Why Use Emergency Manuals: Evidence from Medicine

Babcock W.
Resuscitation during Anesthesia.
Anesth Analg 1924;3:208-13

Berkenstadt H, Ben-Menachem E, Dach R, Ezri T, Ziv A, Rubin O, Keidan I.
Deficits in the provision of cardiopulmonary resuscitation during simulated obstetric crises: results from the Israeli board of anesthesiologists.
Anesth Analg 2012;115(5):1122-6

Berry WR.
Cardiac resuscitation in the operating room: reflections on how we can do better.
Can J Anaesth 2012;59:522-6

Gaba DM.
Human error in dynamic medical domains.
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Gaba DM.
Human error in anesthesia mishaps.
Int Anesthesiol Clin 1989;27(3):137

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

Hall, C., Robertson, D., Rolfe, M. et al. Do cognitive aids reduce error rates in resuscitation team performance? Trial of emergency medicine protocols in simulation training (TEMPIST) in Australia. Hum Resour Health 18, 1 (2020).

Kurrek MM, Devitt JH, Cohen M.
Cardiac arrest in the OR: how are our ACLS skills?
Can J Anaesth 1998;45:130-2

Lipman SS, Daniels KI, Carvalho B, Arafeh J, Harney K, Puck A, Cohen SE, Druzin M.
Deficits in the provision of cardiopulmonary resuscitation during simulated obstetric crises.
Am J Obstet Gynecol 2010;203:179.e1-5

Saxena S, Krombach JW, Nahrwold DA, Pirracchio R. Anaesthesia-specific checklists: A systematic review of impact. Anaesth Crit Care Pain Med. 2020 Feb;39(1):65-73. doi: 10.1016/j.accpm.2019.07.011. Epub 2019 Jul 30. PMID: 31374366.

Semeraro F, Signore L, Cerchiari EL.
Retention of CPR performance in anaesthetists.
Resuscitation 2006;68:101-8

Simmons WR, Huang J.
Operating Room Emergency Manuals Improve Patient Safety: A Systemic Review. Cureus 11(6): e4888. doi:10.7759/cureus.4888

Smith KK, Gilcreast D, Pierce K.
Evaluation of staff’s retention of ACLS and BLS skills.
Resuscitation 2008;78:59-65

Stiegler MP, Neelankavil JP, Canales C, Dhillon A.
Cognitive errors detected in anaesthesiology: a literature review and pilot study.
Br J Anaesth 2012;108(2):229-35

Steigler MP, Ruskin KJ.
Decision-making and safety in anesthesiology.
Curr Opin Anaesthesiology 2012;25:724-9

Urman RD, August DA, Chung S, Jiddou AH, Buckley C, Fields KG, Morrison JB, Palaganas JC, Raemer D. The effect of emergency manuals on team performance during two different simulated perioperative crises: A prospective, randomized controlled trial. J Clin Anesth. 2021 Feb;68:110080. doi: 10.1016/j.jclinane.2020.110080. Epub 2020 Oct 6. PMID: 33032123.

Why Use Emergency Manuals: Evidence from High-stakes Industries, Psychology, and Human Factors


Accident report: Loss of thrust in both engines after encountering a flock of birds and subsequent ditching on the Hudson River. National Transportation Safety Board. 2010

Aircraft Accident Report – United Airlines, Inc., McDonnell-Douglas DC-8-61, N8082U, Portland, Oregon, December 28, 1978. National Transportation Safety Board

Dismukes R, Berman B, Loukopoulos L.
The limits of expertise: Rethinking pilot error and the causes of airline accidents.
Aldershot, Hampshire, England: Ashgate, 2007.

Dismukes RK, Goldsmith TE, Kochan JA.
Effects of Acute Stress on Aircrew Performance: Literature Review and Analysis of Operational Aspects.
NASA Technical Memorandum TM-2015-218930.  Moffett Field, CA: NASA Ames Research Center, 2015.

