Why Use Emergency Manuals: Evidence From Medicine
Alidina S, Goldhaber-Fiebert SN, Hannenberg AA, Hepner DL, Singer SJ, Neville
BA, Sachetta JR, Lipsitz SR, Berry WR. Factors associated with the use of
cognitive aids in operating room crises: a cross-sectional study of US hospitals
and ambulatory surgical centers. Implement Sci. 2018 Mar 26;13(1):50.
Babcock W. Resuscitation during Anesthesia. Anesth Analg 1924;3:208-13
Berkenstadt H, Ben-Menachem E, Dach R, Ezri T, Ziv A, Rubin O, Keidan I. Deficits in the provision of cardiopulmonary resuscitation during simulated obstetric crises: results from the Israeli board of anesthesiologists. Anesth Analg 2012;115(5):1122-6
Berry WR. Cardiac resuscitation in the operating room: reflections on how we can do better. Can J Anaesth 2012;59:522-6
Gaba DM. Human error in dynamic medical domains. In: Bogner MS, ed. Human Error in Medicine. Hillsdale, NJ: Lawrence Erlbaum Associates, Inc, 1995:197-224
Gaba DM. Human error in anesthesia mishaps. Int Anesthesiol Clin 1989;27(3):137
Ghaferi AA, Birkmeyer JD, Dimick JB. Complications, failure to rescue, and mortality with major inpatient surgery in Medicare patients. Ann Surg 2009;250:1029-34
Kurrek MM, Devitt JH, Cohen M. Cardiac arrest in the OR: how are our ACLS skills? Can J Anaesth 1998;45:130-2
Lipman SS, Daniels KI, Carvalho B, Arafeh J, Harney K, Puck A, Cohen SE, Druzin M. Deficits in the provision of cardiopulmonary resuscitation during simulated obstetric crises. Am J Obstet Gynecol 2010;203:179.e1-5
Semeraro F, Signore L, Cerchiari EL. Retention of CPR performance in anaesthetists. Resuscitation 2006;68:101-8
Smith KK, Gilcreast D, Pierce K. Evaluation of staff’s retention of ACLS and BLS skills. Resuscitation 2008;78:59-65
Stiegler MP, Neelankavil JP, Canales C, Dhillon A. Cognitive errors detected in anaesthesiology: a literature review and pilot study. Br J Anaesth 2012;108(2):229-35
Steigler MP, Ruskin KJ. Decision-making and safety in anesthesiology. Curr Opin Anaesthesiology 2012;25:724-9
Why use Emergency Manuals: Evidence from high-stakes industries, psychology, and human factors
Aviation
Aircraft Accident Report – United Airlines, Inc., McDonnell-Douglas DC-8-61, N8082U, Portland, Oregon, December 28, 1978. National Transportation Safety Board
Psychology and Human Factors
Committee on Quality of Healthcare in America. To Err Is Human: Building A Safer Health System. Vol. 6. Kohn LT, Corrigan J, Donaldson MS, eds.Washington, D.C.: National Academy Press, 2000
Kahneman D, Klein G. Conditions for intuitive expertise: a failure to disagree. Am Psychol 2009;64(6):515
Klein G. Naturalistic decision making. Hum Factors 2008;50(3):456-60
Orasanu J, Connolly T. The reinvention of decision making. In: Klein GA, Orasanu J, Calderwood R, Zsambok CE, eds. Decision Making in Action: Models and Methods. Norwood, NJ: Ablex Publishing Co, 1993:3-20
Tversky A, Kahneman D. Judgement under uncertainty: heuristics and biases. Science 1974;85(41257):1124-31
Theory
Driskell JE, Salas E, Johnston J. Does stress lead to a loss of team perspective? Group Dynamics: Theory, Research, and Practice1999;3:291
Checklists and Cognitive Aids From Non-Emergency Settings in Medicine
Abbett SK, Yokoe DS, Lipsitz SR, Bader AM, Berry WR, Tamplin EM, Gawande AA. Proposed Checklist of Hospital Interventions to Decrease the Incidence of Healthcare-associated Clostridium Difficile Infection. Infection Control and Hospital Epidemiology. 2009;30(11):1062-9
Berenholtz SM, Pronovost PJ, Lipsett PA, Hobson D, Earsing K, Farley JE, Milanovich S, Garrett-Mayer E, Winters BD, Rubin HR, Dorman T, Perl TM. Eliminating catheter-related bloodstream infections in the intensive care unit. Crit Care Med 2004;32(10):2014-20
