Circulation 36,825 • Volume 18, No. 1 • Spring 2003

Checklists Cover Critical Details

Loren A. Bauman, MD

To the Editor

The practice of anesthesiology contains dynamics and complexity similar to that found in the aviation industry. Meticulous preparation, constant monitoring and frequent adjustments, temporally precise execution of critical maneuvers, and crisis management are important elements in both professions. Studies of decision-making and human error in airline disasters revealed the need for organized management of specific situations []. Checklists found in the aircraft’s procedure manuals are used to control the infinite variables that must be managed, particularly during emergencies. As a pilot of 38 years and an anesthesiologist of 15 years, I began using aviation style checklists early in my career for routine but critical maneuvers in the operating room to insure that I didn’t commit the anesthetic equivalent of taking off with my door open or landing with my landing gear up.

Designing and executing operation-specific anesthetics are common, nearly routine, elements of anesthesia practice. Critical errors can occur when patient-specific data are lost or forgotten during the hustle of daily practice. As a supervising, academic pediatric anesthesiologist, I am frequently called to induce a patient whom I evaluated 20-60 minutes earlier. During that interlude, I have reviewed other pre-ops of patients for similar operations, each containing modest variation in their histories. Critical details are easily lost in the noise of the constant data flow.

Just before I induce the patient, I use a checklist as a last-minute confirmation that I haven’t forgotten critical detail. I advocate a quick re-check for those issues that are not part of the operation-specific anesthetic but require a deviation, variation, or alternation in that plan.

CABINS: Cardiac, Airway, Bleeding, Intolerances, NPO, Steroids (Table 1). I have taken to listing a CABINS score on the top of the anesthesia record, the score reflecting the number of positives in the acronym. This does not replace the anesthetic pre-op, but it quickly refocuses my attention to issues outside the procedure-specific aesthetic, and I hope, prevents me from using barbiturate in a patient with porphyria or non-depolarizating muscle relaxants in a patient with prior history of anaphylaxis. The jingle takes all of 10 seconds to recite and focuses my attention away from the considerable details of the pre-op to those issues that alter the operation-specific anesthetic.

Acronyms are a means to help us remember critically important and commonly bulky information. CABINS is helpful to me because it forces me to ritualistically recall important data prior to the induction. CABINS is my checklist, based on my practice population, practice style, and operating routines. The real value to any checklist is to invent or modify one for your own practice, giving consideration to your anesthetic routines, patient population, and operating room demands. The process of developing the checklist is at least as helpful as its ritualistic use.

Loren A. Bauman, MD
Winston-Salem, NC