Psychology and Human Factors

Committee on Quality of Healthcare in America.
To Err Is Human: Building A Safer Health System.
Vol. 6. Kohn LT, Corrigan J, Donaldson MS, eds.Washington, D.C.: National Academy Press, 2000

Kahneman D, Klein G.
Conditions for intuitive expertise: a failure to disagree.
Am Psychol 2009;64(6):515

Klein G.
Naturalistic decision making.
Hum Factors 2008;50(3):456-60

Reason J.
Combating omission errors through task analysis and good reminders.
Quality & safety in health care 2002;11(1):40-4.

Orasanu J, Connolly T.
The reinvention of decision making.
In: Klein GA, Orasanu J, Calderwood R,

Zsambok CE, eds.
Decision Making in Action: Models and Methods.
Norwood, NJ: Ablex Publishing Co, 1993:3-20

Tversky A, Kahneman D.
Judgement under uncertainty: heuristics and biases.
Science 1974;85(41257):1124-31


Driskell JE, Salas E, Johnston J.
Does stress lead to a loss of team perspective?
Group Dynamics: Theory, Research, and Practice 1999;3:291

Checklists and Cognitive Aids from Non-OR Settings in Medicine

Abbett SK, Yokoe DS, Lipsitz SR, Bader AM, Berry WR, Tamplin EM, Gawande AA.
Proposed Checklist of Hospital Interventions to Decrease the Incidence of Healthcare-associated Clostridium Difficile Infection.
Infection Control and Hospital Epidemiology. 2009;30(11):1062-9

Abir G, Austin N, Seligman KM, Burian BK, Goldhaber-Fiebert SN. Cognitive Aids in Obstetric Units: Design, Implementation, and Use. Anesth Analg. 2020 May;130(5):1341-1350. doi: 10.1213/ANE.0000000000004354. PMID: 31425259.

Berenholtz SM, Pronovost PJ, Lipsett PA, Hobson D, Earsing K, Farley JE, Milanovich S, Garrett-Mayer E, Winters BD, Rubin HR, Dorman T, Perl TM.
Eliminating catheter-related bloodstream infections in the intensive care unit.
Crit Care Med 2004;32(10):2014-20

Birkmeyer JD.
Strategies for improving surgical quality–checklists and beyond.
N Engl J Med 2010;363:1963-5

Bould MD, Hayter MA, Campbell DM, Chandra DB, Joo HS, Naik VN.
Cognitive aid for neonatal resuscitation: a prospective single-blinded randomized controlled trial.
Br J Anaesth 2009;103(4):570-5

Chen YKArriaga A

Clebone A, Burian BK, Polaner DM.
A timeout checklist for pediatric regional anesthetics.
Regional Anesthesia and Pain Medicine, 42(1), 105-108. 2017. doi: 10.1097/AAP.0000000000000509.

Combs CA,  Montgomery DM, Toner L, Dildy GA,
Society for Maternal-Fetal Medicine Special Statement: Checklist for initial management of amniotic fluid embolism, American Journal of Obstetrics and Gynecology, Volume 224, Issue 4, 2021, Pages B29-B32, ISSN 0002-9378,

Dellinger RP, Vincent JL.
The surviving sepsis campaign sepsis change bundles and clinical practice.
Crit Care 2005;9(6):653-4

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

Gawande A.
The checklist manifesto: how to get things right.
1st ed. New York: Metropolitan Books

Hales BM, Pronovost PJ.
The checklist—a tool for error management and performance improvement.
J Crit Care 2006;21(3):231-5

Hales B, Terblanche M, Fowler R, Sibbald W.
Development of medical checklists for improved quality of patient care.
Int J Qual Health Care 2008;20(1): 22-30

Haynes AB, et al.
A surgical safety checklist to reduce morbidity and mortality in a global population.
N Engl J Med 2009;360:491-9

Koers L, van Haperen M, Meijer CGF, van Wandelen SBE, Waller E, Dongelmans D, Boermeester MA, Hermanides J, Preckel B. Effect of Cognitive Aids on Adherence to Best Practice in the Treatment of Deteriorating Surgical Patients: A Randomized Clinical Trial in a Simulation Setting. JAMA Surg. 2020 Jan 1;155(1):e194704. doi: 10.1001/jamasurg.2019.4704. Epub 2020 Jan 15. PMID: 31774483; PMCID: PMC6902237.

