Emergency Manual


Implementation Tips

Provided here are a combination of broad considerations for clinical implementation and answers to Frequently Asked Questions (FAQs) we have received regarding implementation experience at Stanford. The latter are provided in the context of a detailed literature search, iterative simulation testing of perioperative cognitive aids that started in the late 1980s, and Stanford clinical implementation in 2012. Please note that each institution is different and successful methods at one may not always apply to all. A copy of this section is also provided when you download the Emergency Manual.

Why Implement? A Summary for local champions

Implementation Team

Accessibility: Physical, Electronic, or Both?


Physical Copy


Training and Familiarity

Printing Tips & Order a Sample

Your Feedback & Implementation Suggestions


Why Implement? A Summary for local champions

Reasons institutions should institute an emergency manual (supported by published literature in multiple fields)

  1. Medical simulation studies show that integrating an emergency manual into the operating room results in better management during critical events.
  2. Pilots and nuclear power plant operators use similar cognitive aids for emergencies and rare events.
  3. During a critical event, the stacks of relevant literature are rarely accessible.
  4. Memory worsens under stress and distractions interrupt our planned actions.
  5. Expertise requires significant repetitive practice, so none of us are experts in every emergency.

Please see Why and How to Implement Emergency Manuals (for leaders) video here.

Implementation Team

We strongly recommend putting together an implementation team, given the common barriers to successful clinical implementation and the hugely increased success when these are addressed proactively. It is vital to obtain input and buy-in from multiple interdisciplinary stakeholders with complementary knowledge, and to have the support of Operating Room and hospital leadership. Our Stanford implementation team leader, Sara Goldhaber-Fiebert M.D., is an anesthesiologist as well as simulation faculty, but the team is broad and interdisciplinary. Key input and support in planning the implementation launch came from Stanford Anesthesia Cognitive Aid Group Emergency Manual developers, Chair of Anesthesia, OR director, CMO and CEO of the hospital, surgical leadership, multiple OR/hospital committees, and anesthesia faculty as well as residents. Vital active implementation team members for trainings include nurse educators, a simulationist, and a medical student, as well as anesthesia technicians and clinical engineers for durable accessibility of the emergency manuals.

You do not need to wait to have the full team before proceeding, but can present the idea for input and support at places like an anesthesia improvement committee, surgical team quality council, and hospital level quality and safety committee.


Accessibility: Physical, Electronic, or Both?

We have found that having a physical copy is extremely useful during critical events, even if there is an easily accessible electronic copy as well. This has been repeatedly true during both simulated and clinical critical events. Successful use during events has gone way up institutionally after introducing a physical copy near the anesthesia workstation. In fact, during interdisciplinary trainings (see below) many nurses requested a second physical copy be installed near nursing computer and after these were added OR staff familiarity and involvement in use have increased.


Static electronic pdf versions on anesthesiologist’s and/or nursing charting computers are attractive in being inexpensive and relatively easy to roll out. Adding an emergency manual pdf to institutional or departmental websites is an economical way to provide an educational resource, which is available to all anesthetizing and OR locations as well as easy to update. However, limitations are slower or impractical use during a crisis. These often include issues such as facing away from patient/action, requiring a few clicks to navigate there, and being in a fixed location in room with use potentially blocking access to other supplies. Various groups around the country are working already on more interactive electronic systems, harnessing the interactive strengths of computers and allowing team members to view information on dynamic large screens that provide a shared mental model of patient data as well as management information. Current simulation testing indicates there are still challenges to overcome in making these systems more useful and less distracting than physical copies, but in time these challenges will likely be addressed well. We highly encourage simulation testing of whatever system you use, to determine whether and how clinicians decide to and are able to utilize the resource during a critical event.

Physical Copy: See also Printing Tips & Order a Sample to order a model

If you are printing a physical copy for each anesthetizing location, there are several important issues and challenges to consider. Depending on the specifics at your institution, you may choose a different version than others.


Ideally, an emergency manual should be:

  • Hung visibly in a consistent place in relevant areas, for easy access during critical events but without blocking daily work flow
  • Durable, wipeable, low flammability all to enable ongoing OR use
  • Flexible for movement within room balanced with not disappearing (i.e. Should it be labeled or attached in some way? Who will check that it is present?)
  • Inexpensive and/or potential to update.

The nitty-gritty from our experience printing usable and durable emergency manuals, given many FAQs about this:

After significant research into materials and methods, the Stanford team chose to hang a bound, laminated ‘book’ from a grommet that fits onto a 3M Command medium plastic adhesive hook, as above.

The table of contents is always on front cover for easy access, the covers as well as section headers are thicker than internal pages to make them easy to find. There are ‘sidebar tabs’ rather than external tabs given the significant cost increase for cut-tabs or labor of adding them post-production, either of which are possible.

In subsequent iterations, we have added ‘improvements’:

We are aware that cost as well as desired format are a big challenge for all, which is why we chose to share the pdf at no cost under a Creative Commons License Creative Commons License instead of adding the cost of publication for institutions wishing to implement. This way, printing is the only cost to making easily usable physical copies widely accessible.

Printing sheets to internally make 3-ring binders may be the most inexpensive approach initially, though ‘hidden’ lamination and labor costs may add up if counted and binder format presents a few challenges that may or may not be easily solved at your institution. Consider: Where will the binder ‘live’? Will it be visible when needed? Will it be present when needed? Will it be used when needed? Our experience is that binders may be left in a drawer of anesthesia carts, and used much less frequently than a visibly hanging and always present emergency manual, though this will be training and culture dependent.

