Surgery: OR Crisis Checklists

Most Americans can expect to undergo seven operations during their lifetime, and there will be one surgery for every 25 individuals worldwide each year. Given how universal surgery has become, it is one of the most critical moments in people’s lives with the potential for significant impact on health and well-being. Despite advances in medical care, surgery still presents a significant risk of patient harm, much of which can be avoided when surgical teams follow proven patient safety practices to reduce errors. This is true both when the operation goes as planned as well as when unexpected events occur in the operating room (OR).

Crises in the OR, such as patient cardiac arrest or hemorrhage, are rare, but when they occur, they require a rapid, effective response from the surgical team to ensure a good outcome for the patient. Studies have shown that surgical teams are more likely to forget important steps when in an emergency or under stress. Despite this, these teams have historically had to rely on memory to get them through critical events, often leaving them unprepared to properly manage crises.

Cognitive aids, such as checklists and manuals, have long been used in high-risk industries like aviation, and tools like the WHO Surgical Safety Checklist have shown to be effective in reducing morbidity and mortality. The Ariadne Labs team used its experience in developing and modifying surgical safety checklists to create a tool that addresses unpredictable and dangerous events in the OR. With our partners, Ariadne Labs developed the Operating Room Crisis Checklists, a compendium of 12 checklists to guide surgical teams during unexpected, critical events in the OR.

Developing the OR Crisis Checklists

In 2011, a group of experts came together to determine the most critical events that could threaten patient safety during an operation and settled on 12 scenarios, including cardiac arrest, hemorrhage, and fire in the OR.

For each scenario, the group determined the necessary steps to appropriately manage the event, pulling from evidence-based practices and national clinical guidelines. Having the right information, though, was half of the challenge. The next step was to create a tool that is quickly intuitive and easy to use under stressful circumstances. For this, the team turned to information architecture and visual communication expert Chris Barnes to guide the process. An inventory of all the information to be included in the checklists was created, with each item then ranked in terms of importance.

Testing the OR Crisis Checklists

Given the relative infrequency of the events addressed by the OR Crisis Checklists, a live clinical trial to test the tool was not feasible. The study team needed to find an alternative option to study the tool’s effectiveness. Medical simulation centers offer a high-fidelity environment for structured observation of these unpredictable events in a research setting. Ariadne Labs recruited clinical teams from one academic medical center and two community hospitals in the Boston area. The teams were presented with a series of crisis events and assessed for whether they followed evidence-based practices to manage the events. In half of the randomly chosen events, the team was given the OR Crisis Checklists to use. In the other half, the teams worked from memory, as is the case typically.

When the checklists were not used, clinical teams completed only 77 percent of the proven lifesaving steps necessary in an emergency. When the teams used the crisis checklists, they closed the gap, completing nearly 100 percent of the lifesaving steps to effectively manage an OR emergency. The findings reflect a 75 percent reduction in missed steps.

The simulation participants noted that they liked using the tools, and nearly all participants said that they would want the checklists to be used by the surgical team if they were the patients. Overall, the study found that the checklists were not only effective in promoting evidence-based practices, but were also acceptable to the surgical teams. Read more about the study on the Research page and in the New England Journal of Medicine.

Implementation Toolkit for the OR Crisis Checklists

We collaborated with Stanford University to launch an online implementation toolkit Implementing Emergency Checklists website in October 2017. The new website reflects feedback from a survey of the 12,000 clinicians who have downloaded the OR Crisis Checklists and emergency manuals, cognitive aids for health care providers during critical OR events. The website provides the resources and tools health care leaders and clinical teams need to effectively integrate the OR Crisis Checklists into their practice.

Emergency Manuals Implementation Collaborative: We have also partnered with other organizations that share the goal of promoting the spread and use of cognitive aids like checklists. While Ariadne Labs was developing and testing the original OR Crisis Checklists in 2011, the Stanford Anesthesia Cognitive Aid Group launched the Stanford Perioperative Emergency Manual. This compilation of 23 protocols is designed for real-time clinical use, was tested in simulated crises, and was implemented with all Stanford operating personnel in 2012.

Ariadne Labs and Stanford then brought our complementary streams of work together, forming the Emergency Manual Implementation Collaborative (EMIC), now comprised of 309 members dedicated to the adoption and effective use of emergency manuals to enhance patient safety. This collaboration is the first to bring together the United States’ leading experts in surgery, anesthesiology, simulation training, patient safety, and surgical team communication. The initial focus is perioperative care, while sharing our lessons with other fields of health care. EMIC’s goals are to:

  • Provide a framework for clinicians and teams to train for, manage, debrief, and report critical events.
  • Embed the effective clinical use of emergency manuals into patient care.
  • Build a community to share tools, overcome barriers, and facilitate implementation.
  • Provide resources to improve care in dynamic fields of health care with high intrinsic hazard.