitive biases differentially influenced six themes of surgical performance. For example, overconfidence bias associated with inaccurate perceptions of ability, whereas anchoring bias associated with inaccurate risk-benefit estimations and not considering alternative options. Anchoring and confirmation biases associated with actual patient harm, such as never events. No studies investigated cognitive bias source or mitigation strategies.Cognitive biases have a negative impact on surgical performance and patient outcomes across all points of surgical care. This review highlights the scarcity of research investigating the sources that give rise to cognitive biases in surgery and the mitigation strategies that target these factors.
View details for DOI 10.1093/bjs/znad004
View details for PubMedID 36752583
Electroencephalography can provide advance warning of technical errors during laparoscopic surgery.
Intraoperative adverse events lead to patient injury and death, and are increasing. Early warning systems (EWSs) have been used to detect patient deterioration and save lives. However, few studies have used EWSs to monitor surgical performance and caution about imminent technical errors. Previous (non-surgical) research has investigated neural activity to predict future motor errors using electroencephalography (EEG). The present proof-of-concept cohort study investigates whether EEG could predict technical errors in surgery.In a large academic hospital, three surgical fellows performed 12 elective laparoscopic general surgeries. Audiovisual data of the operating room and the surgeon's neural activity were recorded. Technical errors and epochs of good surgical performance were coded into events. Neural activity was observed 40 s prior and 10 s after errors and good events to determine how far in advance errors were detected. A hierarchical regression model was used to account for possible clustering within surgeons. This prospective, proof-of-concept, cohort study was conducted from July to November 2021, with a pilot period from February to March 2020 used to optimize the technique of data capture and included participants who were blinded from study hypotheses.Forty-five technical errors, mainly due to too little force or distance (n = 39), and 27 good surgical events were coded during grasping and dissection. Neural activity representing error monitoring (p = .008) and motor uncertainty (p = .034) was detected 17 s prior to errors, but not prior to good surgical performance.These results show that distinct neural signatures are predictive of technical error in laparoscopic surgery. If replicated with low false-alarm rates, an EEG-based EWS of technical errors could be used to improve individualized surgical training by flagging imminent unsafe actions-before errors occur and cause patient harm.
View details for DOI 10.1007/s00464-022-09799-2
View details for PubMedID 36478137
The Operating Room Black Box: Understanding Adherence to Surgical Checklists.
Annals of surgery
2022; 276 (6): 995-1001
OBJECTIVE: We report for the first time the use of the Operating Room Black Box (ORBB) to track checklist compliance, engagement, and quality.BACKGROUND: Implementation of operative checklists is associated with improved outcomes. Compliance is difficult to monitor. Most studies report either no assessment of checklist compliance or deployed in-person short-term assessment. The ORBB a novel artificially intelligence-driven data analytic platform affords the opportunity to assess checklist compliance without disrupting surgical workflow.METHODS: This was a retrospective review of prospectively collected ORBB data. Operative cases included elective surgery at a quaternary referral center. Cases were analyzed as prepolicy change (first 9 months) or as a postpolicy change (last 9 months). Measures of checklist compliance, engagement, and quality were assessed.RESULTS: There were 3879 cases that were performed and monitored for checklist compliance between August 15, 2020, and February 20, 2022. The overall scores for compliance, engagement, and quality were 81%, 84%, and 67% respectively. When broken down by phase, the scores for time-out were compliance 100%, engagement 98%, and quality 61%. Scores for the debrief phase were 81% for compliance, 98% for engagement, and 66% for quality. After a hospital policy change, the debrief scores improved significantly (85%; P <0.001 for compliance, 88%; P <0.001 for engagement and 71%; P <0.001 for quality).CONCLUSIONS: ORBB provides the unprecedented ability to assess not only compliance with surgical safety checklists but also engagement and quality. Utilization of this technology allows the assessment of compliance in near real time and to accurately address safety threats that may arise from noncompliance.
View details for DOI 10.1097/SLA.0000000000005695
View details for PubMedID 36120866
Healthcare professionals' perception of safety culture and the Operating Room (OR) Black Box technology before clinical implementation: a cross-sectional survey.