Birkmeyer JD. Strategies for improving surgical quality–checklists and beyond. N Engl J Med 2010;363:1963-5
Bould MD, Hayter MA, Campbell DM, Chandra DB, Joo HS, Naik VN. Cognitive aid for neonatal resuscitation: a prospective single-blinded randomized controlled trial. Br J Anaesth 2009;103(4):570-5
Dellinger RP, Vincent JL. The surviving sepsis campaign sepsis change bundles and clinical practice. Crit Care 2005;9(6):653-4
Gawande A. The checklist manifesto: how to get things right. 1st ed. New York: Metropolitan Books
de Vries EN, Prins HA, Crolla RM, et al. Effect of a comprehensive surgical safety system on patient outcomes. N Engl J Med 2010;363:1928-37
Hales BM, Pronovost PJ. The checklist—a tool for error management and performance improvement. J Crit Care 2006;21(3):231-5
Hales B, Terblanche M, Fowler R, Sibbald W. Development of medical checklists for improved quality of patient care. Int J Qual Health Care 2008;20(1): 22-30
Haynes AB, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 2009;360:491-9
Mills PD, DeRosier JM, Neily J, McKnight SD, Weeks WB, Bagian JP. A cognitive aid for cardiac arrest: you can’t use it if you don’t know about it. Jt Comm J Qual Saf 2004;30(9):488-96
Neily J, Mills PD, Young-Xu Y, et al. Association between implementation of a medical team training program and surgical mortality. JAMA 2010;304:1693-700
Nelson KL, Shilkofski NA, Haggerty JA, Saliski M, Hunt EA. The use of cognitive AIDS during simulated pediatric cardiopulmonary arrests. Simul Healthc 2008;3(3):138-45
Semel ME, Resch S, Haynes AB, Funk LM, Bader A, Berry WR, Weiser TG, Gawande AA. Adopting A Surgical Safety Checklist Could Save Money And Improve The Quality of Care in US Hospitals. Health Affairs. 2010; 29(9): 1593-1599
Spector, J. M., Agrawal, P., Kodkany, B., Lipsitz, S., Lashoher, A., Dziekan, G., … & Gawande, A. (2012). Improving quality of care for maternal and newborn health: prospective pilot study of the WHO Safe Childbirth Checklist Program. PLoS One, 7(5), e35151
van Klei WA, Hoff RG, van Aarnhem EE, et al. Effects of the introduction of the WHO “Surgical Safety Checklist” on in-hospital mortality: a cohort study. Ann Surg 2012;255:44-9
Weiser, T. G., Haynes, A. B., Dziekan, G., Berry, W. R., Lipsitz, S. R., & Gawande, A. A. (2010). Effect of a 19-item surgical safety checklist during urgent operations in a global patient population. Annals of surgery, 251(5), 97
Checklists, Cognitive Aids, and Manuals in Operating Room Emergencies
Arriaga AF, Bader AM, Wong JM, Lipsitz SR, Berry WR, Ziewacz JE, Hepner DL, Boorman DJ, Pozner CN, Smink DS, Gawande AA. Simulation-Based Trial of Surgical-Crisis Checklists. New England Journal Of Medicine 2013;368:246-53
Augoustides, John G. T. MD, FASE, FAHA; Atkins, Joshua MD, PhD; Kofke, W. Andrew MD, MBA, FCCM. Much Ado About Checklists: Who Says I Need Them and Who Moved My Cheese?. Anesth Analg. 2013 November.
Burden AR, Carr ZJ, Staman GW, Littman JJ, Torjman MC. Does every code need a “reader?” improvement of rare event management with a cognitive aid “reader” during a simulated emergency: a pilot study. Simulation in Healthcare. 2012 Feb; 7: 1-9.
Clebone A, Burian BK, Watkins SC, Gálvez JA, Lockman JL, Heitmiller ES; Members of the Society for Pediatric Anesthesia Quality and Safety Committee (see Acknowledgments). The Development and Implementation of Cognitive Aids for Critical Events in Pediatric Anesthesia: The Society for Pediatric Anesthesia Critical Events Checklists. Anesth Analg. 2017 Mar;124(3):900-907.
