Checklists: Make Them Part of Your Emergency Plan

< Back

May 2014 Volume 78 Number 5
Checklists: Make Them Part of Your Emergency Plan Keith J. Ruskin, M.D.

Anesthesiology is unique among medical specialties in that most anesthetics and surgical procedures are uneventful. When a critical event does happen, there is often little or no warning. Things happen quickly, and a previously routine procedure can rapidly become life-threatening; the initial response to a critical event may determine its outcome. Anesthesiologists must be ready to detect and manage unpredicted emergencies at any time. One interesting study found that early recognition and effective management of complications were as important to improving mortality as was avoiding complications during surgery altogether.1


Emergency readiness requires that the caregiver have the knowledge, skills and equipment necessary to resolve the problem, but it’s easy to forget critical items when things are not going well. The use of checklists and established procedures, long an accepted practice in aviation, can help us to quickly establish a diagnosis and begin treatment. Checklists may also offer unanticipated benefits: One hospital found that adequate staffing was maintained more often and reporting of critical events improved after the World Health Organization Surgical Safety Checklist was implemented.2 In fact, ambulatory surgical centers can receive an incentive payment from the Centers for Medicare & Medicaid Services if they use a checklist.


If a specific type of problem can be anticipated (for example, massive hemorrhage in a postpartum patient being brought to the O.R.), then a plan should be ready before the surgery begins. Everyone on the care team should be briefed on the critical events most likely to occur and the actions that will be taken during an emergency. For example, Washington University has developed a surgical safety checklist for lengthy robotic surgical procedures. This checklist is intended to be used several hours after the procedure has started and includes items such as rechecking the patient’s position and padding, identifying the cause of the prolonged operating time, assessing blood loss and vital signs, and verifying that all equipment is working properly.3 Although each institution is slightly different, checklists such as these can help to prevent complications.


What kinds of checklists are available for anesthesiologists? The Department of Anesthesiology at Stanford University has been working with a consortium of anesthesiologists to create a free emergency manual Tobin et al. have developed a checklist for trauma and emergency anesthesia that covers room preparation, induction, maintenance, resuscitation and postoperative management.4 The Society for Pediatric Anesthesia has also published a pediatric critical events checklist you can download from This checklist is also available as a free iPhone App; just search for “Pediatric Critical Events Checklist.” The Ariadne Lab has created a series of crisis checklists that were validated using simulations of critical events. They are available at


How effective are checklists? A study led by Atul Gawande concluded that using checklists led to a significant improvement in the management of O.R. crises.5 Checklists are only one part of an organized approach to training and clinical practice. When an emergency occurs, it’s important to call for help as quickly as possible. Delegate tasks as your personnel arrive. There should be one person who is clearly in charge and directs the others, but that person should ask for advice and help as needed. During that study of simulated emergencies, some steps were missed even though they were on the checklist. Using a checklist is a skill that requires training and regular practice.


Management of critical events in high-risk specialties such as anesthesiology requires a rapid, coordinated and correct response by a team of physicians, nurses and other health care providers. All team members should participate in team training as well as courses to improve crisis resource management and situational awareness skills. Checklists are an important part of any management strategy, so even the most highly trained anesthesiologists should use checklists when things go wrong.

Keith J. Ruskin, M.D. is Professor of Anesthesiology and Neurosurgery, Yale University School of Medicine, New Haven, Connecticut.


1. Ghaferi AA, Birkmeyer JD, Dimick JB. Variation in hospital mortality associated with inpatient surgery. N Engl J Med. 2009;361(14):1368-75.

2. Haugen AS, Søfteland E, Eide GE, Sevdalis N, Vincent CA, Nortvedt MW, et al. Impact of the World Health Organization’s Surgical Safety Checklist on safety culture in the operating theatre: a controlled intervention study. Br J Anaesth. 2013;110(5):807-15.

3. Song JB, Vemana G, Mobley JM, Bhayani SB. The second “time-out”: a surgical safety checklist for lengthy robotic surgeries. Patient Saf Surg. 2013;7(1):19.

4. Tobin JM, Grabinsky A, McCunn M, Pittet JF, Smith CE, Murray MJ, et al. A checklist for trauma and emergency anesthesia. Anesth Analg. 2013;117(5):1178-84.

5. Arriaga AF, Bader AM, Wong JM, Lipsitz SR, Berry WR, Ziewacz JE, et al. Simulation-based trial of surgical-crisis checklists. N Engl J Med. 2013;368(3):246-53.