Simulation-based trial of surgical-crisis checklists

New England Journal of Medicine

Volumn 368, Issue 3, 2013, Pages 246-253

  Arriaga, Alexander F ^a   Bader, Angela M ^a   Wong, Judith M ^a   Lipsitz, Stuart R ^a   Berry, William R ^a   Ziewacz, John E ^a,b   Hepner, David L ^a   Boorman, Daniel J ^c   Pozner, Charles N ^a   Smink, Douglas S ^a   Gawande, Atul A ^a  

^a BRIGHAM AND WOMEN S HOSPITAL   (United States)

^b UNIVERSITY OF MICHIGAN HEALTH SYSTEM   (United States)

^c Boeing Commercial Aircraft Co   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

ARTICLE; CHECKLIST; CLINICAL STUDY; CONTROLLED STUDY; CRISIS CHECKLIST; FEASIBILITY STUDY; HUMAN; INTERRATER RELIABILITY; OPERATING ROOM; OPERATING ROOM PERSONNEL; OUTCOME ASSESSMENT; PARTICIPANT OBSERVATION; PHYSICIAN ATTITUDE; PRIORITY JOURNAL; PROCESS DEVELOPMENT; PROFESSIONAL COMPETENCE; PROFESSIONAL KNOWLEDGE; RISK REDUCTION; SCORING SYSTEM; TOTAL QUALITY MANAGEMENT;

EID: 84872461035     PISSN: 00284793     EISSN: 15334406     Source Type: Journal    
DOI: 10.1056/NEJMsa1204720     Document Type: Article

References (39)

