**9.1 Checklists**

Use of procedural checklists to enhance safety has been proven to be effective in various industries, and healthcare is no exception [40]. These point-of-care cognitive aids are a useful way to augment procedural memory and could be especially useful in high-risk prehospital procedures in distracting and austere environments. For example, checklists for intubation have been extensively studied for in-hospital use, and though not proven to have a mortality benefit, checklist use was associated with statistically significant decreases in peri-intubation hypoxic events [41]. One longitudinal before and after a study conducted using data from an air ambulance company concluded that not only did use of checklists decrease hypoxic and hypotensive events during RSI but also improved the first-pass intubation success rates [42]. A similar study on a ground ALS service showed a checklist as part of a bundle of care showed lower rates of peri-intubation hypoxia, further demonstrating that checklists are a helpful resource for patient safety [43].

Though not studied, checklists could be of benefit for improving outcomes in a variety of high-risk prehospital procedures. A high-quality checklist should be easy to read, written in plain language, and could include various data such as patient considerations, necessary equipment and medications, procedural steps, and countermeasures should complications be encountered.

#### **9.2 Competency assessments**

Ensuring provider competency prior to performing high-risk procedures is vital to patient safety. Competency assessments should not only be aimed at procedural steps but also include evaluation of appropriateness of use of the high-risk procedure based on patient condition. Just as in medication safety, knowing the indications, alternatives, and ideal patient demographic for a procedure is just as important as being able to physically perform the procedure itself. Initial provider certification is issued based on a basic level of competency to appropriately implement and perform a procedure; however, it is up to an agency to credential a provider based on an assessment of those procedural competencies. In addition to initial credentialing, the NAEMSP recommends that "reverification of a provider's cognitive, affective, psychomotor, and critical thinking skills, pertinent to relevant clinical situations, occurs no less frequently than every two (2) years" [44].

#### **9.3 Simulation**

Simulation has been proven effective for evaluating and teaching psychomotor skills, communication, teamwork, and patient management in a variety of medical environments. Though not well studied for use in the prehospital setting, the ability to repeat uncommon, high-risk procedures in a controlled environment affords the provider opportunity to gain experience, education, and muscle memory in tandem [45]. Moreover, prehospital simulations and assessments can be used to strengthen non-procedural skills, such as communication, leadership skills, stress management, and decision-making, all of which are fundamental to patient safety. Simulation is not only useful for initial and ongoing education but also as a remediation tool for both self-identified and agency-specific performance improvement initiatives [46].
