Checklist improves crisis management

Surgical crisis simulations in three hospitals found that using a checklist rather than relying on memory alone leads to better adherence to critical processes of care. The study, published in the New England Journal of Medicine1, had teams randomly assigned to manage simulated crisis situations in the operating room with a checklist or without. The authors looked at whether the teams adhered to the standard process of care or not.

The members of the teams were randomly assigned to work together. There were 17 of them, participating in 106 simulated surgical-crisis scenarios. Participants included anesthesia staff (attending physicians, residents, and certified registered nurse anesthetists), operating-room nurses, surgical technologists, and a mock surgeon participant. Teams spent six hours in a high-fidelity simulated operating room. They were presented with crises such as air embolism, anaphylaxis, asystolic cardiac arrest, hemorrhage followed by ventricular fibrillation, malignant hyperthermia, unexplained hypotension and hypoxemia followed by unstable bradycardia, and unstable tachycardia.

Checklists resulted in more adherence to protocols. Among the results: in a situation with unstable tachycardia, teams using checklists promptly delivered synchronized cardioversion with all shocks synchronized. Those without did not have a single synchronized shock. In situations with unstable bradycardia, teams using checklists had prompt transcutaneous pacing, while those without had a greater than 10-minute delay in transcutaneous pacing because the setting selected by the provider was below the energy level needed to enable pacing. In cases of anaphylaxis, no checklist teams missed half the critical care processes, including never calling for help and insufficient fluid resuscitation. Without a checklist, it took more than a minute and a half to start chest compressions for patients with ventricular fibrillation, but teams with checklists were able to complete all seven critical care processes for malignant hyperthermia, including dantrolene administration, cooling, treatment of hyperkalemia, and discontinuation of volatile anesthetic agents.

Checklists include one for before anesthesia, one for before the first incision, and one for before the patient leaves the OR, and can be viewed at


1. Arriaga AF, Bader AM, Waong JM et al. Simulation-based trial of surgical-crisis checklists. N Engl J Med 2013; 368:246-253.