1. Webb RK, Currie M, Morgan CA, et al. The Australian Incident Monitoring Study: an analysis of 2000 incident reports. Anaesth Intensive Care 1993;21:520-8.
2. Charuluxananan S, Punjasawadwong Y, Suraseranivongse S, et al. The Thai Anesthesia Incidents Study (THAI Study) of anesthetic outcomes: II. Anesthetic profiles and adverse events. J Med Assoc Thai 2005;88:Suppl 7:S14-S29.
3. Ghaferi AA, Birkmeyer JD, Dimick JB. Variation in hospital mortality associated with inpatient surgery. N Engl J Med 2009;361:1368-75.
4. Ghaferi AA, Birkmeyer JD, Dimick JB. Complications, failure to rescue, and mortality with major inpatient surgery in Medicare patients. Ann Surg 2009;250:1029-34.
5. Ghaferi AA, Osborne NH, Birkmeyer JD, Dimick JB. Hospital characteristics associated with failure to rescue from complications after pancreatectomy. J Am Coll Surg 2010;211:325-30.
6. Agency for Healthcare Research and Quality. Guide to patient safety indicators. Rockville, MD: AHRQ, 2003 (http://www.qualityindicators.ahrq.gov/ Downloads/Software/SAS/V21R2A/psi-guide-rev2.pdf).
7. Ghaferi AA, Birkmeyer JD, Dimick JB. Hospital volume and failure to rescue with high-risk surgery. Med Care 2011;49:1076-81.
8. Semeraro F, Signore L, Cerchiari EL. Retention of CPR performance in anaesthetists. Resuscitation 2006;68:101-8.
9. Kurrek MM, Devitt JH, Cohen M. Cardiac arrest in the OR: how are our ACLS skills? Can J Anaesth 1998;45:130-2.
10. Smith KK, Gilcreast D, Pierce K. Evaluation of staff's retention of ACLS and BLS skills. Resuscitation 2008;78:59-65.
11. Aircraft accident report: loss of thrust in both engines after encountering a flock of birds and subsequent ditching on the Hudson River. Washington, DC: National Transportation Safety Board, 2010 (http://www.ntsb.gov/ doclib/reports/2010/aar1003.pdf).
12. Gawande A. The checklist manifesto: how to get things right. New York: Metropolitan Books, 2010.
13. Haynes AB, Weiser TG, Berry WR, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 2009;360:491-9.
14. de Vries EN, Prins HA, Crolla RM, et al. Effect of a comprehensive surgical safety system on patient outcomes. N Engl J Med 2010;363:1928-37.
15. Neily J, Mills PD, Young-Xu Y, et al. Association between implementation of a medical team training program and surgical mortality. JAMA 2010;304:1693-700.
16. van Klei WA, Hoff RG, van Aarnhem EE, et al. Effects of the introduction of the WHO "Surgical Safety Checklist" on inhospital mortality: a cohort study. Ann Surg 2012;255:44-9.
17. Birkmeyer JD. Strategies for improving surgical quality - checklists and beyond. N Engl J Med 2010;363:1963-5.
18. Medicare and Medicaid programs: hospital outpatient prospective payment; ambulatory surgical center payment; hospital value-based purchasing program; physician self-referral; and patient notification requirements in provider agreements. Baltimore: Centers for Medicare and Medicaid Services (http://gpo.gov/fdsys/pkg/FR-2011-11-30/pdf/2011-28612.pdf).
19. Harrison TK, Manser T, Howard SK, Gaba DM. Use of cognitive aids in a simulated anesthetic crisis. Anesth Analg 2006;103:551-6.
20. Gaba DM, Fish KJ, Howard SK. Crisis management in anesthesiology. New York: Churchill Livingstone, 1994.
21. Malignant hyperthermia protocol poster. Sherburne, NY: Malignant Hyperthermia Association of the United States (http://medical.mhaus.org).
22. Runciman WB, Webb RK, Klepper ID, Lee R, Williamson JA, Barker L. The Australian Incident Monitoring Study: crisis management - validation of an algorithm by analysis of 2000 incident reports. Anaesth Intensive Care 1993;21:579-92.
23. Neumar RW, Otto CW, Link MS, et al. Part 8: adult advanced cardiovascular life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2010;122:Suppl 3: S729-S767. [Erratum, Circulation 2011;123(6):e236.]
24. Moitra VK, Gabrielli A, Maccioli GA, O'Connor MF. Anesthesia advanced circulatory life support. Can J Anaesth 2012;59:586-603.
25. Runciman WB, Merry AF. Crises in clinical care: an approach to management. Qual Saf Health Care 2005;14:156-63.
26. Ziewacz JE, Arriaga AF, Bader AM, et al. Crisis checklists for the operating room: development and pilot testing. J Am Coll Surg 2011;213(12):212.e10-217.e10. [Erratum, J Am Coll Surg 2012; 215:310.]
27. Aircraft accident report: United Airlines, Inc., McDonnell-Douglas DC-8-61, N8082U, Portland, Oregon, December 28, 1978. Washington, DC: National Transportation Safety Board, 1979 (http://libraryonline.erau.edu/online-full- text/ntsb/aircraft-accident-reports/AAR79-07.pdf).
28. Aircraft accident report: Northwest Airlines, Inc., McDonnell Douglas DC-9-82, N312RC, Detroit Metropolitan Wayne County Airport, Romulus, Michigan, August 16, 1987. Washington, DC: National Transportation Safety Board, 1988 (http://libraryonline.erau.edu/online-full-text/ntsb/aircraft-accident-reports/ AAR88-05.pdf).
29. Rosen MA, Salas E, Wilson KA, et al. Measuring team performance in simulation-based training: adopting best practices for healthcare. Simul Healthc 2008;3:33-41.
30. Holzman RS, Cooper JB, Gaba DM, Philip JH, Small SD, Feinstein D. Anesthesia crisis resource management: real-life simulation training in operating room crises. J Clin Anesth 1995;7:675-87.
31. Cooper JB. Are simulation and didactic crisis resource management (CRM) training synergistic? Qual Saf Health Care 2004;13:413-4.
32. Moorthy K, Vincent C, Darzi A. Simulation based training. BMJ 2005;330:493-4.
33. Chu L, Fuller AJ, Goldhaber-Fiebert S, Harrison TK. A visual guide to crisis management. Philadelphia: Lippincott Williams & Wilkins, 2011.
34. Gorovitz S, MacIntyre A. Toward a theory of medical fallibility. Hastings Cent Rep 1975;5:13-23.
35. Vincent C. Patient safety. Chichester, United Kingdom: Wiley-Blackwell, 2010.
36. Reason JT. Human error. Cambridge, United Kingdom: Cambridge University Press, 1990.
37. Babcock W. Resuscitation during anesthesia. Anesth Analg 1924;3:208-13.
38. Berry WR. Cardiac resuscitation in the operating room: reflections on how we can do better. Can J Anaesth 2012; 59:522-6. [Erratum, Can J Anaesth 2012; 59:821.]
39. Smith GC, Pell JP. Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised controlled trials. BMJ 2003;327:1459-61.