Background: The Veterans Health Administration's (VHA's) National Center for Patient Safety developed a cognitive aid to help anesthesiologists manage rare, high-mortality adverse events.
Methods: Six months after the aids were sent to VHA facilities with anesthesia machines, anesthesia providers were surveyed about their knowledge and use of the aid.
Results: Seven 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.
Discussion: A cognitive aid for use in rare emergencies proved clinically useful to anesthesia providers.