Mills PD, DeRosier JM, Neily J, McKnight SD, Weeks WB, Bagian JP.
A cognitive aid for cardiac arrest: you can’t use it if you don’t know about it.
Jt Comm J Qual Saf 2004;30(9):488-96

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

Nelson KL, Shilkofski NA, Haggerty JA, Saliski M, Hunt EA.
The use of cognitive AIDS during simulated pediatric cardiopulmonary arrests.
Simul Healthc 2008;3(3):138-45

Semel ME, Resch S, Haynes AB, Funk LM, Bader A, Berry WR, Weiser TG, Gawande AA.
Adopting A Surgical Safety Checklist Could Save Money And Improve The Quality of Care in US Hospitals.
Health Affairs. 2010; 29(9): 1593-1599

Spector, J. M., Agrawal, P., Kodkany, B., Lipsitz, S., Lashoher, A., Dziekan, G., … & Gawande, A. (2012).
Improving quality of care for maternal and newborn health: prospective pilot study of the WHO Safe Childbirth Checklist Program.
PLoS One, 7(5), e35151

Staat B, Combs CA. Patient Safety and Quality Committee; Society for Maternal-Fetal Medicine.  SMFM Special Statement: Operative vaginal delivery: checklists for performance and documentation. Am J Obstet Gynecol. 2020 May;222(5):B15-B21. doi: 10.1016/j.ajog.2020.02.011. PMID: 32354409.

van Klei WA, Hoff RG, van Aarnhem EE, et al.
Effects of the introduction of the WHO “Surgical Safety Checklist” on in-hospital mortality: a cohort study.
Ann Surg 2012;255:44-9

Weiser, T. G., Haynes, A. B., Dziekan, G., Berry, W. R., Lipsitz, S. R., & Gawande, A. A. (2010).
Effect of a 19-item surgical safety checklist during urgent operations in a global patient population.
Annals of surgery, 251(5), 97

Checklists, Cognitive Aids, and Manuals in Operating Room Emergencies

Arriaga AF, Bader AM, Wong JM, Lipsitz SR, Berry WR, Ziewacz JE, Hepner DL, Boorman DJ, Pozner CN, Smink DS, Gawande AA. Simulation-Based Trial of Surgical-Crisis Checklists.
New England Journal Of Medicine 2013;368:246-53

Arsenis, Nicole; Paik, Hanna; Kitaev, Timur. Evaluating Perceived Barriers to Cognitive Aid Use Among Anesthesia Providers During Malignant Hyperthermia, Myocardial Ischemia, and Unanticipated Difficult Airway.
University of Southern California ProQuest Dissertations Publishing,  2021. 28002089.

Augoustides, John G. T. MD, FASE, FAHA; Atkins, Joshua MD, PhD; Kofke, W. Andrew MD, MBA, FCCM.
Much Ado About Checklists: Who Says I Need Them and Who Moved My Cheese?.
Anesth Analg 2013 November.

Burden AR, Carr ZJ, Staman GW, Littman JJ, Torjman MC.
Does every code need a “reader?” improvement of rare event management with a cognitive aid “reader” during a simulated emergency: a pilot study.
Simulation in Healthcare. 2012 Feb; 7: 1-9.

