#  A Novel Cognition-based Guidance System to Improve Surgical Safety 

 



### Overview

Medical errors causing preventable adverse events are the third leading cause of death in the U.S. The role of human cognition in contributing to errors in complex healthcare environments is increasingly being recognized. Many studies have demonstrated a direct relationship between cognitive performance metrics and patient outcomes. Notwithstanding, the role of cognition in improving safety has not received enough attention. Cardiac surgical OR is a high-impact area to improve patient safety and save lives. High mental workload during complex cardiac surgery and associated reduction of spare attentional capacity is bound to have a detrimental effect on a team's ability to detect their own errors. In the proposed project, we will explore and evaluate novel approaches to using process and patient real-time data, and device status information dynamically and proactively to provide guidance forward from the current surgical state. The proposed Cognition-based Guidance System will be deployed intraoperatively. We believe that human errors in the cardiac OR can be reduced by supporting individual and team interactions via dynamically updated electronic guidance that are responsive to the details of the on-going process (i.e., context-aware), to the patient's current medical condition (i.e., patient-aware), and to cognitive workload demands on the participating clinicians (i.e., workload-aware).

### Funding

NIH Award Number: [R01HL126896-07](https://reporter.nih.gov/search/JIXJt3XL_EqOX8_YpV9S5Q/project-details/10893225), [R01HL126896-06](https://reporter.nih.gov/search/JIXJt3XL_EqOX8_YpV9S5Q/project-details/10893225)

### Collaborators

- Prof. Roger D. Dias, MD, PhD, MBA
- Dr. Ryan Harari, PhD
- Prof. George S. Avrunin, PhD
- Prof. Lori A. Clarke, PhD
- Prof. Leon J. Osterweil, PhD
- Prof. David Jensen, PhD
- Dr. Heather M. Conboy, PhD
- Dr. Julian M. Goldman, MD
- Dr. David Arney, PhD, MPH
- Prof. Steven J. Yule, PhD
- Dr. Lauren R. Kennedy-Metz, PhD

