Background: Systematically observing clinical performance in the operating room (OR) to support patient safety initiatives faces numerous logistical and methodological challenges. These may be solved by new audio-video recording technologies like the OR Black Box, which is a tool similar to black boxes in aviation. This study aimed to identify barriers and enablers that may influence patients', clinicians' and senior leadership team members' support of the OR Black Box in order to guide its future implementation.

Methods: Patients, clinicians and senior leadership team members were recruited to participate in semistructured interviews informed by the theoretical domains framework (TDF) to identify factors relevant to planning OR Black Box implementation. Deidentified interview transcripts were analysed in duplicate following a TDF coding structure.

Results: Data saturation was achieved at 15 patients, 17 clinicians and 9 senior leadership team members. Seven domains were relevant for patients, nine for clinicians and four for senior leadership. Knowledge and Beliefs about consequences were barriers and enablers for all three groups. Memory, attention and decision processes and Social influences were enablers for both clinicians and senior leadership. Environmental context and resources, Emotion and Behavioural regulation were found to be barriers and enablers for both clinicians and patients. Social/professional role and identity and Reinforcement were enablers for patients only and Optimism and Intentions were barriers and enablers to clinicians.

Conclusions: While most stakeholders were supportive of the OR Black Box, we identified many key areas that need to be addressed during its implementation. It is critical to ensure all stakeholders have adequate and accurate information about the OR Black Box system and research goals, and that the OR Black Box is positioned as a patient safety initiative for learning from and improving practice.