Many clinicians and institutions have asked us how to buy a finished product emergency manual like the one depicted above (earlier version), and others have asked for printing tips. While we are not selling them directly, we are happy to share the contact and details for the printer (See also Printing Tips & Order a Sample) we worked with since 2011 (no financial benefit to us!) so that you can order a sample and work directly with a business that understands the issues above and can provide bulk pricing. We have developed this detailed section so that others do not need to “reinvent the wheel” from scratch, but we are very open to improvements. If you have or find alternative methods/materials for hanging emergency manuals that meet the bulleted characteristics above, please share by emailing us at stanfordemergencymanual@googlegroups.com


Training and Familiarity

Integrating emergency manuals into educational efforts in clinical settings or associated simulation centers have dual benefits:

  1. Content review for rare but treatable critical events becomes accessible for practitioners or trainees, often spurring further in-depth discussion in trainee settings e.g. Intraoperative review by anesthesia and/or nursing teams for ‘What If’ events, particularly those that are potential for current patient.
  2. Format becomes familiar. Why and how emergency manual use can help patients becomes much clearer to clinicians and teams. These create a reinforcing spiral of effective use during future clinical event.

Simulation studies and literature from other high-stakes industries have made clear that any helpful resource is only useful during emergencies if it is already familiar to clinicians. Without prior training or exposure, clinicians do not think to use it, may push it aside without ‘seeing’ it, and any helpers are much less efficient in finding information.

At Stanford, the earliest frequent trainings were for anesthesia residents and some attendings within annual Anesthesia Crisis Resource Management courses, which have integrated iterative versions of cognitive aids and emergency manuals (see Development History) to encourage efficient delivery of key best practices during critical events. Attendings are increasingly getting systematic exposure to emergency manual use as part of departmental Grand Rounds, emails about implementation including soliciting input from local faculty, and Stanford MOCA courses (Maintenance of Certification in Anesthesia Part IV ABA simulation requirement). In 2012, we expanded to include interdisciplinary simulation-based trainings for OR staff.

After initial simulation exposure for many anesthesia clinicians, departmental emails and faculty meetings surrounding clinical launch encouraged use as an educational resource for teaching and review in the OR, with significant positive response and increasing familiarity.

Other institutions we have spoken to are also doing team training for OR critical events, with many planning to integrate emergency manuals. Below is a conglomeration of ideas, methods, and issues to consider:

There are pros and cons to any of the above approaches, with different logistical challenges requiring involvement from interdisciplinary institutional leaders. Multiple approaches may be complementary.


Printing Tips & Order a Sample

Many institutions and simulation centers have asked Stanford Anesthesia Cognitive Aid Group how to buy copies of an optimized physical Emergency Manual. We are not financially connected at all, but after many requests we provide below detailed information from the printer we used, or feel free to print your own copy anywhere.

Information below is from Alpha Graphics


Pricing and Order Sample

Contact Info


AlphaGraphics San Francisco has produced a printed Emergency Manual that meets the specific criteria the Stanford team defined, and has been in use in all Stanford hospitals’ anesthetizing locations since fall 2012, with iterative improvements. There is no financial relationship, and you should contact Alpha Graphics San Francisco with any questions, orders, or requests for samples at staffingsf@alphagraphics.com

The specific criteria were:

  1. Durability and ability to resist damage due to liquid exposure
  2. Wipeability
  3. Low flammability
  4. The manual must be able to be hung from a hook +/- tethered to a chain to ensure proper storage and a radius of flexible usage.
  5. Ability to quickly find covers by having a tactile ability to identify those pages in high pressure, time-sensitive situations.

By using digital print technology, they can customize front cover emergency numbers, general phone numbers page, and local Hemorrhage procedures (Event 14) for each specific institution.

See permissions for local customization at http://emergencymanual.stanford.edu/downloads.html#_Toc_2

Their printed manuals use a durable plastic coil binding, along with a laminated hanging strip with an (MRI-compliant) brass grommet for easy hanging. For future updates or page additions, these coil bindings can be removed and replaced by any local printer (eg FedEx), often less than $5, or they can be rebound by hand in-house with readily available plastic coils and a coil crimping tool.

By using a combination of front and back cover laminated pages along with state-of-the-art synthetic paper, they have achieved a balance of usability based on the above criteria, while making it cost efficient for widespread deployment.


Quantities:      10-49… …..$54 per book plus shipping and tax

                        >50………..$49 per book plus shipping and tax

                        >500………Please contact Alpha Graphics below

You may order a sample for $27 plus shipping.

Samples of Version 3.0 should be available in fall 2016.

Contact Info

Please contact Alpha Graphics directly for more information or to Order a Sample at staffingsf@alphagraphics.com or 415-781-4910 and ask for Andre. Please note that AlphaGraphics is a nationwide network of print centers but this Emergency Manual is only available specifically from AlphaGraphics San Francisco www.us684.alphagraphics.com.

Save PDF to mobile phone

If you download emergency manual to an iDevice with iBooks, it will give you option to ‘Save to iBooks’ so you can view pdf anywhere.

Your Feedback & Implementation Suggestions

Please tell us what you are doing at your institution for implementing emergency manuals or other types of cognitive aids or checklists, and share any challenges or successes.

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