Fundamentals of Managing the Operative Catastrophe
Operative catastrophes are low-frequency events that require rapid and coordinated management under stressful conditions. Although these events may be rare at the individual provider level, they can be a common occurrence when viewed in aggregate in large medical centers. As the surgical volume worldwide continues to grow, it is of critical importance in surgical management that we turn our attention to mechanisms of preventing and addressing potentially catastrophic events, such as through the use of structured cognitive aids including crisis checklists and emergency manuals.
KeywordsOperative catastrophes Emergency manuals Crisis checklists Cognitive aids Crisis/crew resource management
This work is supported by grants from the University of Pennsylvania, McCabe Fund, and Bach Fund. The authors would like to thank Maryann Henry, CRNA, MS, and Carlene McLaughlin, CRNA, MSN, PhD, for their review of the work and their efforts to advance the principles of crisis management and patient safety. The views expressed in this article are those of the authors and do not necessarily represent the official views of supporting entities.
- Bhatti NI. Chapter 6: surgical management of the difficult adult airway. In: Flint PW, et al., editors. Cummings otolaryngology. 6th ed. Philadelphia: Elsevier Saunders; 2014.Google Scholar
- 1.Charuluxananan S, Suraseranivongse S, Jantorn P, Sriraj W, Chanchayanon T, Tanudsintum S, Kusumaphanyo C, Suratsunya T, Poajanasupawun S, Klanarong S, Pulnitiporn A. Multicentered study of model of anesthesia related adverse events in Thailand by incident report (The Thai anesthesia incidents monitoring study): results. J Med Assoc Thai. 2008;91(7):1011.PubMedGoogle Scholar
- 13.Operating Room Crisis Checklists. Ariadne Labs, Brigham and Women’s Hospital, and Harvard School of Public Health; 2013 (Revised July 2016). http://www.emergencymanuals.org/free-tools.html.
- 17.Apfelbaum JL, Hagberg CA, Caplan RA, Blitt CD, Connis RT, Nickinovich DG, Benumof JL, Berry FA, Bode RH, Cheney FW, Guidry OF. Practice guidelines for management of the difficult airway an updated report by the American society of anesthesiologists task force on management of the difficult airway. Anesth. 2013;118(2):251–70.CrossRefGoogle Scholar
- 19.Flint PW, Haughey BH, Robbins KT, Thomas JR, Niparko JK, Lund VJ, Lesperance MM. Cummings otolaryngology-head and neck surgery. Amsterdam: Elsevier Health Sciences; 2014.Google Scholar
- 22.Walls RM, Murphy MF, editors. Manual of emergency airway management. 4th ed. Philadelphia: Lippincott Williams & Wilkins; 2013.Google Scholar
- 25.Stanford Anesthesia Cognitive Aid Group.1 Emergency Manual: Cognitive aids for perioperative critical events. See http://emergencymanual.stanford.edu for latest version. Creative Commons BY-NC-ND. 2016 (Version 3) (http://creativecommons.org/licenses/by-nc-nd/3.0/legalcode).
- 29.Szabo A, August DA, Klainer S, Miller AD, Kaye AD, Raemer DB, Urman RD. The use of emergency manuals in perioperative crisis management: a cautious approach. J Med Pract Manage. 2014;30:8–12.Google Scholar