How do you remember all critical steps in an emergency situation? 

Cognitive aids in everyday practice

We are all aware of the fact that not only is “To err is human”, but also “To forget is human”. This has been scientifically proven: after extensive training for Advanced Cardiac Life Support – part of the routine business of anesthesiologists – 100% of participants passed the following exam, but 6 months later, only 60% of anesthesiologists still passed the same exam successfully.

So, if we cannot remember essential steps of life-saving treatments in an exam situation, how can we rely on that knowledge in stressful emergencies with a high perceptual workload, where we must use all available cognitive capacity?

If we must work under pressure, Cognitive Aids are useful tools and part of the Crisis Resource Management Key Points. They can help us remember and consider essential treatment steps; they are an essential tool to further improve our work as experts in our field.

Cognitive Aids have frequently been proven to be helpful, not only in the operating room but also on the surgical ward.

(Effect of Cognitive Aids on Adherence to Best Practice in the Treatment of Deteriorating Surgical Patients: A Randomized Clinical Trial in a Simulation Setting. Koers L, van Haperen M, Meijer CGF, van Wandelen SBE, Waller E, Dongelmans D, Boermeester MA, Hermanides J, Preckel B. JAMA Surg. 2020 Jan 1;155(1):e194704. doi: 10.1001/jamasurg.2019.4704.)

So, why do we use a handwritten list for shopping on the weekend, but resist using cognitive aids in our daily clinical work?

Arguments include not being familiar with the tool, finding it distracting in a critical situation, disagreeing on the format of a specific tool, it being time-intensive to make a tool, and so on.

And yes, you need to make yourself familiar with the Cognitive Aid in your hospital, but this only takes a few minutes, time that you will most likely have during one of your next anaesthesia procedures. Remember, these Cognitive Aids do not cover the newest scientific findings; they summarise the knowledge we all should have about a given topic on one page. It’s about getting familiar with this patient safety tool!

And yes, using such a tool during an emergency situation can indeed distract you from other tasks. But you do not have to read it yourself; anyone in the room, e.g. a circulating surgical nurse or a student present in the operating room, can read it out loud. This has been proven to ensure that no essential steps are missed in an emergency situation.

And yes, there are different formats, and everyone might prefer a given layout. In the end, it does not matter which design the Cognitive Aids have; what matters is that they are available and used.

(A Comparative Analysis of the Impact of Two Different Cognitive Aid Bundle Designs on Adherence to Best Clinical Practice in Simulated Perioperative Emergencies. van Haperen M, Kemper TCPM, Koers L, van Wandelen SBE, Waller E, de Klerk ES, Eberl S, Hollmann MW, Preckel B. J Clin Med. 2024 Sep 5;13(17):5253. doi: 10.3390/jcm13175253.)

It’s good to know that numerous Cognitive Aids for emergency situations are already available, so it should not take much time to adopt one and align it with your local needs. In addition, fully electronic systems are available.

Thus, if you do not yet have Cognitive Aids in your hospital, it’s time to build and introduce them to further improve patient safety in our daily clinical work.

Author: Benedikt Preckel, Chair of the Patient Safety and Quality Committee, ESAIC Anaesthesiologist, Amsterdam UMC location AMC, The Netherlands