BMJ open quality
2022; 11 (4)
Comprehensive data capture systems such as the Operating Room Black Box (OR Black Box) are becoming more widely implemented to access quality data in the complex environment of the OR. Prior to installing an OR Black Box, we assessed perceptions on safety attitudes, impostor phenomenon and privacy concerns around digital information sharing among healthcare professionals in the OR. A parallel survey was conducted in Canada, hence, this study also discusses cultural and international differences when implementing new technology in healthcare.A cross-sectional survey using three previously validated questionnaires (Safety Attitudes Questionnaire (SAQ), Clance Impostor Phenomenon Scale, Dispositional Privacy Concern) was distributed through Research Electronic Data Capture to 145 healthcare professionals from the OR (July to December 2019). Analysis of variance and analysis of covariance were used to test for differences.124 responded (86%): 100 completed the survey (69%) (38 nurses, 10 anaesthesiologists, 36 obstetricians/gynaecologists, 16 residents). Significant variability in all six SAQ domains, safety climate and teamwork being the lowest ranked and job satisfaction ranked highest for all groups. The SAQ varied in all domains in Canada. Moderate to frequent impostor phenomenon was experienced by 71% predominantly among residents (p=0.003). 72% in the Canadian study. Residents were most comfortable with digital information sharing (p<0.001), only 13% of all healthcare professionals were concerned/heavy concerned compared with 45% in Canada.The different healthcare professional groups had diverse perceptions about safety culture, but were mainly concerned about safety climate and teamwork in the OR. Impostor phenomenon decreased with age. All groups were unconcerned about digital information sharing. The Canadian study had similar findings in terms of impostor phenomenon, but a variety within the SAQ and were more concerned about data safety, which could be due to medical litigation per se and is not widespread in Scandinavia compared with North America.
View details for DOI 10.1136/bmjoq-2022-001819
View details for PubMedID 36588330
View details for PubMedCentralID PMC9730368
- Healthcare professionals' perception of safety culture and the Operating Room (OR) Black Box technology before clinical implementation: a cross-sectional survey BMJ OPEN QUALITY 2022; 11 (4)
Assessing endovascular team performances in a hybrid room using the Black Box system: a prospective cohort study.
The Journal of cardiovascular surgery
The hybrid room (HR) is a complex, high-risk environment, requiring teams (surgeons, anesthesiologists, nurses, technologists) to master various skills, including the 'As Low As Reasonably Achievable' principle of radiation safety. This prospective single center cohort reports the first use of the Operating Room Black Box (ORBB) in a HR. This medical data recording system captures procedural and audiovisual data to facilitate structured team performance analysis.Patients planned for endovascular repair of an infrarenal abdominal aortic aneurysm (EVAR) or treatment of symptomatic iliac-femoral-popliteal atherosclerotic disease (Peripheral Vascular Interventions or PVI) were included. Validated measures and established assessment tools were used to assess (non-)technical, radiation safety and environmental distractions.Six EVAR and sixteen PVI procedures were captured. Technical performance for one EVAR was rated 19/35 on the procedure-specific scale, below the 'acceptable' score of 21. Technical skills were rated above acceptable in all PVI procedures. Shared decision making and leadership were rated highly in 12/22 cases, whereas surgical communication and nurses' task management were rated low in 14/22 cases. Team members rarely stepped back from the C-arm during digital subtraction angiography. Radiation safety behavior was scored below 'acceptable' in 14/22 cases. A median (Interquartile Range) number of 12 (6-23) auditory distractions was observed per procedure.The ORBB facilitates holistic workplace-based assessment of endovascular performance in a HR by combining objective assessment parameters and rating scale-based evaluations. Strengths and weaknesses were identified in team members' (non-)technical and radiation safety practices. This technology has the potential to improve vascular surgical practice, though human input remains crucial.
View details for DOI 10.23736/S0021-9509.22.12226-3
View details for PubMedID 36168949
Surgeons' Leadership Style and Team Behavior in the Hybrid Operating Room: Prospective Cohort Study.
