The development of a crisis management manual for anesthetists and anesthesiologists

Crisis management is part and parcel of anesthesia practice. Cognitive science research and also common sense tell us that no one thinks clearly in a crisis. Taking example from other high-stress occupations, this paper describes the development of an anesthesia crisis management manual, based on data from 4000 anesthesia incidents reported anonymously by practicing anesthetists in Australia and New Zealand. Beginning with a “core algorithm” mnemonic, COVER ABCD A SWIFT CHECK, for routine monitoring and also for rendering any crisis situation “safe,” the anesthetist then chooses 1 of 24 specific, internally validated “sub-algorithms” to diagnose and correct the problem.