Clebone A, Burian BK, Watkins S, Galvez J, Lockman J, Heitmiller E and the Members of the Society for Pediatric Anesthesia Quality and Safety Committee.
The development and implementation of cognitive aids for critical events in pediatric anesthesia: The Society for Pediatric Anesthesia Critical Events Checklists.
Anesthesia and Analgesia 124(3), 900-907. 2017. doi: 10.1213/ANE.0000000000001746.

Cowan J, Hutton M, Owen A, Lam D, Bracco D, Hurdle H, Lohser J, Hirshberg J, Cory J, Chow L, McDonald S, Haber J. Cognitive Aids for the Management of Thoracic Anesthesia Emergencies: Consensus Guidelines on Behalf of a Canadian Thoracic Taskforce. J Cardiothorac Vasc Anesth. 2022 Aug;36(8 Pt A):2719-2726. doi: 10.1053/j.jvca.2021.10.032. Epub 2021 Oct 28. PMID: 34802832.

Gaba DM, Fish KJ, Howard SK.
Crisis management in anesthesiology.
New York: Churchill Livingstone; 1994

Gaba DM.
Perioperative cognitive AIDS in anesthesia: what, who, how, and why bother?.
Anesth Analg 2013 November.

Greig, P.R., Zolger, D., Onwochei, D.N., Thurley, N., Higham, H. and Desai, N. (2023), Cognitive aids in the management of clinical emergencies: a systematic review. Anaesthesia, 78: 343-355.

Hannenberg AA. Cognitive Aids in the Management of Critical Events. Anesthesiol Clin. 2020 Dec;38(4):789-800. doi: 10.1016/j.anclin.2020.08.002. Epub 2020 Oct 13. PMID: 33127028.

Harrison TK, Manser T, Howard SK, Gaba DM.
Use of cognitive aids in a simulated anesthetic crisis.
Anesth Analg 2006;103:551-6

Goldhaber-Fiebert SN, Howard SK.
Implementing Emergency Manuals: Can Cognitive Aids Help Translate Best Practices for Patient Care During Acute Events?.
Anesth Analg. 2013 Oct [E-pub ahead of print]

Goldhaber-Fiebert S, Lei V, Jackson M, McCowan K.
Simulation-based Team Training: Crisis Resource Management and the Use of Emergency Manuals in the OR.
MedEdPORTAL Publications 2014.

Goldhaber-Fiebert SN, Lei V, Bereknyei S, Nandagopal K.
Perioperative Emergency Manuals in Clinical Clerkships: Curricula on “Why, How, and When to Use” for Teaching Medical Students.
MedEdPORTAL Publications 2015.

Goldhaber-Fiebert SN, Lei V, Nandagopal K, Bereknyei S.
Emergency Manual Implementation: Can Brief Simulation-Based OR Staff Trainings Increase Familiarity and Planned Clinical Use?
Jt Comm J Qual Patient Saf. 2015(41):212–220.

Koca A, Abraham P, Cejka JC, Lilot M, Rimmelé T. Cognitive aids: What are we talking about? J Clin Anesth. 2021 Nov;74:110433. doi: 10.1016/j.jclinane.2021.110433. Epub 2021 Jun 26. PMID: 34182260.

Marshall, Stuart.
The Use of Cognitive Aids During Emergencies in Anesthesia: A Review of the Literature. Anesthesia and Analgesia (2013).

McEvoy MD, Smalley JC, Field LC, Furse CM, Rieke H.
Use of cognitive aids significantly increases retention of skill for management of cardiac arrest.
Abstract. American Society of Anesthesiologists Annual Meeting 2010

Moitra VK, Gabrielli A, Maccioli GA, O’Connor MF.
Anesthesia advanced circulatory life support.
Can J Anesth 2012; 59: 586-603

Mulroy, Michael.
Emergency Manuals: The Time Has Come.
Anesthesia Patient Safety Foundation; June 2013.

