Operating Room 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
Testing the OR Crisis Checklists
Spreading the OR Crisis Checklists