Journal Article
Study

Use of an emergency manual during an intraoperative cardiac arrest by an interprofessional team: a positive-exemplar case study of a new patient safety tool.

Merrell SB, Gaba DM, Agarwala A, et al. Joint Commission journal on quality and patient safety. 2018;44:477-484.

Emergency manuals have been adopted from high reliability industries as a cognitive aid for guiding interprofessional teams during clinical crises. Investigators interviewed emergency manual users after an intraoperative cardiac arrest and conceptualized how the manual helped provide optimal care. A PSNet interview reviews more broadly how to achieve high reliability in health care.