### Publications & Presentations

- Mishra, S., Dias, R. D., **Zenati, M. A.**, & Chaspari, T. (2024). [Acoustic Patterns of Interprofessional Communication and Quality of Teamwork in the Cardiac Operating Theatre](https://pmc.ncbi.nlm.nih.gov/articles/PMC11285017/). *The Hamlyn Symposium on Medical Robotics*.
- Dias, R. D., Harari, R. E., **Zenati, M. A.**, Rance, G., Srey, R., Chen, L., & Gombolay, M. (2024). [A Clinician-Centered Explainable Artificial Intelligence Framework for Decision Support in the Operating Theatre](https://pmc.ncbi.nlm.nih.gov/articles/PMC11285016/). *The Hamlyn Symposium on Medical Robotics*.
- Harari, R., Dias, R. D., Salas, E., Unhelkar, V., Chaspari, T., & **Zenati, M.** (2024). [Misalignment of Cognitive Processes within Cardiac Surgery Teams](https://pmc.ncbi.nlm.nih.gov/articles/PMC11287473/). *The Hamlyn Symposium on Medical Robotics*.
- Dias, R. D., Yule, S. J., Harari, R., & **Zenati, M. A.** (2024). [Exploring Intraoperative Cognitive Biases in Cardiac Surgery Teams](https://pmc.ncbi.nlm.nih.gov/articles/PMC11342855/). *Applied Human Factors and Ergonomics Conference*.
- Dias, R. D., Kennedy-Metz, L. R., Srey, R., Rance, G., Ebnali, M., Arney, D., Gombolay, M., & **Zenati, M. A.** (2023). [Using Digital Biomarkers for Objective Assessment of Perfusionists' Workload and Acute Stress During Cardiac Surgery](https://pmc.ncbi.nlm.nih.gov/articles/PMC10371197/). *10th International Work-Conference on Bioinformatics and Biomedical Engineering (IWBBIO 2023)*.
- Arney, D., Zhang, Y., Kennedy-Metz, L. R., Dias, R. D., Goldman, J. M., & **Zenati, M. A.** (2023). [An Open-Source, Interoperable Architecture for Generating Real-Time Surgical Team Cognitive Alerts from Heart-Rate Variability Monitoring](https://pmc.ncbi.nlm.nih.gov/articles/PMC10145698/). *Sensors*.
- **Zenati, M. A.**, Dias, R. D., & Kennedy-Metz, L. R. (2022). [Commentary: Nontechnical skills redux](https://pmc.ncbi.nlm.nih.gov/articles/PMC8387494/). The Journal of Thoracic and Cardiovascular Surgery.
- Kennedy-Metz, L. R., Arshanskiy, M., Keller, S., Arney, D., Dias, R. D., & **Zenati, M. A.** (2022). [Association Between Operating Room Noise and Team Cognitive Workload in Cardiac Surgery](https://pmc.ncbi.nlm.nih.gov/articles/PMC9382699/). *IEEE Conference on Cognitive and Computational Aspects of Situation Management (CogSIMA)*.
- Dias, R. D., Kennedy-Metz, L. R., Yule, S. J., Gombolay, M., & **Zenati, M. A.** (2022). [Assessing Team Situational Awareness in the Operating Room via Computer Vision](https://pmc.ncbi.nlm.nih.gov/articles/PMC9386571/). *IEEE Conference on Cognitive and Computational Aspects of Situation Management (CogSIMA)*.
- Ebnali, M., Kennedy-Metz, L. R., Conboy, H. M., Clarke, L. A., Osterweil, L. J., Avrunin, G., Miccile, C., Arshanskiy, M., Phillips, A., **Zenati, M. A.**, & Dias, R. D. (2022). [A Coding Framework for Usability Evaluation of Digital Health Technologies](https://pmc.ncbi.nlm.nih.gov/articles/PMC9413016/). *International Conference on Human-Computer Interaction*.
- Dias, R. D., **Zenati, M. A.**, Rance, G., Srey, R., Arney, D., Chen, L., Paleja, R., Kennedy-Metz, L. R., & Gombolay, M. (2022). [Using machine learning to predict perfusionists' critical decision-making during cardiac surgery](https://pmc.ncbi.nlm.nih.gov/articles/PMC9355042/). *Computer Methods in Biomechanics and Biomedical Engineering: Imaging & Visualization*.
- Abi-Jaoudé, J. G., Kennedy-Metz, L. R., Dias, R. D., Yule, S. J., & **Zenati, M. A.** (2022). [Measuring and Improving Emotional Intelligence in Surgery: A Systematic Review](https://pmc.ncbi.nlm.nih.gov/articles/PMC8683575/). *Annals of Surgery.*
- Kennedy-Metz, L. R., Barbeito, A., Dias, R. D., & **Zenati, M. A.** (2022). [Importance of high-performing teams in the cardiovascular intensive care unit](https://pmc.ncbi.nlm.nih.gov/articles/PMC8481338/). *The Journal of Thoracic and Cardiovascular Surgery.*
- Dias, R. D., **Zenati, M. A.**, Conboy, H. M., Clarke, L. A., Osterweil, L. J., Avrunin, G. S., & Yule, S. J. (2021). [Dissecting Cardiac Surgery: A Video-based Recall Protocol to Elucidate Team Cognitive Processes in the Operating Room](https://pmc.ncbi.nlm.nih.gov/articles/PMC7241253/). *Annals of Surgery*.