Annals of surgery
OBJECTIVE: This study aimed to assess the relationship between surgeons' leadership style and team behavior in the hybrid operating room through video coding. Secondly, possible fluctuations in leadership styles and team behavior during operative phases were studied.SUMMARY/BACKGROUNDDATA: Leadership is recognized as a key component to successful team functioning in high-risk industries. The 'full range of leadership' theory is commonly used to evaluate leadership, marking transformational, transactional and passive. Few studies have examined the effects of these leadership styles on team behavior in surgery and/or their fluctuations during surgery.METHODS: A single-center study included patients planned for routine endovascular procedures. A medical data capture system was used to allow post-hoc video coding through Behavior Anchored Rating Scales. Multilevel statistical analysis was performed to assess possible correlations between leadership style and three team behavior indicators (speaking up, knowledge sharing, collaboration) on an operative phase level.RESULTS: Twenty-two cases were analyzed (47 hours recording). Transformational leadership is positively related to the extent to which team members work together (gamma=0.20, P<0.001), share knowledge (gamma=0.45, P<0.001) and speak up (gamma=0.64, P<0.001). Passive leadership is significantly positively correlated with speaking up (gamma=0.29, P=0.004). Leadership style and team behavior clearly fluctuate during a procedure, with similar patterns across different types of endovascular procedures.CONCLUSIONS: Consistent with other professional fields, surgeons' transformational leadership enhances team behavior, especially during the most complex operative phases. This suggests that encouraging surgeons to learn and actively implement a transformational leadership style is meaningful to enhance patient safety and team performance.
View details for DOI 10.1097/SLA.0000000000005645
View details for PubMedID 35904023
Surgical data science - from concepts toward clinical translation.
Medical image analysis
2021; 76: 102306
Recent developments in data science in general and machine learning in particular have transformed the way experts envision the future of surgery. Surgical Data Science (SDS) is a new research field that aims to improve the quality of interventional healthcare through the capture, organization, analysis and modeling of data. While an increasing number of data-driven approaches and clinical applications have been studied in the fields of radiological and clinical data science, translational success stories are still lacking in surgery. In this publication, we shed light on the underlying reasons and provide a roadmap for future advances in the field. Based on an international workshop involving leading researchers in the field of SDS, we review current practice, key achievements and initiatives as well as available standards and tools for a number of topics relevant to the field, namely (1) infrastructure for data acquisition, storage and access in the presence of regulatory constraints, (2) data annotation and sharing and (3) data analytics. We further complement this technical perspective with (4) a review of currently available SDS products and the translational progress from academia and (5) a roadmap for faster clinical translation and exploitation of the full potential of SDS, based on an international multi-round Delphi process.
View details for DOI 10.1016/j.media.2021.102306
View details for PubMedID 34879287
Implementation of the Operating Room Black Box Research Program at the Ottawa Hospital Through Patient, Clinical, and Organizational Engagement: Case Study
JOURNAL OF MEDICAL INTERNET RESEARCH
2021; 23 (3): e15443
A large proportion of surgical patient harm is preventable; yet, our ability to systematically learn from these incidents and improve clinical practice remains limited. The Operating Room Black Box was developed to address the need for comprehensive assessments of clinical performance in the operating room. It captures synchronized audio, video, patient, and environmental clinical data in real time, which are subsequently analyzed by a combination of expert raters and software-based algorithms. Despite its significant potential to facilitate research and practice improvement, there are many potential implementation challenges at the institutional, clinician, and patient level. This paper summarizes our approach to implementation of the Operating Room Black Box at a large academic Canadian center.We aimed to contribute to the development of evidence-based best practices for implementing innovative technology in the operating room for direct observation of the clinical performance by using the case of the Operating Room Black Box. Specifically, we outline the systematic approach to the Operating Room Black Box implementation undertaken at our center.Our implementation approach included seeking support from hospital leadership; building frontline support and a team of champions among patients, nurses, anesthesiologists, and surgeons; accounting for stakeholder perceptions using theory-informed qualitative interviews; engaging patients; and documenting the implementation process, including barriers and facilitators, using the consolidated framework for implementation research.During the 12-month implementation period, we conducted 23 stakeholder engagement activities with over 200 participants. We recruited 10 clinician champions representing nursing, anesthesia, and surgery. We formally interviewed 15 patients and 17 perioperative clinicians and identified key themes to include in an information campaign run as part of the implementation process. Two patient partners were engaged and advised on communications as well as grant and protocol development. Many anticipated and unanticipated challenges were encountered at all levels. Implementation was ultimately successful, with the Operating Room Black Box installed in August 2018, and data collection beginning shortly thereafter.This paper represents the first step toward evidence-guided implementation of technologies for direct observation of performance for research and quality improvement in surgery. With technology increasingly being used in health care settings, the health care community should aim to optimize implementation processes in the best interest of health care professionals and patients.
