Journal of the American College of Surgeons
Volume 213, Issue 2 , Pages 212-217.e10 , August 2011

Crisis Checklists for the Operating Room: Development and Pilot Testing

  • John E. Ziewacz, MD, MPH

      Affiliations

    • Department of Health Policy and Management, Harvard School of Public Health, Boston, MA
    • Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA
    • Department of Neurosurgery, University of Michigan Health Systems, Ann Arbor, MI
  • ,
  • Alexander F. Arriaga, MD, MPH

      Affiliations

    • Department of Health Policy and Management, Harvard School of Public Health, Boston, MA
    • Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA
    • Department of Surgery, Brigham and Women's Hospital, Boston, MA
  • ,
  • Angela M. Bader, MD, MPH

      Affiliations

    • Department of Health Policy and Management, Harvard School of Public Health, Boston, MA
    • Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA
    • Department of Anesthesiology, Brigham and Women's Hospital, Boston, MA
  • ,
  • William R. Berry, MD, MPH, MPA

      Affiliations

    • Department of Health Policy and Management, Harvard School of Public Health, Boston, MA
    • Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA
  • ,
  • Lizabeth Edmondson, BA

      Affiliations

    • Department of Health Policy and Management, Harvard School of Public Health, Boston, MA
    • Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA
  • ,
  • Judith M. Wong, MD

      Affiliations

    • Department of Health Policy and Management, Harvard School of Public Health, Boston, MA
    • Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA
    • Department of Neurosurgery, Brigham and Women's Hospital, Boston, MA
  • ,
  • Stuart R. Lipsitz, ScD

      Affiliations

    • Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA
  • ,
  • David L. Hepner, MD

      Affiliations

    • Department of Anesthesiology, Brigham and Women's Hospital, Boston, MA
  • ,
  • Sarah Peyre, EDD

      Affiliations

    • STRATUS Center for Medical Simulation, Brigham and Women's Hospital, Boston, MA
  • ,
  • Steven Nelson, BA

      Affiliations

    • STRATUS Center for Medical Simulation, Brigham and Women's Hospital, Boston, MA
  • ,
  • Daniel J. Boorman, BS

      Affiliations

    • Boeing Aircraft Corporation, Seattle, WA
  • ,
  • Douglas S. Smink, MD, MPH, FACS

      Affiliations

    • Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA
    • Department of Surgery, Brigham and Women's Hospital, Boston, MA
    • STRATUS Center for Medical Simulation, Brigham and Women's Hospital, Boston, MA
  • ,
  • Stanley W. Ashley, MD, FACS

      Affiliations

    • Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA
    • Department of Surgery, Brigham and Women's Hospital, Boston, MA
  • ,
  • Atul A. Gawande, MD, MPH, FACS

      Affiliations

    • Department of Health Policy and Management, Harvard School of Public Health, Boston, MA
    • Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA
    • Department of Surgery, Brigham and Women's Hospital, Boston, MA
    • Corresponding Author InformationCorrespondence address: Atul Gawande, MD, MPH, Department of Surgery, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115

Received 14 March 2011 ,Revised 14 April 2011 ,Accepted 14 April 2011.

