• Julia Neily, Joseph M DeRosier, Peter D Mills, Michael J Bishop, William B Weeks, and James P Bagian.
• Field Office of the Veterans Health Administration, National Center for Patient Safety, White River Junction, Vermont, USA. Julia.Neily@va.gov
• Jt Comm J Qual Patient Saf. 2007 Aug 1;33(8):502-11.

BackgroundThe Veterans Health Administration's (VHA's) National Center for Patient Safety developed a cognitive aid to help anesthesiologists manage rare, high-mortality adverse events.MethodsSix months after the aids were sent to VHA facilities with anesthesia machines, anesthesia providers were surveyed about their knowledge and use of the aid.ResultsSeven percent of respondents had used the cognitive aid in an emergency ("emergent users"). Most (87%) of respondents were aware of the aid. Half used it only as a reference ("reference users"), 30% were nonusers, and 13% of respondents were unaware of the aid. User groups did not differ regarding exposure to emergencies. All emergent users reported that it helped during an emergency, and 93% reported that it was well designed and easy to use. Emergent users were more likely than other groups to have first found out about it through formal orientation (53%; p < .001). Nonusers (46%) and reference users (38%) were more likely than emergent users (30%) and those who never saw it (5%) to have first found out about it through informal communication with a colleague (p = < 0.001). The majority of those who never saw the aid first became aware of it through this survey (71%; p < .001). The aid was used most commonly for difficult airway.DiscussionA cognitive aid for use in rare emergencies proved clinically useful to anesthesia providers.

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