To the outside observer, the process of carrying out a well-orchestrated operation, no matter how complex, can appear routine almost to the point of boredom. Well-trained members of the team do their jobs, and, with the possible exception of a few moments that are more tense or difficult than others, things go smoothly.

When a crisis erupts, a different set of procedures comes into play. Well-prepared teams usually deal with surgical crises in the operating room (OR) just as effectively. Nevertheless, such teams may be unavailable under certain circumstances, and even the best teams may not be well-drilled in how to handle every crisis.

To ensure that surgical teams are capable of effectively responding to emergency situations, the American College of Surgeons (ACS), through its membership on the Council on Surgical and Perioperative Safety (CSPS), is participating in a campaign to introduce and implement crisis checklists in the OR and perioperative arena.

The value of checklists

The use of checklists has migrated from the flight line to the operating room, but the surgical profession has only begun to appreciate the potential benefits and applications of this instrument. The purpose of checklists in the OR is to ensure that critical steps in preparing for and performing operations are taken and not left to memory. Situations most vulnerable to oversight are those that are, or are perceived to be, routine and those that arise during crises. Checklists provide a parachute.

Simulation laboratories have proliferated as a means of improving surgical training and as a way of testing and improving process in the OR. A number of simulation trials have tested the applicability and utility of crisis checklists. Clinicians who used them in simulated crises expressed a strong desire to have crisis checklists available, not just for training, but in the clinical setting. Initial implementation projects have been initiated at the Brigham and Women’s Hospital, Boston, MA; Stanford University, CA; and Cooper University Health System based in Camden, NJ.

The concept is hardly new. Educational programs, such as the Advanced Trauma Life Support® and Advanced Cardiac Life Support programs and the military Combat Casualty Care Course, have used checklists as an instructional expedient for many years.

The CSPS campaign

The CSPS, which the ACS was instrumental in establishing, has partnered with Ariadne Labs at the Harvard School of Public Health to launch and support a coordinated campaign to stimulate the availability and the implementation of crisis checklists. The CSPS is a unique collaborative of seven organizations representing health care professionals who are involved in perioperative care: the ACS, the American Association of Nurse Anesthetists, the American Association of Surgical Physician Assistants, the Association of PeriOperative Registered Nurses, the American Society of Anesthesiologists, the American Society of PeriAnesthesia Nurses, and the Association of Surgical Technologists. The combined membership exceeds 250,000, and the total number of individuals in the seven professions exceeds 2 million.

The CSPS intends to launch a campaign to inform its membership and the surgical community at large of the importance and effectiveness of crisis checklists and of strategies for introducing them into practice. Early experience points to the critical role of a local champion and a multidisciplinary implementation team dedicated to promoting checklist customization and adoption. Ideally, training in the use of crisis checklists would take place in a simulated operating room environment, with or without a formal simulation laboratory. Multidisciplinary staff involvement is an essential component, and so is recognition of local resources, needs, and circumstances.

The CSPS plans to expose all members of the perioperative team to the concept of crisis checklists through advocacy and education on a national level. The idea is to create a framework to implement a multidisciplinary, multi-institutional collaboration. A coordinated message from the seven organizations that comprise the CSPS will support efforts both nationally and locally.

The surgical community has the opportunity to lead in the development, adoption, and implementation of crisis checklists in collaboration with other professionals in the operating room and perioperative area. Checklists offer additional ways to improve patient care and surgical outcomes using a familiar tool. More information will be made available over the next few months.

Web resources for the implementation team are available at www.projectcheck.org and at http://emergencymanual.stanford.edu, or on the CSPS website at http://www.cspsteam.org.

Dr. Dagi is Distinguished Scholar and Professor, The School of Medicine, Dentistry Biomedical Sciences, Queen\'s University Belfast, Northern Ireland; and lecturer, department of global health and social medicine, Harvard Medical School, Boston, MA; Chair, ACS Committee on Perioperative Care; and member, CSPS Board of Directors.

Dr. Healy is Emeritus Gerald B. Healy Chair in Otolaryngology, Children\'s Hospital, Boston; professor of otology and laryngology, Harvard Medical School; ACS Past-President and Past-Chair of the Board of Regents; and member, CSPS Board of Directors.

ACS joins campaign to encourage use of surgical crisis checklists