Operating Room Crisis Checklists, Second Generation

The Doctors Company Foundation funds a project to update and expand a crisis checklist compendium that improves clinicians’ ability to rescue patients from complications and minimize harm.

Grantee Profile

Ariadne Labs is a joint center for health systems innovation at the Harvard T.H. Chan School of Public Health and Brigham & Women’s Hospital. Ariadne’s mission is to reduce suffering and improve healthcare delivery for every patient, everywhere, every time. The Safe Surgery/Safe Systems program at Ariadne develops solutions to equitably reduce surgical complications and improve the quality of care delivery with an emphasis on teamwork, communication, and adherence to best surgical practices.

The Challenge

The purpose of OR Crisis Checklists (ORCCs) is to improve clinicians’ capacity to rescue patients from complications and to minimize the resultant harm. When a crisis occurs, surgical teams have no time to waste. They must be prepared with the necessary tools and knowledge to respond quickly and safely. A key objective of the ORCC Second Generation project was to update, expand, digitize, and optimize the usability of Ariadne Labs’ 2011 crisis checklist compendium.

The format of the 2011 checklists limited end-users’ ability to modify the material to conform to local resources, practices, and standards. While we have always encouraged users to review and customize the content, modifying the 2011 checklists was very difficult for users without expertise in high-end graphic design software. We set out to convert the checklists to a format in which selected content could be readily edited without compromising the usability of the tools.

“Our goal is to spread these tools as widely as possible and get them into as many operating rooms as we can. Thankfully, crisis events occur rarely, but their management can consequently be intrinsically unfamiliar to teams. Add to that the recognized cognitive challenges of performing under stress, and the need for these tools becomes apparent. They are designed to ensure complete and coordinated care in critical events.”
Alex Hannenberg, MD, Principal Investigator­


  • Ariadne Labs’ Safe Surgery/Safe Systems program received a grant of $84,008 to optimize the usability of the crisis checklist compendium through local customization and digitization.
  • A checklist package of 12 critical events has evolved into the expanded and updated package of 17 critical events that are now available in both mobile-friendly online and printable versions. The online version includes an editing tool that allows for local customization. We also developed three new resources that guide users through the checklists’ customization, use, and implementation.
  • In 2011, the initial review team consisted of a handful of clinical experts. Twelve years later, the ORCC Second Generation project involved an international team of more than 40 physicians, pharmacists, and patient safety leaders focusing on the specific clinical events addressed by the checklists.
  • By enabling local customization, the checklists are ultimately more effective because they can be tailored to fit the context of a specific implementation.
  • We improved the scope and usability of the tool—which we hope will be demonstrated in increased uptake.
  • In providing an online version, we have also increased accessibility as the tool can be accessed anywhere, at any time, through any mobile or desktop device.

Sara Hyland, PharmD, BCCCP, perioperative clinical pharmacist, observed: “These checklists are the first step in empowering intraoperative clinicians to provide the best possible care during a crisis. Patients benefit when clinicians have what they need to immediately assess and respond to unanticipated complications in a safe and efficient manner.”

Goals Achieved

The checklists developed by a team at Ariadne Labs in 2011 have shown that in medical simulations, clinical teams using the ORCCs
demonstrated a 75 percent improvement in performance. These checklists anchor on teamwork, communication, and surgical best practices to help ensure that surgical teams are well equipped to handle crisis events as they occur.

The project to update and expand the ORCCs has resulted in a substantial increase in content and functionality, allowing users to choose from a menu of options to operationalize the checklists. The new webpage on the Ariadne Labs website has become a roadmap for the four use options to: (1) download the standard PDF version of all 17 checklists for printing or viewing on an electronic device with a PDF reader; (2) access the web-based version of the 17 standard-content checklists on any device, including smartphones and tablets; (3) use the web-based editing tool to make institution-specific updates to the compendium in a customized PDF document; or (4) download the website code to locally host a customized digital version. These newly developed user pathways map directly to the intended objectives of this project.

The ORCC Second Generation project drew on the expertise of an international review board of physicians, pharmacists, and patient safety leaders, a substantial advance toward a more robust and interdisciplinary team of reviewers than the 2011 compendium project. This multidisciplinary group of more than 40 leading experts contributed knowledge in critical events ranging from hemorrhage to cardiac arrest to ensure that the content in the new checklist compendium reflects the most up-to-date standards and protocols. A tool intended for use by a multidisciplinary OR team benefits from multidisciplinary review and contribution. Our panel of expert volunteer reviewers from multiple disciplines was instrumental in providing comprehensive reviews of the material—a necessary step to ensure patient safety during crises in the operating room.

Alex Arriaga, MD, MPH, ScD, a leading researcher on cognitive aids, noted: “Teamwork is a foundational hallmark of patient safety. The acute management of a medical crisis involves several disciplines, and the development of crisis checklists involves leveraging the knowledge of experts.”

Assessment/Takeaways/Next Steps

The team at Ariadne is eager to identify additional opportunities to support the continued improvement of the online version of the material. While the update accomplished the key objective of optimizing the checklists through customization, we have identified a way to further enhance the tools to allow users to customize and save a modified online version to a server (with help from the user’s local IT resources). This work on developing the revised OR checklist compendium has provoked consideration of the obstetrics-oriented Labor and Delivery Crisis Checklist—a similar project addressing high morbidity, low-frequency events that would also benefit from update, expansion, and digitization.

For Further Information

Here is an index of the 17 Operating Room Crisis Checklists:

SUSPECTED EVENT (alphabetical)
Air Embolism - Venous
Bradycardia - Unstable
Cardiac Arrest - Asystole/PEA
Cardiac Arrest - VF/VT
Delayed Emergence
Failed Airway
Local Anesthetic Systemic Toxicity (LAST)
Malignant Hyperthermia
Myocardial Ischemia
OB Hemorrhage
Tachycardia - Unstable
Transfusion Reaction