Checkmate in Crises?

Arriaga AF, Bader AM, Wong JM et al. Simulation-Based Trial of Surgical-Crisis Checklists. New England Journal of Medicine 2013; 368:246-253.

RHH Journal Club. May 30th, 2013. Dr John Whitaker

Full-text article (if available)

Does the use of crisis checklists in simulated healthcare emergencies improve management?


Operating theatre crises occur frequently in large hospitals, but are rare for individual clinicians and management can be difficult and complex. Other high risk industries use checklists in the management of such events. Use of crisis checklists in healthcare is relatively untested

Study Design

Simulation based, randomised, controlled trial to investigate whether crisis checklists significantly improve adherence to best practices when managing intraoperative emergencies. Participants from one academic hospital and two community hospitals near Boston, USA.


  • Population – 17 teams consisting of anaesthetic, nursing and (sometimes) surgical staff selected both by random selection and sign-up sheets.
  • Intervention/Comparison – Performed 6 (or 8) simulated scenarios. Different groups carried out the same scenarios, but assigned randomly to be with/without a checklist
  • Outcomes – Failure to adhere to key life-saving processes in each scenario. Participants also surveyed on their perceptions of the clinical usefulness and relevance of the checklists.
  • Analysis – Simulations recorded, and assessed by 3 different physicians, differences assessed by initially working in pairs until kappa score >0.9. Any differences in opinion escalated to expert review. 15% of data reviewed by an outside, blinded expert. Multivariate analysis to take into account the effects of institution, time of day, scenario order.


  • Randomised
  • Not blinded – Difficult to imagine how this would be practical
  • Efforts made to eliminate observational bias
  • Control group – Each scenario is performed by different groups, some with, some without checklists


  • 17 teams performed 106 scenarios
  • Without checklists 23% of steps missed. With checklists 6% missed. 75% reduction (P <0.001)
  • Agreement between assessors was high (κ > 0.92), and agreement with outside assessor was also good (κ=0.91). Only 1% of decisions were referred for expert review
  • No difference in results between centres, or when senior staff present
  • Every team performed better when checklists used
  • 97% of participants agreed that they would want the checklist used if they were the patient in the scenario


Intraoperative emergencies are similar in the UK vs. US and are predictable

Checklists are a simple, low cost, effective intervention and we already implement them to some extent


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