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Critical action procedures testing: a novel method for test-enhanced learning


  • Samuel M Galvagno Jr,

    1. Department of Anaesthesiology and Critical Care Medicine, Division of Adult Critical Care, Johns Hopkins Hospital, Baltimore, Maryland, USA
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  • B Scott Segal

    1. Department of Anaesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Samuel M Galvagno Jr, Department of Anaesthesiology and Critical Care Medicine, Johns Hopkins Hospital, 600 North Wolfe Street, Meyer 2, Baltimore, Maryland 21287-9106, USA. Tel: 00 1 443 682 1466; Fax: 00 1 410 955 8978; E-mail:


Context  Human error is a leading cause of adverse events in anaesthesia. Residents’ knowledge of how to respond to rare, yet potentially life-threatening events has been shown to deteriorate over time and thus cost-effective educational interventions are indicated. Previous research has shown that test-enhanced learning has the potential to strengthen both clinical knowledge and performance. We hypothesised that critical action procedures (CAPs) tests, similar to those employed by high-performance aircraft pilots, would help improve resident knowledge about how to respond to rare and potentially catastrophic events encountered during the perioperative period.

Methods  Knowledge assessments were administered to 29 first-year anaesthesiology residents over the course of 9 months. Five-minute closed-book tests were administered with fill-in-the-blank questions regarding the American Society of Anesthesiologists’ difficult airway guideline, advanced cardiac life support protocols, an institutional airway fire protocol and drug dosing for malignant hyperthermia. Inter-group comparisons were evaluated using the Kruskal–Wallis test. The difference between the pre-test and final test scores for each subsection was determined with the Mann–Whitney U-test for independent samples.

Results  Composite subtest scores, when compared with baseline pre-test scores and subsequent scores, and when adjusted for attrition, significantly improved over the course of 9 months (20.5% versus 80%; P ≤ 0.001). Likert-based survey data indicated a positive report for attainment of knowledge.

Conclusions  In this longitudinal observational study of first-year anaesthesiology residents, CAPs testing helped improve knowledge about critical events. Although the study was limited by its small number of subjects, a significant attrition rate and the lack of a control group, it demonstrates a cost-effective educational intervention that improved resident knowledge. This intervention may enable residents to transfer learned skills from theoretical testing situations to real-life scenarios. We propose the use and further study of CAPs testing as a cost-effective modality to augment both simulated and actual experiential learning.