References 

  1. Webb RK, Currie M, Morgan CA, et al. The Australian Incident Monitoring Study: an analysis of 2000 incident reports. Anaesth Intens Care. 1993;21:520–528
  2. Charuluxananan S, Punjasawadwong Y, Suraseranivongse S, et al. The Thai anesthesia incidents study of anesthetic outcomes II (Anesthetic profiles and adverse events). J Med Assoc Thai. 2005;88(Suppl 7):S14–S29
  3. Weiser TG, Regenbogen SE, Thompson KD, et al. An estimation of the global volume of surgery: a modeling strategy based on available data. Lancet. 2008;372(9633):139–144
  4. Kurrek MM, Devitt JH, Cohen M. Cardiac arrest in the OR: how are our ACLS skills?. Can J Anaesth. 1998;45:130–132
  5. Semeraro F, Signore L, Cerchiari EL. Retention of CPR performance in anaesthetists. Resuscitation. 2006;68:101–108
  6. Lipman SS, Daniels KI, Carvalho B, et al. Deficits in the provision of cardiopulmonary resuscitation during simulated obstetric crises. Am J Obstet Gynecol. 2010;203:179.e1–179.e5
  7. Stross JK. Maintaining competency in advanced cardiac life support skills. JAMA. 1983;249:3339–3341
  8. 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;360:491–499
  9. de Vries EN, Prins HA, Crolla RM. Effect of a comprehensive surgical safety system on patient outcomes. N Engl J Med. 2010;363:1928–1937
  10. Neily J, Mills PD, Young-Xu Y, et al. Association between implementation of a medical team training program and surgical mortality. JAMA. 2010;304:1693–1700
  11. Birkmeyer JD. Strategies for improving surgical quality—checklists and beyond. N Engl J Med. 2010;363:1963–1965
  12. Karl RC. Aviation. J Gastrointestinal Surg. 2009;13:6–8
  13. Harrison TK, Manser T, Howard SK, Gaba DM. Use of cognitive aids in a simulated anesthetic crisis. Anesth Analg. 2006;103:551–556
  14. Runciman WB, Webb RK, Klepper ID, et al. Crisis management—validation of an algorithm by analysis of 2000 incident reports. Anesth Intens Care. 1993;21:579–592
  15. Runiciman WB, Kluger MT, Morris RW, et al. Crisis management during anesthesia: the development of an anaesthetic crisis management manual. Qual Saf Health Care. 2005;14:e1
  16. Gaba DM, Fish KJ, Howard SK. Crisis management in anesthesia. New York: Churchill Livingstone; 1994;
  17. Runciman WB, Merry AF. Crises in clinical care: an approach to management. Qual Saf Health Care. 2005;14:156–163
  18. Weiser TG, Haynes AB, Lashoher A, et al. Perspectives in quality: designing the WHO Surgical Safety Checklist. Int J Qual Health Care. 2010;22:365–370
  19. Smith KK, Gilcreast D, Pierce K. Evaluation of staff's retention of ACLS and BLS skills. Resuscitation. 2008;78:59–65
  20. Watterson L, Flanagan B, Donovan B, et al. Anaesthetic simulators: training for the broader health-care profession. Aust N Z J Surg. 2000;70:735–737
  21. Scott DJ, Cendan JC, Pugh CM, et al. The changing face of surgical education: simulation as the new paradigm. J Surg Res. 2008;147:189–193
  22. Moorthy K, Vincent C, Darzi A. Simulation based training. BMJ. 2005;330:493–494
  23. Vincent C. Patient safety. In: 2nd ed.. London: Elsevier; 2006;p. 341–367
  24. Byrne AJ, Jones JG. Responses to simulated anaesthetic emergencies by anaesthetists with different durations of clinical experience. Br J Anaest. 1997;78:553–556
  25. Reason J. Human error. Cambridge, UK: Cambridge University Press; 1990;
  26. Ruesseler M, Weinlich M, Muller MP, et al. Simulation training improves ability to manage medical emergencies. Emerg Med J. 2010;27:734–738
  27. Daniels K, Arafeh J, Clark A, et al. Prospective randomized trial of simulation versus didactic teaching for obstetrical emergencies. Simul Healthc. 2010;5:40–45
  28. Tofil NM, White ML, Grant M, et al. Severe contrast reaction emergencies: high-fidelity simulation training for radiology residents and technologists in a children's hospital. Acad Radiol. 2010;17:934–940
  29. Paskins Z, Kirkcaldy J, Allen M, et al. Design, validation and dissemination of an undergraduate assessment tool using SimMan® in simulated medical emergencies. Med Teach. 2010;32:e12–e17
  30. Siu LW, Boet S, Borges BC. High-fidelity simulation demonstrates the influence of anesthesiologists' age and years from residency on emergency cricothyroidotomy skills. Anesth Analg. 2010;111:955–960
  31. Murray DJ, Boulet JR, Avidan M, et al. Performance of residents and anesthesiologists in a simulation-based skill assessment. Anesthesiology. 2007;107:705–713
  32. Kim J, Neilipovitz D, Cardinal P, et al. A pilot study using high-fidelity simulation to formally evaluate performance in the resuscitation of critically ill patients: the University of Ottawa Critical Care Medicine, High-Fidelity Simulation, and Crisis Resource Management 1 Study. Crit Care Med. 2006;34:2167–2174
  33. Gaba DM, Howard SK, Flanagan B, et al. Assessment of clinical performance during simulated crises using both technical and behavioral ratings. Anesthesiology. 1998;89:8–18
  34. Moorthy K, Munz Y, Forrest D, et al. Surgical crisis management skills training and assessment: a simulation-based approach to enhancing operating room performance. Ann Surg. 2006;244:139–147
  35. Price JW, Price JR, Prat DD, et al. High-fidelity simulation in anesthesiology training: a survey of Canadian anesthesiology residents' simulator experience. Can J Anesth. 2010;57:134–142
  36. Undre S, Koutantji M, Sevdalis N, et al. Multidisciplinary crisis simulations: the way forward for training surgical teams. World J Surg. 2007;31:1843–1853
  37. Kurrek MM, Devitt JH. Simulated anaesthetic emergencies. Br J Anaest. 1997;79:689
  38. Holzman RS, Cooper JB, Gaba DM, et al. Anesthesia crisis resource management: real-life simulation training in operating room crises. J Clin Anesth. 1995;7:675–687
  39. In:  Kohn LT,  Corrigan JM,  Donaldson MS editor. To err is human: building a safer health system. Washington, DC: National Academies Press; 1999;
  40. Landrigan CP, Parry GJ, Bones CB, et al. Temporal trends in rates of patient harm resulting from medical care. N Engl J Med. 2010;363:2124–2134
  41. Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med. 2006;355:2725–2732

 Disclosure Information: Nothing to disclose.

 Supported by a grant from the Agency for Healthcare Research and Quality (AHRQ; 1R18 HS018537-01). It's contents are solely the responsibility of the authors and do not necessarily represent the official views of the AHRQ.

PII: S1072-7515(11)00343-7

doi: 10.1016/j.jamcollsurg.2011.04.031

Journal of the American College of Surgeons
Volume 213, Issue 2 , Pages 212-217.e10 , August 2011