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In both aviation and anesthesiology, some emergencies may develop abruptly, whereas others may evolve over time. Major anesthesia societies have adopted the use of checklists. The American Society of Regional Anesthesia and Pain Medicine published a practice advisory on local anesthetic systemic toxicity in , which included a checklist on the treatment of LAST.

A study using high-fidelity simulations of medical management tasks demonstrated that when the LAST checklist was utilized, there was better treatment, including proper ACLS protocol and more appropriate use of intralipid. Interestingly, there was higher knowledge retention 2 months later in the checklist group. This checklist has since been revised, illustrating that checklists are dynamic tools that require modification based both on local institutional differences and on temporal changes in clinical evidence. The Society for Pediatric Anesthesia SPA developed a cognitive aid for pediatric critical events that consists of 27 checklists.

Lack of familiarity with the format led to frustration with use. Anesthesia trainees preferred paper over an electronic version, because of concern regarding technology barriers. The authors concluded that more simulation-based training with the use of cognitive aids is needed to make them more usable, as suggested by the conceptual framework for emergency manuals implementation.

The Society for Obstetric Anesthesia and Perinatology developed a consensus statement on the management of cardiac arrest in pregnancy, which recommends that a checklist emphasizing key tasks be immediately available. In a simulation-based study of malignant hyperthermia and maternal cardiac arrest scenarios, the use of a checklist reader was more likely to lead to completion of all critical steps during an emergency than when no reader was utilized.

There has been little work investigating the best methods to incorporate crisis checklists and emergency manuals into everyday practice; many questions remain unanswered: 1 What is the optimal format for organizing them? From simulation-based trials, we believe that there is sufficient collective evidence to conclude that using a well-designed cognitive aid will lead to substantially fewer missed critical steps than would working from memory alone in crisis situations. Nonetheless, preparing for crises still requires training to attain competence in managing the event and effectively using a cognitive aid.

The first several steps in responding to an emergency may need to be done immediately, without the use of a cognitive aid. The next priorities are understanding effective checklist implementation and how best to use them in clinical practice.

Like many healthcare innovations, these tools will not implement themselves, nor jump off the walls during crises. Changing human behavior, particularly of entire groups and systems, is challenging. Four factors have been suggested as being important for successful implementation of emergency manuals: create or modify an existing tool , familiarize, use, and integrate. In contrast, the Expert Recommendations for Implementing Change group developed a detailed compilation of 73 specific implementation strategies, actively vetted in multiple rounds by an expert group of clinician implementers and implementation researchers.

Emergency Manuals Implementation Collaborative.

Management and Leadership: Improving Performance in Times of Crisis. A Practical Guide.

The implementation sciences promote the role of leadership buy-in. Leaders of multiple efforts to develop and implement cognitive aids formed the Emergency Manuals Implementation Collaborative EMIC to publicly share resources and further research on effectiveness and how best to implement and use emergency manuals. EMIC fosters the dissemination and effective use of emergency manuals to enhance patient safety with a primary focus on perioperative crises through shared principles throughout healthcare fields. The primary goals of EMIC are to encourage the use of emergency manuals in clinical practice and to build a community to share tools, overcome barriers, and facilitate implementation of emergency manuals.

Although there is no clear evidence at this point that one design is better than another, operating room providers should consider use of cognitive aids for emergencies in their clinical practice in preference to not using any tool. The results of local use should be monitored and be subject to a process of continuous improvement.


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Published resources for training include curricula and videos on why and how to use emergency manuals. Cognitive aids have been demonstrated to work to counter the effects of stress, ineffective teamwork, and inability to recall all evidence-based actions required for the optimal response in rare events.

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Our hope is that effective training and implementation strategies will lead to a perioperative culture that trains for and encourages appropriately using cognitive aids in conjunction with good teamwork and judgment and thus further reduces preventable perioperative adverse events. Despite the widespread dissemination of tools more than , downloads of Stanford, Ariadne, and SPA tools combined and multiple early-adopter implementing institutions, more research is needed to further assess the impact of implementation strategies and clinical use of emergency manuals.

The authors thank Lizzie Edmondson, B. The authors also thank Steven K. Howard, M. The authors declare no competing interests. National Transportation Safety Board: Crew neglected pre-flight check in crash that killed 7. Accessed October 8, Runway overrun during rejected takeoff. Accessed May 25, A nesthesiology ; 84 —75 [Article] [PubMed]. A nesthesiology ; 49 — [Article] [PubMed].

A nesthesiology ; 66 —6 [Article] [PubMed]. Reason, JT : Human Error. Anesth Analg ; —6 [Article] [PubMed]. Ann Surg ; —10 [Article] [PubMed].