- Kennedy-Metz, L. R., Dias, R. D., & **Zenati, M. A.** (2021). [The Cognitive Relevance of a Formal Pre-incision Time-out in Surgery](https://pmc.ncbi.nlm.nih.gov/articles/PMC8528342/). *European Conference on Cognitive Ergonomics*.
- Kennedy-Metz, L. R., Dias, R. D., Stevens, R. H., Yule, S. J., & **Zenati, M. A.** (2021). [Analysis of Mirrored Psychophysiological Change of Cardiac Surgery Team Members During Open Surgery](https://pmc.ncbi.nlm.nih.gov/articles/PMC7904574/). *Journal of Surgical Education*.
- Seo, S., Kennedy-Metz, L. R., **Zenati, M. A.**, Shah, J. A., Dias, R. D., & Unhelkar, V. V. (2021). [Towards an AI Coach to Infer Team Mental Model Alignment in Healthcare](https://pmc.ncbi.nlm.nih.gov/articles/PMC8893011/). *IEEE Conference on Cognitive and Computational Aspects of Situation Management (CogSIMA)*.
- **Zenati, M. A.**, & Megighian, C. H. (2021). [Commentary: The need for emotional intelligence coaching in cardiothoracic surgery](https://pmc.ncbi.nlm.nih.gov/articles/PMC8547430/). *The Journal of Thoracic and Cardiovascular Surgery*.
- Kennedy-Metz, L. R., Mascagni, P., Torralba, A., Dias, R. D., Perona, P., Shah, J. A., Padoy, N., & **Zenati, M. A.** (2021). [Computer Vision in the Operating Room: Opportunities and Caveats](https://pmc.ncbi.nlm.nih.gov/articles/PMC7908934/). *IEEE Transactions on Medical Robotics and Bionics*.
- Kennedy-Metz, L. R., Dias, R. D., Srey, R., Rance, G. C., Conboy, H. M., Haime, M. E., Quin, J. A., Yule, S. J., & **Zenati, M. A.** (2021). [Analysis of Dynamic Changes in Cognitive Workload During Cardiac Surgery Perfusionists' Interactions with the Cardiopulmonary Bypass Pump](https://pmc.ncbi.nlm.nih.gov/articles/PMC8207176/). *Human Factors*.
- Kennedy-Metz, L. R., Bizzego, A., Dias, R. D., Furlanello, C., Esposito, G., & **Zenati, M. A.** (2020). [Feasibility of Healthcare Providers' Autonomic Activation Recognition in Real-Life Cardiac Surgery Using Noninvasive Sensors](https://pmc.ncbi.nlm.nih.gov/articles/PMC7923697/). *HCI International 2020 - Late Breaking Posters*.
- Kennedy-Metz, L. R., Dias, R. D., Srey, R., Rance, G. C., Furlanello, C., & **Zenati, M. A.** (2020). [Sensors for Continuous Monitoring of Surgeon's Cognitive Workload in the Cardiac Operating Room](https://pmc.ncbi.nlm.nih.gov/articles/PMC7699221/). *Sensors*.
- Conboy, H. M., Kennedy-Metz, L. R., Avrunin, G. S., Clarke, L. A., Osterweil, L. J., Dias, R. D., & **Zenati, M. A.** (2020). [Digital Cognitive Aids to Support Adaptation of Surgical Processes to COVID-19 Protective Policies](https://pmc.ncbi.nlm.nih.gov/articles/PMC8555746/). *IEEE Conference on Cognitive and Computational Aspects of Situation Management (CogSIMA)*.
- Kennedy-Metz, L. R., Wolfe, H. L., Dias, R. D., Yule, S. J., & **Zenati, M. A.** (2020). [Surgery Task Load Index in Cardiac Surgery: Measuring Cognitive Load Among Teams](https://pmc.ncbi.nlm.nih.gov/articles/PMC7744397/). *Surgical Innovation*.
- Dias, R. D., Shah, J. A., & **Zenati, M. A.** (2020). [Artificial intelligence in cardiothoracic surgery](https://pmc.ncbi.nlm.nih.gov/articles/PMC7959017/). *Minerva Cardioangiologica*.
- **Zenati, M. A.**, Kennedy-Metz, L., & Dias, R. D. (2020). [Cognitive Engineering to Improve Patient Safety and Outcomes in Cardiothoracic Surgery](https://pmc.ncbi.nlm.nih.gov/articles/PMC7060831/). *Seminars in Thoracic and Cardiovascular Surgery*.
- **Zenati, M. A.**, & Yule, S. J. (2020). [Commentary: Another Dutch treat](https://pmc.ncbi.nlm.nih.gov/articles/PMC7301962/). *The Journal of Thoracic and Cardiovascular Surgery*.
- Kennedy-Metz, L. R., Bizzego, A., Esposito, G., Dias, R. D., **Zenati, M. A.**, & Furlanello, C. (2020). [Autonomic Activity and Surgical Flow Disruptions in Healthcare Providers during Cardiac Surgery](https://pmc.ncbi.nlm.nih.gov/articles/PMC8329755/). *IEEE Conference on Cognitive and Computational Aspects of Situation Management (CogSIMA)*.
- **Zenati, M. A.**, Leissner, K. B., Zorca, S., Kennedy-Metz, L., Yule, S. J., & Dias, R. D. (2019). [First Reported Use of Team Cognitive Workload for Root Cause Analysis in Cardiac Surgery](https://pmc.ncbi.nlm.nih.gov/articles/PMC6584063/). *Seminars in Thoracic and Cardiovascular Surgery*.
