Ai Voice Engines Modernize the Operating Room in Cardiac Surgery

Authors: Zain Khalpey, MD, PhD, FACS, Ezekiel Mendoza, BS, Scott Kramer, Joel Evans, Amina Khalpey, PhD

Modernizing the Surgical Checklist Manifesto with Artificial Intelligence and Voice Assistive Technology as a Co-pilot in the Operating Room

Surgical Time-out

Surgical errors are a significant cause of morbidity and mortality in the operating room. These errors can range from minor mistakes such as leaving a sponge inside a patient to major errors such as performing the wrong surgery on a patient. The surgical time-out is a crucial step in the surgical process that aims to mitigate these errors by identifying and correcting potential problems before they occur.

More specifically, a surgical time-out is when the surgical team stops to verify the correct patient and procedure. At the highest level, during a surgical timeout, each team member performs their assigned duties: the surgeon reviews the procedure steps, the nurse confirms that all equipment is ready, and the anesthesiologist checks the patient’s vitals. This break in activity allows everyone to confirm that they are ready to proceed with the surgery. Implementation of a formal “time-out” has been associated with reduction in patient morbidity, mortality, and surgical complications1.

However, human error can still occur during this process. In an investigation with Vanderbilt University Medical Center, surgical time-out was observed in 166 non-emergent cases. It noted staff compliance, any non-routine events, and distractions. It showed that while compliance to performing a time out was high, there were regular distractions and adherence to the time-out specifics was not always completed2.

To minimize errors, increase compliance and adherence, some facilities are beginning to incorporate electronic and digitalized methods for surgical timeouts. It can be used to confirm patient information and procedure steps, as well as to alert the team if any critical steps have been missed. This helps to ensure that everyone is on the same page and that the procedure can proceed safely and efficiently. Given evidence of reduction in patient morbidity, mortality and complications, there is still room for improvement on compliance and adherence. Implementing an electronic checklist system has shown to increase compliance by up to 30% on surgical cases4. In addition, variations of digitalized timeouts have shown benefit to operating room surgical staff as it increased implementation requests for future use3.

Incorporation of New Technology

As digitalization and data science continue to advance, health care professionals are turning to artificial intelligence and machine learning algorithms as a way to make patient care more accurate, efficient, and up-to-date. Incorporating artificial intelligence technology and voice integration into the operating room as assistance to the surgical team is a promising endeavor. Voice recognition, real-time feedback, and data collection are some methods to improve surgical timeouts. It builds on the foundation in Atul Gawande’s The Checklist Manifesto. Despite the increasing complexity of surgery, having simple checklists will have immense effects on improving outcomes. What was once a revolutionary concept can again be modernized in today’s era.

By analyzing data from past surgeries and identifying patterns and trends, machine learning algorithms can identify potential problems before they occur and suggest corrective actions. We can explore the various ways in which a voice integrated system with machine learning algorithms can be applied to the surgical time-out. In addition, the voice integrated system can serve as a member of the team and as a co-pilot to reduce errors and to improve efficiency. Instead of introducing the possibility of the mishandling of papers and documents, the team can interact with the voice integrated system via voice and receive prompts back via voice, visual cues or other mechanisms, at any stage of the procedure. The use of voice also allows the team to be prompted and interact hands-free. The flow would be more ‘natural’ than a sterile checklist. It tells the patient’s story in a complete and engaging way in the operating room.

A major cause of surgical errors is patient misidentification. This can occur when the wrong patient is brought into the operating room, when the correct patient’s information is mixed up with another patient’s information, or scheduling errors, such as the wrong procedure name input in the electronic medical record (EMR) system. It is crucial that this is one of the first steps in the surgical time-out that must be addressed, otherwise the system will not let the surgical team proceed. All of this can be completed with a voice integrated system in which anyone on the surgical team can communicate and confirm. It can be used to verify the correct patient information against other sources, such as EMR or pre-admission testing data. By cross-referencing this information, the algorithm can identify any discrepancies and alert the surgical team to resolve them. In addition, if a certain combination of patient demographics (age, gender, and medical history) is consistently associated with a higher risk of surgical errors, the algorithm can flag this information and alert the surgical team to double-check the patient’s identity. 

