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What’s New in the Patient Safety World

March 2021

Medical Crisis Checklists in the ED



Our regular readers know we are big fans of checklists for multiple problems and in multiple venues (see list of our prior columns on checklists below). A special type of checklist is one intended for use in crisis situations. Checklists for crises were, of course, pioneered in aviation, where pilots and crew members need to take immediate action to avert disasters. Doing the wrong thing or missing critical steps in such crises can be catastrophic, so having a checklist to guide one’s responses is important.


“Crisis” checklists have been shown to be helpful in dealing with crises in the OR (February 2013 What's New in the Patient Safety World column “Checklists for Surgical Crises”). So why not use them in other venues in healthcare where crises occur and require prompt interventions? How about the emergency department?


Dryver and colleagues used simulated environments to test crisis checklists for events often seen in emergency departments (Dryver 2021). They looked at eight crises often seen in the ED (anaphylactic shock, life-threatening asthma exacerbation, hemorrhagic shock from upper gastrointestinal bleeding, septic shock, calcium channel blocker poisoning, tricyclic antidepressant poisoning, status epilepticus, increased intracranial pressure). They then did simulations, once with access to a crisis checklist and once without access. They were only simulated cases. But the lessons learned are helpful.


They found that the median percentage of interventions performed was 38.8% without checklist access and 85.7% with checklist access. The benefit of checklist access was similar in the four EDs and independent of senior physician and senior nurse experience, type of crisis and use of usual cognitive aids. Moreover, there was no evidence that use of the checklists led to any delays in the initial performance of emergency measures.


Most participants reported that they would use the checklists if they had a similar case in reality. Most participants gave a score of 5 or 6 (on a Likert scale of 1–6) to the statement ‘I would use the checklist if I got a similar case in reality’.


Our August 16, 2011 Patient Safety Tip of the Week “Crisis Checklists for the OR” highlighted the work done by Atul Gawande and colleagues (Ziewacz 2011) on use of checklists for various crises that might be encountered in the OR. They had 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.


Gawande and colleagues (Arriaga 2013) later expanded on that experience and tested the crises checklists in multiple settings with multiple teams in simulated scenarios (see our February 2013 What's New in the Patient Safety World column “Checklists for Surgical Crises”). They had 17 teams in one academic and two community hospital settings participate in the scenarios, randomized to either using the checklists or dealing with the crises simply by memory. There were a total of 106 simulated crisis scenarios in all. They found that 6% of necessary steps were missed when the checklists were used, compared to 23% of steps missed when memory alone was used. That translates to a 75% improvement! Those numbers are similar to those found in their initial 2011 study. Virtually every team performed better when using the checklists. And 97% of respondents to a survey stated that they would want checklists used if they were a patient undergoing surgery.


The appendices to the 2011 article (Ziewacz 2011) contain the actual checklists they developed and, for each “crisis” a list of the key processes and steps identified as being important. The conditions for which this group developed crisis checklists include malignant hyperthermia, surgical fires, air embolism, anaphylaxis, unstable bradycardia, unstable tachycardia, cardiac arrest (asystolic and VF/VT), failed airway, unexpected hemorrhage, hypotension and hypoxia. And Ariadne Labs, an outgrowth of the Harvard and Stanford initiatives on crisis checklists, has many valuable resources and a toolkit to help you with implementation.


Hepner et al. also published an excellent review of operating room crisis checklists and emergency manuals (Hepner 2017).


Just et al. assessed the effectiveness of checklists for emergency procedures on medical staff performance in intensive care crises (Just 2015). Participants completed 4 crisis scenarios in a simulation setting, in which they were randomized to use checklists or to perform without any aid. In 2 of the scenarios, checklists could be used immediately (type 1 scenarios); and for the remaining, some further steps, for example, confirming diagnosis, were required first (type 2 scenarios). When using checklists, participants initiated items faster and more completely according to appropriate treatment guidelines (9 vs 7 items with and without checklists). Benefit of checklists was better in type 2 scenarios than in type 1 scenarios. In type 2 scenarios, time to complete 50% and 75% of items was faster with the use of checklists.


Subbe et al. (Subbe 2017) led a collaborative developing crisis checklists for rapid response teams to use for in-hospital emergencies. They began with a literature search that failed to identify any studies on crisis checklist outside the OR or ICU.  So, they developed their own crisis checklists and pilot tested them in a simulated setting. Iterations with feedback and retesting in the simulated environment resulted in a number of crisis checklists. Topics for checklists developed included gastrointestinal bleed, myocardial infarction, sepsis, acute kidney injury, fast atrial fibrillation, respiratory distress, “un-specifically unwell”, altered mental status, and objective signs of instability on National Early Warning Score (NEWS) level 3, NEWS level 5, NEWS level 7. They also developed several crisis checklists for the OR, including anaphylaxis. Airway, and advanced life support. When clinical teams were asked to assess their performance during patient management of common simulated emergencies they felt that the use of checklists improved their team work, communication, and overall performance.


You’re probably asking yourself “why are all these studies using simulation to evaluate use of checklists?”. Well, that’s because many of the conditions or situations for which they are intended are relatively infrequent, so it is unlikely that any single site will have enough cases to assess how the checklists facilitated care in actual cases.


We think it is well worth your while having your OR teams or ER teams or ICU 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 teams will likely be better prepared to handle these relatively rare but critical scenarios.



Some of our prior columns on checklists:

·       May 2019 “WHO Surgical Safety Checklist Cut Mortality 37% in Scotland”

·       July 16, 2019 “Avoiding PICC’s in CKD”

·       June 2020 “Are Two Checklists Better Than One?”







Dryver E, Lundager Forberg J, Hεrd af Segerstad C, et al. Medical crisis checklists in the emergency department: a simulation-based multi-institutional randomised controlled trial. BMJ Quality & Safety 2021; Published Online First: 17 February 2021



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



Arriaga AF, Bader AM, Wong JM, et al. Simulation-Based Trial of Surgical-Crisis Checklists. N Engl J Med 2013; 368: 246-253



Ariadne Labs. Surgery: OR Crisis Checklists.



Hepner DL, Arriaga AF, Cooper JB, et al. Operating Room Crisis Checklists and Emergency Manuals. Anesthesiology 2017; 127(2): 384-392



Just KS, Hubrich S, Schmidtke D, et al. The effectiveness of an intensive care quick reference checklist manual--a randomized simulation-based trial. J Crit Care 2015; 30: 255–260



Subbe CP, Kellett J, Barach P, et al. Crisis checklists for in-hospital emergencies: expert consensus, simulation testing and recommendations for a template determined by a multi-institutional and multi-disciplinary learning collaborative. BMC Health Serv Res 2017; 17: 334





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