- Dias, R. D., **Zenati, M. A.**, Stevens, R., Gabany, J. M., & Yule, S. J. (2019). [Physiological synchronization and entropy as measures of team cognitive load](https://pmc.ncbi.nlm.nih.gov/articles/PMC7226673/). *Journal of Biomedical Informatics*.
- Rance, G., Arney, D., Srey, R., Goldman, J. M., & **Zenati, M. A.** (2019). [Establishing a Ventilator-Heart Lung Machine Communication Bridge to Mitigate Errors when Weaning from Bypass](https://pmc.ncbi.nlm.nih.gov/articles/PMC6436169/). *The Journal of Extra-Corporeal Technology*.
- Srey, R., Rance, G., Shapeton, A. D., Leissner, K. B., & **Zenati, M. A.** (2019). [A Quick Reference Tool for Goal-Directed Perfusion in Cardiac Surgery](https://pmc.ncbi.nlm.nih.gov/articles/PMC6749167/). *The Journal of Extra-Corporeal Technology*.
- **Zenati, M. A.**, & Scarinci, A. (2018). [Cutting off the lizard's tail in surgery](https://pmc.ncbi.nlm.nih.gov/articles/PMC6100786/). *The Journal of Thoracic and Cardiovascular Surgery*.
- Dias, R. D., Conboy, H. M., Gabany, J. M., Clarke, L. A., Osterweil, L. J., Arney, D., Goldman, J. M., Riccardi, G., Avrunin, G. S., Yule, S. J., & **Zenati, M. A.** (2018). [Intelligent Interruption Management System to Enhance Safety and Performance in Complex Surgical and Robotic Procedures](https://pmc.ncbi.nlm.nih.gov/articles/PMC6267949/). *International Workshop on Computer-Assisted and Robotic Endoscopy*.
- Dias, R. D., Conboy, H. M., Gabany, J. M., Clarke, L. A., Osterweil, L. J., Avrunin, G. S., Arney, D., Goldman, J. M., Riccardi, G., Yule, S. J., & **Zenati, M. A.** (2018). [Development of an Interactive Dashboard to Analyze Cognitive Workload of Surgical Teams During Complex Procedural Care](https://pmc.ncbi.nlm.nih.gov/articles/PMC6289194/). *IEEE Conference on Cognitive and Computational Aspects of Situation Management (CogSIMA)*.
- Dias, R. D., Ngo-Howard, M. C., Boskovski, M. T., **Zenati, M. A.**, & Yule, S. J. (2018). [Systematic review of measurement tools to assess surgeons' intraoperative cognitive workload](https://pmc.ncbi.nlm.nih.gov/articles/PMC5878696/). *The British Journal of Surgery*.
- Avrunin, G. S., Christov, S. C., Clarke, L. A., Conboy, H. M., Osterweil, L. J., & **Zenati, M. A.** (2018). [Process Driven Guidance for Complex Surgical Procedures](https://pmc.ncbi.nlm.nih.gov/articles/PMC6371362/). *American Medical Informatics Association Annual Symposium*.
- Avrunin, G. S., Clarke, L. A., Conboy, H. M., Osterweil, L. J., Dias, R. D., Yule, S. J., Goldman, J. M., & **Zenati, M. A.** (2018). [Toward Improving Surgical Outcomes by Incorporating Cognitive Load Measurement into Process-Driven Guidance](https://pmc.ncbi.nlm.nih.gov/articles/PMC6103223/). *International Workshop on Software Engineering in Healthcare Systems (SEHS)*.
- Arney, D., Rance, G., Rithy, S., Goldman, J. M., & **Zenati, M. A.** (2018). [A Novel Interoperable Safety System for Improved Coordination and Communication in Cardiac Surgery](https://pmc.ncbi.nlm.nih.gov/articles/PMC6360335/). *International Workshop on Computer-Assisted and Robotic Endoscopy*.
- Tarola, C. L., Hirji, S., Yule, S. J., Gabany, J. M., Zenati, A., Dias, R. D., & **Zenati, M. A.** (2018). [Cognitive Support to Promote Shared Mental Models during Safety-Critical Situations in Cardiac Surgery (Late Breaking Report)](https://pmc.ncbi.nlm.nih.gov/articles/PMC6364745/). *IEEE Conference on Cognitive and Computational Aspects of Situation Management (CogSIGMA)*.
- Conboy, H. M., Avrunin, G. S., Clarke, L. A., Osterweil, L. J., Christov, S. C., Goldman, J. M., Yule, S. J., & **Zenati, M. A.** (2017). [Cognitive Support During High-Consequence Episodes of Care in Cardiovascular Surgery](https://pmc.ncbi.nlm.nih.gov/articles/PMC5526347/). *IEEE International Multi-Disciplinary Conference on Cognitive Methods in Situation Awareness and Decision Support (CogSIGMA)*.
- Tarola, C. L., Quin, J. A., Haime, M. E., Gabany, J. M., Taylor, K. B., Leissner, K. B., & **Zenati, M. A.** (2016). [Computer-Assisted Process Modeling to Enhance Intraoperative Safety in Cardiac Surgery](https://pmc.ncbi.nlm.nih.gov/articles/PMC5177530/). *JAMA Surgery*.



 



 

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