Crisis Management and Communications (Updated September 2014)

A nesthesiology ; 89 :8—18 [Article] [PubMed]. Simulation Gaming ; 32 : —93 [Article]. National Transportation Safety Board: Aircraft accident report: Loss of thrust in both engines after encountering a flock of birds and subsequent ditching on the Hudson River. Accessed March 28, Gawande, A : The checklist manifesto: How to get things right. Babcock, WW : Resuscitation during anesthesia. Anesth Analg ; 6 — Circulation ; suppl 2 :S—64 [Article] [PubMed]. Anaesth Intensive Care ; 21 —92 [PubMed]. Accessed October 10, Resuscitation ; 78 —65 [Article] [PubMed].

Resuscitation ; 68 —8 [Article] [PubMed]. Resuscitation ; 85 —7 [Article] [PubMed]. Anesth Analg ; — [Article] [PubMed]. Ann Surg ; —41 [Article] [PubMed]. There is, however, enormous value in organizing proper training and development sessions for employees. Training allows employees to acquire new skills, sharpen existing ones, perform better, increase productivity and be better leaders.

Here are a few reasons that demonstrate the importance of training and development.

New Hire Orientation Training is particularly important for new employees. This can be conducted by someone within the company and should serve as a platform to get new employees up to speed with the processes of the company and address any skill gaps. Tackle shortcomings Every individual has some shortcomings and training and development helps employees iron them out.

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For example, at RateGain we have divided the entire headcount in several groups to provide focused training which is relevant to those groups - sales training, first time managers, middle management, senior leadership, executive leadership. Improvement in performance If shortcomings and weaknesses are addressed, it is obvious that an employee's performance improves.

Training and development, however, also goes on to amplify your strengths and acquire new skill sets. It is important for a company to break down the training and development needs to target relevant individuals. If I can draw examples from my organization, every department has targeted training groups. These generally revolve around product development training, QA training, PMP among others where internal and external process experts facilitate various programs.

Employee satisfaction A company that invests in training and development generally tends to have satisfied employees. However, the exercise has to be relevant to the employees and one from which they can learn and take back something. It will be futile if training and development become tedious and dull, and employees attend it merely because they have to.

As a company, we stress on industry specific training and send many employees for international seminars and conferences that can be beneficial to them.

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Increased productivity In a rapidly evolving landscape, productivity is not only dependent on employees, but also on the technology they use. Focus group interviews: Focus groups are particularly useful for providing qualitative data. We specifically used focus groups, firstly, to confirm our interpretation of the findings from the interviews and, secondly, to construct deeper meaning from the emerging findings.

To ensure anonymity, the different levels of employees were kept apart in the focus groups, and we did not share the original interpretations or words used during the interviews. Additional data sources: A number of additional sources were used, such as process documents detailing issues like tracking and correcting faults, strategies related to cost saving and efficiency, and time sheets. We were also taken on a tour of the facility. We took particular interest in flowcharts indicating the manufacturing processes, the use of buckets to measure waste at the end of shifts, and the large number — comparatively speaking — of female operators on the production line.

We also noted other tours being conducted.

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This data were captured as field notes. All the interviews and focus groups were recorded using two separate digital devices. Transcribed interviews: Interviews were transcribed. In order to accurately capture the perceptions, emotions, actions, and words of the interviewees and focus group participants, we used field notes to supplement the digital recordings Hahn, The field notes and voice recordings were used jointly in finalising the transcripts. We paid specific attention to capturing the full narrative of the recording during the transcription process, making additional annotations to reflect pertinent non-verbal communication such as emotions and facial expressions.

Insights recorded during the interviews and focus groups on the written notes were included in the transcripts. We attempted to accurately reflect, through the field notes, from both a descriptive and reflective point of view, the content of both the focus groups and the interviews. We kept these field notes in a transcript file. A personal log was completed directly after each interview or focus group, in order to assess and refine the data collected during the interviews.

Data analysis: We selected the process proposed by Merriam to complete the data analysis, namely category construction, sorting categories and data, naming the categories, and deciding on the number of categories Merriam, , pp. The process of constructing categories starts with studying the transcripts, field notes, and any other documentation associated with the interviews.

The research question acts as the backdrop against which initial observations are noted. The codes aim to highlight data that may have specific value beyond the mere description of the setting within which the data were obtained Lowe, Our open coding involved coding by sentence or paragraph, using interview transcripts. We used the open codes as the first step in constructing categories. Next, we reviewed the transcripts in order to identify common descriptions, and to group these together.

This grouping process can be referred to as axial coding. Strauss and Corbin explained axial coding as the process whereby data are connected in fresh ways, under created categories or subcategories. We repeated the process described above with all the sets of interview data, with the aim of identifying patterns and regularities, which became the overarching categories and themes within which items were logically grouped Merriam, , p. We allocated names to the categories that reflected the detail we saw in the data.