Gaba DM, Fish KJ, Howard SK. Crisis management in anesthesiology. New York: Churchill Livingstone; 1994
Gaba DM. Perioperative cognitive AIDS in anesthesia: what, who, how, and why bother?. Anesth Analg. 2013 November.
Harrison TK, Manser T, Howard SK, Gaba DM. Use of cognitive aids in a simulated anesthetic crisis. Anesth Analg 2006;103:551-6
Goldhaber-Fiebert SN, Howard SK. Implementing Emergency Manuals: Can Cognitive Aids Help Translate Best Practices for Patient Care During Acute Events?.Anesth Analg. 2013 Oct [E-pub ahead of print]
Goldhaber-Fiebert S, Lei V, Jackson M, McCowan K. Simulation-based Team Training: Crisis Resource Management and the Use of Emergency Manuals in the OR. MedEdPORTAL Publications; 2014.
Goldhaber-Fiebert SN, Lei V, Bereknyei S, Nandagopal K. Perioperative Emergency Manuals in Clinical Clerkships: Curricula on “Why, How, and When to Use” for Teaching Medical Students. MedEdPORTAL Publications, 2015.
Goldhaber-Fiebert SN, Pollock J, Howard SK, Bereknyei Merrell S. Emergency Manual Uses During Actual Critical Events and Changes in Safety Culture From the Perspective of Anesthesia Residents: A Pilot Study. Anesth Analg. 2016 Sep;123(3):641-9.
Goldhaber-Fiebert SN, Lei V, Nandagopal K, Bereknyei S. Emergency Manual Implementation: Can Brief Simulation-Based OR Staff Trainings Increase Familiarity and Planned Clinical Use? Jt Comm J Qual Patient Saf. 2015(41):212–220.
Marshall, Stuart. The Use of Cognitive Aids During Emergencies in Anesthesia: A Review of the Literature. Anesthesia and Analgesia (2013).
McEvoy MD, Smalley JC, Field LC, Furse CM, Rieke H. Use of cognitive aids significantly increases retention of skill for management of cardiac arrest.Abstract. American Society of Anesthesiologists Annual Meeting 2010
Moitra VK, Gabrielli A, Maccioli GA, O’Connor MF. Anesthesia advanced circulatory life support. Can J Anesth 2012; 59: 586-603
Mulroy, Michael. Emergency Manuals: The Time Has Come. Anesthesia Patient Safety Foundation; June 2013.
Nanji KC, Cooper JB. It is time to use checklists for anesthesia emergencies: simulation is the vehicle for testing and learning. Reg Anesth Pain Med. 2012 Jan-Feb; 37: 1-2
Neal JM, Mulroy MF, Weinberg GL et al. American Society of Regional Anesthesia and Pain Medicine Checklist for Managing Local Anesthetic Stystemic Toxicity: 2012 Version. Reg Anesth Pain Med. 2012 Jan-Feb; 37: 16-8
Neal JM, Hsiung RL, Mulroy MF, Halpern BB, Dragnich AD, Slee AE. ASRA checklist improves trainee performance during a simulated episode of local anesthetic systemic toxicity. Reg Anesth Pain Med 2012;37(1):8-15
Neily J, DeRosier JM, Mills PD, Bishop MJ, Weeks WB, Bagian JT. Awareness and use of a cognitive aid for anesthesiology. Jt Comm J Qual Saf 2007;33(8):502-11
Podraza Stiegler, Marjorie and Sara Goldhaber-Fiebert. “Cognitive Errors and Cognitive Aids in Anesthesiology”. Patient Safety Newsletter. 77-5 May 2013: 10-12
Runciman WB, Webb RK, Klepper ID, Lee R, Williamson JA, Barker L. The Australian Incident Monitoring Study. Crisis management–validation of an algorithm by analysis of 2000 incident reports. Anaesth Intensive Care 1993;21:579-92
Runciman WB, Merry AF. Crises in clinical care: an approach to management. Qual Saf Health Care 2005;14:156-63
Ruskin, KJ. Checklists: Make Them Part of Your Emergency Plan. ASA Newsletter: Patient Safety. May 2014: 78(5): 20-21.