Nanji KC, Cooper JB.
It is time to use checklists for anesthesia emergencies: simulation is the vehicle for testing and learning. Reg Anesth Pain Med. 2012 Jan-Feb; 37: 1-2

Neal JM, Mulroy MF, Weinberg GL et al.
American Society of Regional Anesthesia and Pain Medicine Checklist for Managing Local Anesthetic Stystemic Toxicity: 2012 Version.
Reg Anesth Pain Med. 2012 Jan-Feb; 37: 16-8

Neal JM, Hsiung RL, Mulroy MF, Halpern BB, Dragnich AD, Slee AE.
ASRA checklist improves trainee performance during a simulated episode of local anesthetic systemic toxicity.
Reg Anesth Pain Med 2012;37(1):8-15

Neily J, DeRosier JM, Mills PD, Bishop MJ, Weeks WB, Bagian JT.
Awareness and use of a cognitive aid for anesthesiology.
Jt Comm J Qual Saf 2007;33(8):502-11

Podraza Stiegler, Marjorie and Sara Goldhaber-Fiebert.
Cognitive Errors and Cognitive Aids in Anesthesiology.
Patient Safety Newsletter 77-5 May 2013: 10-12

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

Runciman WB, Merry AF.
Crises in clinical care: an approach to management.
Qual Saf Health Care 2005;14:156-63

Ruskin, KJ.
Checklists: Make Them Part of Your Emergency Plan.
ASA Newsletter: Patient Safety May 2014: 78(5): 20-21.

Schild S, Sedlmayr B, Schumacher AK, Sedlmayr M, Prokosch HU, St Pierre M; German Cognitive Aid Working Group. A Digital Cognitive Aid for Anesthesia to Support Intraoperative Crisis Management: Results of the User-Centered Design Process. JMIR Mhealth Uhealth. 2019 Apr 29;7(4):e13226. doi: 10.2196/13226. PMID: 31033445; PMCID: PMC6658227.

Stiegler MP, August DA.
Cognitive Aids: Trending, Transformative, or Just Too Much?
ASA Newsletter: Patient Safety May 2014: 78(5): 16-18.

Tobin, J. M., et al.
A Checklist for Trauma and Emergency Anesthesia.
Anesthesia and Analgesia 2013.

Watkins SC, Anders S, Clebone A, Hughes E, Zeigler L, Patel V, Shi Y, Shotwell MS, McEvoy M, Weinger MB.
Paper or plastic? Simulation based evaluation of two versions of a cognitive aid for managing pediatric peri-operative critical events by anesthesia trainees: evaluation of the society for pediatric anesthesia emergency checklist.
J Clin Monit Comput 2015 Jun 12.

Ziewacz JE, Arriaga AF, Bader AM, et al.
Crisis checklists for the operating room: development and pilot testing.
J Am Coll Surg 2011;213:212-7 e10

Crew Resource Management, Team Training and Simulation-Based Training, Debriefing

Clancy CM, Tornberg DN.
TeamSTEPPS: assuring optimal teamwork in clinical settings.
Am J Med Qual 2007;22(3):214

Cooper JB.
Are simulation and didactic crisis resource management (CRM) training synergistic?
Qual Saf Health Care 2004;13:413-4

Dismukes RK, Gaba DM, Howard SK.
So many roads: facilitated debriefing in healthcare.
Simulation in Healthcare 1(2), 1-3. 2006.

Dunn EJ, Mills PD, Neily J, Crittenden MD, Carmack AL, Bagian JP.
Medical team training: applying crew resource management in the Veterans Health Administration.
Jt Comm J Qual Patient Saf 2007;33(6):317-25

Gaba DM, Howard SK, Fish KJ Smith BE, Sowb YA.
Simulation-based training in anesthesia crisis resource management (ACRM): a decade of experience.
Simulation & Gaming 2001;32(2):175-93

Howard SK, Gaba DM, Fish KJ, Yang G, Sarnquist FH.
Anesthesia crisis resource management training: teaching anesthesiologists to handle critical incidents.
Aviat Space Environ Med 1992;63(9):763­-70

