Patient Safety Tip of the Week

August 16, 2011    Crisis Checklists for the OR



There are some emergency situations that are so rare that it is hard to prepare for them, yet your actions during such situations may determine life or death. Pilots prepare for such emergencies (for example, they all have to simulate an aerodynamic “stall” so they know what steps to immediately take to right the aircraft). And pilots have standard operating procedures in their myriad of manuals pertaining to a whole host of seldom-encountered emergency situations. Often those standard operating procedures use checklists so that the crew can rapidly go through all the steps required in such emergencies.


We’ve had some experience in setting up such checklists for contingencies in the OR. One example is for malignant hyperthermia, a relatively uncommon but potentially fatal condition that requires specific interventions. It is difficult for any anesthesiologist or OR team to know all the steps necessary in managing such patients (eg. identifying that this is likely malignant hyperthermia rather than a host of other conditions that might produce fever and tachycardia in the anesthetized patient, knowing where your “MH kit” is located, knowing what dosage of dantrolene to use, contacting the MH hotline, etc.). So putting those steps in a checklist can be very useful. Similarly, a checklist for what to do during a surgical fire is sometimes used but, frankly, surgical fires evolve so fast that you don’t have time to pull out a checklist.


Atul Gawande, well-known for his work on checklists (see our Patient Safety Tips of the Week for July 6, 2010 “Book Reviews: Pronovost and Gawande” and January 20, 2009 “The WHO Surgical Safety Checklist Delivers the Outcomes”) and his colleagues (Ziewacz 2011) have just developed a series of “crisis checklists” for 12 of the most frequently occurring operating room crises and tested their use in a high-fidelity surgical simulator. They had OR teams in the surgical simulator address 4 crisis situations with checklists and 4 without. In simulated crises without checklists, the teams’ failure rate to perform critical steps was 24%. When using checklist, the failure rate was only 4%. Surveys of the participating OR teams found that the crisis checklists were very well-received, usable, and likely to prepare the teams well for real crises.


The authors do acknowledge that good performance in simulation is no guarantee that outcomes will be good in real-life OR crises and that there are no definitive studies in aviation or nuclear power that demonstrate simulation exercises improve safety, though simulation is widely accepted.


The conditions for which this group developed crisis checklists do include the above mentioned malignant hyperthermia and surgical fires and also include air embolism, anaphylaxis, unstable bradycardia, unstable tachycardia, cardiac arrest (asystolic and VF/VT), failed airway, unexpected hemorrhage, hypotension and hypoxia.


The appendices to the article contain the actual checklists they developed and, for each “crisis” a list of the key processes and steps identified as being important.


This is a really good article. Even if you don’t have access to a surgical simulator, it would be well worth your while having your OR teams become familiar with these tools and run “drills” on each of these. Especially if you combine these with other team training programs, such as TeamSTEPPS™, your OR teams will likely be better prepared to handle these relatively rare but critical scenarios.




Ziewacz JE, Arriaga AF, Bader AM, Berry WR, et al. Crisis Checklis ts for the Operating Room: Development and Pilot Testing. J Am Coll Surg 2011; 213(2): 212-219















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