View details for DOI 10.2196/15443
View details for Web of Science ID 000636180100002
View details for PubMedID 33724199
View details for PubMedCentralID PMC8074833
Development and Evaluation of a Novel Instrument to Measure Severity of Intraoperative Events Using Video Data.
Annals of surgery
2020; 272 (2): 220–26
To develop and evaluate a novel instrument to measure SEVERE processes using video data.Surgical video data can serve an important role in understanding the relationship between intraoperative events and postoperative outcomes. However, a standard tool to measure severity of intraoperative events is not yet available.Items to be included in the instrument were identified through literature and video reviews. A committee of experts guided item reduction, including pilot tests and revisions, and determined weighted scores. Content validity was evaluated using a validated sensibility questionnaire. Inter-rater reliability was assessed by calculating intraclass correlation coefficient. Construct validity was evaluated on a sample of 120 patients who underwent laparoscopic Roux-en-Y gastric bypass procedure, in which comprehensive video data was obtained.SEVERE index measures severity of 5 event types using ordinal scales. Each intraoperative event is given a weighted score out of 10. Inter-rater reliability was excellent [0.87 (95%-confidence interval, 0.77-0.92)]. In a sample of consecutive 120 patients undergoing gastric bypass procedures, a median of 12 events [interquartile range (IQR) 9-18] occurred per patient and bleeding was the most frequent type (median 10, IQR 7-14). The median SEVERE score per case was 11.3 (IQR 8.3-16.9). In risk-adjusted multivariable regression models, history of previous abdominal surgery (P = 0.02) and body mass index (P = 0.005) were associated with SEVERE scores, demonstrating construct validity evidence.The SEVERE index may prove to be a useful instrument in identifying patients with high risk of developing postoperative complications.
View details for DOI 10.1097/SLA.0000000000003897
View details for PubMedID 32675485
Simulation-Based Training of Non-Technical Skills in Colonoscopy: Protocol for a Randomized Controlled Trial
JMIR RESEARCH PROTOCOLS
2017; 6 (8): e153
Non-technical skills (NTS), such as communication and professionalism, contribute to the safe and effective completion of procedures. NTS training has previously been shown to improve surgical performance. Moreover, increases in NTS have been associated with improved clinical endoscopic performance. Despite this evidence, NTS training has not been tested as an intervention in endoscopy.The aim of this study is to evaluate the effectiveness of a simulation-based training (SBT) curriculum of NTS on novice endoscopists' performance of clinical colonoscopy.Novice endoscopists were randomized to 2 groups. The control group received 4 hours of interactive didactic sessions on colonoscopy theory and 6 hours of SBT. Hours 5 and 6 of the SBT were integrated scenarios, wherein participants interacted with a standardized patient and nurse, while performing a colonoscopy on the virtual reality (VR) simulator. The NTS (intervention) group received the same teaching sessions but the last hour was focused on NTS teaching. The NTS group also reviewed a checklist of tasks relevant to NTS concepts prior to each integrated scenario case and was provided with dedicated feedback on their NTS performance during the integrated scenario practice. All participants were assessed at baseline, immediately after training, and 4 to 6 weeks post-training. The primary outcome measure is colonoscopy-specific performance in the clinical setting.In total, 42 novice endoscopists completed the study. Data collection and analysis is ongoing. We anticipate completion of all assessments by August 2017. Data analysis, manuscript writing, and subsequent submission for publication is expected to be completed by December 2017.Results from this study may inform the implementation of NTS training into postgraduate gastrointestinal curricula. NTS curricula may improve attitudes towards patient safety and self-reflection among trainees. Moreover, enhanced NTS may lead to superior clinical performance and outcomes in colonoscopy.Clinicaltrial.gov NCT02877420; https://www.clinicaltrials.gov/ct2/show/NCT02877420 (Archived by WebCite at http://www.webcitation.org/6rw94ubXX NCT02877420).
View details for DOI 10.2196/resprot.7690
View details for Web of Science ID 000406901300003
View details for PubMedID 28778849
View details for PubMedCentralID PMC5562936