Holzman RS, Cooper JB, Gaba DM, Philip JH, Small SD, Feinstein D.
Anesthesia crisis resource management: real-life simulation training in operating room crises.
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McGaghie WC, Draycott TJ, Dunn WF, Lopez CM, Stefanidis D.
Evaluating the impact of simulation on translational patient outcomes.
Simul Healthc 2011;(6):S42-7

Moorthy K, Vincent C, Darzi A.
Simulation based training.
BMJ 2005;330:493-4

Tannenbaum SI, Goldhaber-Fiebert SN.
Medical team debriefs: simple, powerful, underutilized In: Salas E, Frush K, eds. Improving Patient Safety Through Teamwork and Team Training.
New York: Oxford University Press, 2012:249-53


Alidina S, Goldhaber-Fiebert SN, Hannenberg AA, Hepner DL, Singer SJ, Neville BA, Sachetta JR, Lipsitz SR, Berry WR.
Factors associated with the use of cognitive aids in operating room crises: a cross-sectional study of US hospitals and ambulatory surgical centers.
Implementation Science. 2018 Mar 26;13(1):50.

Catchpole K, Russ S.
The problem with checklists.
BMJ Qual Saf. 2015 Sep;24(9):545-9. Epub 2015 Jun 18.

Clay-Williams R, Colligan L.
Back to basics: checklists in aviation and healthcare.
BMJ Qual Saf. 2015 Jul;24(7):428-31. Epub 2015 May 12.

Conley DM, Singer SJ, Edmondson L, Berry WR, Gawande AA.
Effective Surgical Safety Checklist Implementation.
Journal of the American College of Surgeons. 2011; 212: 873-879

Heath C, Heath D.
Switch: How To Change Things When Change Is Hard.
New York: Random House, Inc., 2010

Designing Checklists and Cognitive Aids

Burian, B. K. (2006).
Aeronautical emergency and abnormal checklists: Expectations and realities.
In Proceedings of the Human Factors and Ergonomics Society 50th Annual Meeting, San Francisco.

Burian, B. K. (2006).
Design guidance for emergency and abnormal checklists in aviation.
In Proceedings of the Human Factors and Ergonomics Society 50th Annual Meeting, San Francisco.

Burian BK, Clebone A, Dismukes RK, Ruskin K. (In press).
More than a tick box: Medical checklist development, design, and use.
Anesthesia and Analgesia.

Carim, G., Torrisi-Steele, G., Henriqson, E. (2022). Trapping Paper Checklists into Screens: How to Free the Resilience Capability of Digital Checklists for Emergency and Abnormal Situations. In: Matos, F., Selig, P.M., Henriqson, E. (eds) Resilience in a Digital Age. Contributions to Management Science. Springer, Cham.

Civil Aviation Authority (CAA) (2000)
Guidance on the design, presentation, and use of electronic checklists. CAP 708. Safety Regulation Group.
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Civil Aviation Authority (CAA) (2006)
Guidance on the design presentation and use of emergency and abnormal checklists. CAP 676.
Safety Regulation Group.
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Drews F.
Adherence Engineering: A New Approach to Increasing Adherence to Protocols.
Ergonomics in Design 2013;21:19-25.
Leadership E-Bulletin. A checklist for creating checklists.

McLaughlin A.
What makes a good checklist. AHRQ Patient Safety Network 2010.

AHRQ Patient Safety Network 2016.

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Weiser TG, Berry WR.
Review article: perioperative checklist methodologies.
Canadian journal of anaesthesia = Journal canadien d’anesthesie 2013;60(2):136-42.

Weiser TG, Haynes AB, Lashoher A, Dziekan G, Boorman DJ, Berry WR, Gawande AA.
Perspectives in quality: designing the WHO Surgical Safety Checklist.
International Journal for Quality in Health Care. 2010;22(5):365-370