Stiegler MP, August DA. Cognitive Aids: Trending, Transformative, or Just Too Much? ASA Newsletter: Patient Safety. May 2014: 78(5): 16-18.
Tobin, J. M., et al. A Checklist for Trauma and Emergency Anesthesia. Anesthesia and analgesia. 2013.
Watkins SC, Anders S, Clebone A, Hughes E, Zeigler L, Patel V, Shi Y, Shotwell MS, McEvoy M, Weinger MB. Paper or plastic? Simulation based evaluation of two versions of a cognitive aid for managing pediatric peri-operative critical events by anesthesia trainees: evaluation of the society for pediatric anesthesia emergency checklist. J Clin Monit Comput. 2015 Jun 12.
Ziewacz JE, Arriaga AF, Bader AM, et al. Crisis checklists for the operating room: development and pilot testing. J Am Coll Surg 2011;213:212-7 e10
Clinical Guidelines for Emergencies
Neal JM, Mulroy MF, Weinberg GL et al. American Society of Regional Anesthesia and Pain Medicine Checklist for Managing Local Anesthetic Stystemic Toxicity: 2012 Version. Reg Anesth Pain Med. 2012 Jan-Feb; 37: 16-8
Neumar RW, Otto CW, Link MS, et al. Part 8: adult advanced cardiovascular life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2010;122:S729-67
Crew Resource Management, Team Training and Simulation-Based Training
Clancy CM, Tornberg DN. TeamSTEPPS: assuring optimal teamwork in clinical settings. Am J Med Qual 2007;22(3):214
Cooper JB. Are simulation and didactic crisis resource management (CRM) training synergistic? Qual Saf Health Care 2004;13:413-4
Dunn EJ, Mills PD, Neily J, Crittenden MD, Carmack AL, Bagian JP. Medical team training: applying crew resource management in the Veterans Health Administration. Jt Comm J Qual Patient Saf 2007;33(6):317-25
Everett TC, Morgan PJ, Brydges R, Kurrek M, Tregunno D, Cunningham L, Chan A, Forde D, Tarshis J. The impact of critical event checklists on medical management and teamwork during simulated crises in a surgical daycare facility. Anaesthesia. 2016 Nov 2.
Gaba DM, Howard SK, Fish KJ Smith BE, Sowb YA. Simulation-based training in anesthesia crisis resource management (ACRM): a decade of experience. Simulation & Gaming 2001;32(2):175-93
Hilton G, Daniels K, Goldhaber-Fiebert SN, Lipman S, Carvalho B, Butwick A. Checklists and multidisciplinary team performance during simulated obstetric hemorrhage. Int J Obstet Anesth. 2016 Feb;25:9-16.
Howard SK, Gaba DM, Fish KJ, Yang G, Sarnquist FH. Anesthesia crisis resource management training: teaching anesthesiologists to handle critical incidents. Aviat Space Environ Med 1992;63(9):763-70
Holzman RS, Cooper JB, Gaba DM, Philip JH, Small SD, Feinstein D. Anesthesia crisis resource management: real-life simulation training in operating room crises. J Clin Anesth 1995;7:675-87
McGaghie WC, Draycott TJ, Dunn WF, Lopez CM, Stefanidis D. Evaluating the impact of simulation on translational patient outcomes. Simul Healthc 2011;(6):S42-7
Moorthy K, Vincent C, Darzi A. Simulation based training. BMJ 2005;330:493-4
Tannenbaum SI, Goldhaber-Fiebert SN. Medical team debriefs: simple, powerful, underutilized In: Salas E, Frush K, eds. Improving Patient Safety Through Teamwork and Team Training. New York: Oxford University Press, 2012:249-53
Implementation
Catchpole K, Russ S. The problem with checklists. BMJ Qual Saf. 2015 Sep;24(9):545-9. Epub 2015 Jun 18.
Clay-Williams R, Colligan L. Back to basics: checklists in aviation and healthcare. BMJ Qual Saf. 2015 Jul;24(7):428-31. Epub 2015 May 12.
Conley DM, Singer SJ, Edmondson L, Berry WR, Gawande AA. Effective Surgical Safety Checklist Implementation. Journal of the American College of Surgeons. 2011; 212: 873-879
Heath C, Heath D. Switch: How To Change Things When Change Is Hard. New York: Random House, Inc., 2010