After patient identification in the surgical time-out is complete, the next step would be confirming the correct procedure and correct roles of the team. Another source of surgical errors is when the surgical team misinterprets the surgical plan or when the patient’s medical history is not fully understood. This new time-out system can be used to address any possible concerns and have the team be in agreement before proceeding. The algorithm can give feedback if the confirmed procedure is consistently associated with a higher risk of errors. It can then flag the procedure and suggest alternative options or additional precautions to be taken. It can be used to analyze the patient’s medical history and identify any potential risks or complications that may arise during the surgery. Once confirmed, the time-out can once again proceed.

The next part of the time-out system would be addressing equipment. Another cause of surgical errors is the use of incorrect or faulty equipment and supplies. This can occur when the wrong equipment is brought into the operating room or when the equipment is not properly sterilized or checked for defects. The surgical team can communicate with the system to verify the correct equipment and supplies for a given surgery based on data from past surgeries and staff feedback. If a certain type of equipment is consistently associated with a higher risk of errors, the algorithm can flag this equipment and suggest alternative options. Additionally, the algorithm can be used to track the maintenance and sterilization of equipment to ensure that it is in good working order before being used in a surgery. By verifying the equipment and supplies before the surgery begins, the surgical team can prevent errors from occurring. Proper surgical instrument preparation has shown to reduce processing and reprocessing cost if there were checks completed beforehand, even up to a $28,000 reduction per year in one study5.


These are all vital steps that need to be completed within a surgical time-out and with the use of new technology, this process can be enhanced.  It will take what was discussed throughout the time-out and automatically integrate it to each hospital’s EMR, without the need for manual input. Now, there would be evidence that all the proper steps were taken beforehand and a place for reference if it were needed. When thinking about future application, the same concept can be used throughout the entire procedure, not just in the surgical time-out. It can be used for real-time monitoring of surgical progress. By employing machine learning algorithms, surgeons and their teams can better anticipate the length of any given procedure, resulting in more accurate scheduling and improved utilization of materials. The increased ability to forecast the operation duration has an added benefit of mitigating unforeseen contingencies due to unexpected length, ultimately leading to a more efficient use of time. One of the more significant advantages is the possibility to reduce the cost of an operation. Use of an operating room can cost $66-$200 per minute for a hospital. The actual procedure (incision opening to closure) will vary, but the algorithms can also monitor pre-incision and post-incision closure events, which can be a variable length with the patient still within an OR. Having an integrated system like this will have a compounding effect on proper and more efficient utilization of resources.

We have built a solution that is currently being tested, as a tool for the surgical team to evolve the surgical time-out in order to mitigate surgical errors and increase staff engagement, compliance, and adherence. In its current iteration, the system acts as an OR assistant, prompting the team to ensure that each step is followed. If there’s a deviation from the process, the team is alerted or in some cases, forced to restart the time out process. In parallel, the solution is recording all dialog end-to-end. In this way, it can analyze the data being collected and look for similarities in its existing data set. From there the solution can make suggestions on alternative ways of performing an associated task. This would, in effect, provide better patient care, and even reduce costs for health care entities. Medical standard practice can be augmented by the power of ever-changing technology. 


1. Haynes AB, Weiser TG, Berry WR, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009;360(5):491-499. doi:10.1056/NEJMsa0810119

2. Freundlich RE, Bulka CM, Wanderer JP, Rothman BS, Sandberg WS, Ehrenfeld JM. Prospective Investigation of the Operating Room Time-Out Process. Anesth Analg. 2020;130(3):725-729. doi:10.1213/ANE.0000000000004126

3. Kiefel K, Donsa K, Tiefenbacher P, et al. Feasibility and Design of an Electronic Surgical Safety Checklist in a Teaching Hospital: A User-Based Approach. Stud Health Technol Inform. 2018;248:270-277.

4. Mainthia R, Lockney T, Zotov A, et al. Novel use of electronic whiteboard in the operating room increases surgical team compliance with pre-incision safety practices. Surgery. 2012;151(5):660-666. doi:10.1016/j.surg.2011.12.005

5. Dyas AR, Lovell KM, Balentine CJ, et al. Reducing cost and improving operating room efficiency: examination of surgical instrument processing. J Surg Res. 2018;229:15-19. doi:10.1016/j.jss.2018.03.038

6. Pellegrini CA. Time-outs and their role in improving safety and quality in surgery. The Bulletin.,Wrong%20Site%2C%20Wrong%20Procedure%2C%20and. Published May 31, 2017.

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