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.
Approach to Improving Safety
Setting of Care
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.