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More than a manual: Stanford's crisis checklist helps those working in the OR

emergency manualI hate forgetting things, so when I have a bit of information that I absolutely must remember, I write it down. Many people employ the same strategy, yet as my colleague Sara Wykes explains in this edition of Inside Stanford Medicine, medical professionals are often held to unrealistic standards where a list, such as mine, could be mistaken as a sign of weakness.

As David Gaba, MD, associate dean for immersive and simulation-based learning at Stanford, explains in the story, this faulty perception of medical manuals couldn't be further from the truth. "Many of us strive to emphasize to students, trainees and experienced clinicians that their use is actually a sign of strength and wisdom and that failing to use them is a sign of weakness and perhaps hubris,” said Gaba.

That's why a team of medical experts from the Stanford Anesthesia Cognitive Aid Group developed an emergency manual for use at Stanford hospitals and other medical facilities. From the story:

It covers protocols for 24 conditions and circumstances. Some, like how to deal with a patient's bradycardia (a slow and unstable heartbeat), will be familiar only to medical professionals. Others, like how to handle a hospital-wide power failure, address what to do first, and thereafter, in such circumstances.


The development group examined every aspect of the emergency manual, down to details whose importance might not seem immediately obvious, including the colors, typefaces, boldfacing of words, size of pages, binding and physical placement within a working space. Over and over, the implementation team tested the manual in simulation with a full medical team, refining elements based on feedback from its users.

This iterative process provided the Stanford team with critical information that helped them make their manual more effective in an emergency setting. "We learned from simulation testing that it is not enough just to put the manual in the OR... we need to train people to use it," said Sara Goldhaber-Fiebert, MD, lead author of an Anesthesia & Analgesia paper (subscription required) detailing the work.

"Just the act of training to use the manual promotes team building and communication, which is critical not just in emergencies, but all the time," agreed Bryan Bohman, MD, the former chief of staff at Stanford Hospital and an anesthesiologist who contributed to the implementation of the Stanford manual.

As Wykes outlines, tangible signs of success emerged after the Stanford team finished training medical professionals to use the manual:

OR nurses requested a second copy be hung near the nursing phone. Computer and anesthesia technicians wanted copies where they work to help them anticipate equipment that might be needed during specific emergencies.

"Having the manual is reassuring, especially when you're going through these catastrophic events... There's always a certain part of you that wonders, 'Have I thought of everything?" said second-year resident at Stanford Jason Johns.

The Stanford emergency manual can be downloaded for free here.

Holly MacCormick is a writing intern in the medical school’s Office of Communication & Public Affairs. She is a graduate student in ecology and evolutionary biology at University of California-Santa Cruz.

Previously: What health-care providers can learn from the nuclear industrySully Sullenberger talks about patient safety and A closer look at Stanford’s simulation technology
Photo by Norbert von der Groeben

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