Secondary Logo

Journal Logo

Editorials: Editorial

Much Ado About Checklists: Who Says I Need Them and Who Moved My Cheese?

Augoustides, John G. T. MD, FASE, FAHA; Atkins, Joshua MD, PhD; Kofke, W. Andrew MD, MBA, FCCM

Author Information
doi: 10.1213/ANE.0b013e31829e443a
  • Free

Medical errors and perioperative team dynamics have long been recognized as major determinants of outcomes in resuscitation for anesthetic emergencies.1,2 In 1924, Dr. Babcock1 published his observations in this journal concerning acute events in the operating room. In this classic article, Dr. Babcock asked the following questions 89 years ago: “Have you a plan of action so developed so that the right thing is always done in the emergency and time is not frittered away with useless or non-essential details?”; and, “Do you ever hold emergency drills in your operating room to see if you are constantly prepared for an instant resuscitation?” He proposed as solutions that emergency resuscitation protocols be not only rehearsed but also posted as reminders in a readily accessible fashion: “If a response is not instantly obtained by simple measures, a fixed emergency routine, posted on the walls of every operating room and drilled into every member of the staff, should be enforced. The details will vary somewhat with local conditions.”1

This visionary plea for cognitive aids and better translation of best practices in perioperative emergencies all those years ago largely failed to change perioperative culture until recently. In this issue of the journal, Drs. Goldhaber-Fiebert and Howard answer Dr. Babcock’s call with their Special Article discussing the role of cognitive aids for enhancing patient care during acute critical events in the perioperative period.3

Although there has been much ado about checklists recently, we as perioperative clinicians, comfortable in our complacency, may feel that all this fuss is unwarranted and respond as follows: “These lists are humbug—who says I need them?” This response is reminiscent of the characters Hem and Haw in the world-famous allegory “Who Moved my Cheese?: An Amazing Way to Deal with Change in Your Work and in your Life.”4 In this parable, the little people, Hem and Haw, live in a maze (representing the environment) and search for cheese (representing happiness and success). When the cheese supply runs out at station C, Hem is angry and demands, “Who moved my cheese?” while Haw begins a search for a new cheese supply. Haw finds new cheese, and, as a result of these experiences, develops a set of rules for himself that can be summarized as follows: Change happens—they keep moving the cheese; Anticipate change—get ready for the cheese to move; Monitor change—smell the cheese often so you know when it is getting old; Adapt to change quickly—the quicker you let go of old cheese, the sooner you can enjoy new cheese; Change—move with the cheese; Enjoy change—savor the adventure and enjoy the taste of new cheese!; Be ready to change quickly and enjoy it again—they keep moving the cheese.4 Drs. Goldhaber-Fiebert and Howard not only answer the prescient Dr. Babcock, but also tell us that we need these checklists and that we need to move with the cheese.

The call for checklists to guide emergency perioperative management has grown steadily since the publication of the 1999 report from the Institute of Medicine, titled “To Err is Human: Building a Safer Health System.”5 The 2001 report, “Making health care safer: a critical analysis of patient safety practices” that was commissioned by the Agency for Healthcare Research and Quality highlighted significant gaps in the evidence base for patient safety practices.6 In an effort to accelerate the adoption of patient safety strategies into clinical practice, a multicenter research group has recently highlighted the most important strategies for patient safety that are encouraged for rapid integration into clinical practice.7 Recommended interventions from this important document pertinent to the perioperative period include checklists, team training, and clinical simulation.7 The powerful synergy of these strategies was underlined in a recent multicenter trial, featuring 17 operating room teams in 106 simulated perioperative crises.8 This landmark trial demonstrated that checklists significantly improved team adherence to critical steps in the delivery of care (adjusted relative risk 0.28; 95% confidence interval, 0.18–0.42; P < 0.001).5 Interestingly, 97% of study participants preferred checklist-guided emergency care if they encountered an acute critical event during anesthesia.6

Where do we go from here? Given the overwhelming evidence and call for the integration of checklists into perioperative emergency protocols, the discussion now centers on translation of this concept into anesthetic practice. And, that is why this Special Article3 is so timely and important.

What are the vital components required for successful and pervasive implementation of cognitive aids to guide management in perioperative emergencies? The authors propose 4 key processes:

  1. Create the cognitive aid with a focus on clear content and effective design
  2. Familiarize teams with the cognitive aid in training exercises
  3. Use the cognitive aids that should be accessible in every anesthetizing location
  4. Integrate the cognitive aids into the perioperative culture of the institution. The checklists can be used in team preparation for emergencies (precrisis), for patient management in real emergencies (intracrisis), and for guiding improvements in delivery of care after resolution of the emergency (postcrisis). This Special Article discusses each of these elements in detail.

Drs. Goldhaber-Fiebert and Howard are members of the Stanford Anesthesia Cognitive Aid Group, which is also affiliated with the Stanford Anesthesia Informatics and Media Lab.9 These groups have posted examples of their cognitive aids on the CogAIDS Web site.9 These cognitive aids can be freely downloaded to assist in the teaching and management of perioperative emergencies.

The weight of the evidence, as summarized in this important article, suggests, however, that it is time to move the implementation of checklists beyond the simulation laboratory (T1 setting)3 into anesthetic practice (T2 and T3 settings)3 both for elective and emergency care. The cheese has moved, and it is time to enjoy the taste of the new offerings.

The content presented by this excellent article is very thought provoking. As the authors make clear, further trials are required to evaluate the elements of their proposed implementation framework, including its generalizability. More questions arise whose answers have yet to be realized. When do checklists become standard of care in delivery of emergency care? Is the failure to use a cognitive aid in an emergency clinically negligent? Who is responsible for developing effective cognitive aids to guide management of perioperative emergencies? Should the checklists be adapted to local conditions? Who “runs” the checklist protocol during a crisis?

There is also another consideration, namely the therapeutic dose of cognitive aids in perioperative practice. Based on this Special Article, it is likely that the current clinical dose is subtherapeutic in that clinical benefit will likely accrue from further integration of this concept into perioperative practice. Yes, we still have a way to travel before we find the new cheese and land in the sweet spot—the therapeutic window. But then, what about checklist toxicity? If this concept is pushed to the extreme, checklist apathy could develop, with deleterious consequences for patient care.

Further trials and clinical experience with these concepts should carefully define the best clinical dose of this strategy in the perioperative setting and assess various options to optimize checklist training, implementation, and clinician buy-in. The nurturing of effective dynamics and communication skills within clinical teams (“the clinical microsystem”) is the foundation for high-quality checklist implementation.10 Although the paradigms for this type of training are in their infancy, they have the potential to realize the dream of Dr. Babcock through successful diffusion, uptake, and integration of these innovations into our clinical culture.11,12

In summary, Drs. Goldhaber-Fiebert and Howard are to be congratulated for presenting the tools for translation of best practices in perioperative crisis management. It is likely that their paper will stimulate a greater awareness of cognitive aids for patient safety for the further enhancement of clinical care and patient research and education in the perioperative setting. The call to action by Dr. Babcock 89 years ago in this journal has fittingly been answered today in this journal so that all our patients may always benefit from “an efficient routine instantly available for resuscitation in every operating room.”1


Name: John G. T. Augoustides, MD, FASE, FAHA.

Contribution: The author helped write the manuscript.

Attestation: This author approved the final manuscript.

Name: Joshua Atkins, MD, PhD.

Contribution: The author helped write the manuscript.

Attestation: This author approved the final manuscript.

Name: W. Andrew Kofke, MD, MBA, FCCM.

Contribution: The author helped write the manuscript.

Attestation: This author approved the final manuscript.

This manuscript was handled by: Sorin J. Brull, MD, FCARCSI (Hon).


1. Babcock W. Resuscitation during anesthesia. Anesth Analg. 1924;3:208–13
2. Berry WR. Cardiac resuscitation in the operating room: reflections on how we can do better. Can J Anaesth. 2012;59:522–6
3. Goldhaber-Fiebert SN, Howard SK. Implementing emergency manuals: can cognitive aids help translate best practices during acute events? Anesth Analg. 2013;117:1149–61
4. Johnson S Who Moved My Cheese?: An Amazing Way to Deal with Change in Your Work and in Your Life. 1998 New York, NY Penguin Putnam
5. Institute of Medicine. To Err is Human: Building a Safer Health System. Available at: Accessed April 24, 2013
6. Shojania KG, Duncan BW, McDdonald KM, Wachter RM, Markowitz AJ. Making health care safer: a critical analysis of patient safety practices. Evid Rep Technol Assess (Summ). 2001:1–668
7. Shekelle PG, Pronovost PJ, Wachter RM, McDonald KM, Schoelles K, Dy SM, Shojania K, Reston JT, Adams AS, Angood PB, Bates DW, Bickman L, Carayon P, Donaldson L, Duan N, Farley DO, Greenhalgh T, Haughom JL, Lake E, Lilford R, Lohr KN, Meyer GS, Miller MR, Neuhauser DV, Ryan G, Saint S, Shortell SM, Stevens DP, Walshe K. The top patient safety strategies that can be encouraged for adoption now. Ann Intern Med. 2013;158:365–8
8. Arriaga AF, Bader AM, Wong JM, Lipsitz SR, Berry WR, Ziewacz JE, Hepner DL, Boorman DJ, Pozner CN, Smink DS, Gawande AA. Simulation-based trial of surgical-crisis checklists. N Engl J Med. 2013;368:246–53
9. Stanford Anesthesia Informatics and Media Lab. CogAIDS. Available at: Accessed April 25, 2013
10. Bohmer RMJ. Leading clinicians and clinicians leading. New Engl J Med. 2013;16:1468–70
11. Geibert RC. Using diffusion of innovation concepts to enhance implementation of an electronic health record to support evidence-based practice. Nurs Adm Q. 2006;30:203–10
12. Crow G. Diffusion of innovation: the leaders’ role in creating the organizational context for evidence-based practice. Nurs Adm Q. 2006;30:236–42
© 2013 International Anesthesia Research Society