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Setting Memorial University of Newfoundland is the only university in Newfoundland and Labrador and has approximately 20,000 students. The university aims to provide both a comprehensive undergraduate program and research-intensive graduate programs. Because of the university’s geographic isolation it is particularly important for the library to provide a comprehensive collection. Unlike in larger centres, researchers can not avail themselves of the resources held by nearby institutions. We therefore tend to adopt a cautious and conservative approach to cancellations or weeding. Problem Over the past decade there has been a steady increase in journal subscription prices while the materials budgets of academic libraries has remained fixed or even decreased. When this trend coincided with a precipitous devaluation of the Canadian dollar beginning in 2013, many Canadian academic libraries were thrust into a serials budget crisis. Librarians at Memorial had implemented many smaller cost-saving measures during 2013 and 2014, however, it became evident that trimming the low-hanging fruit would not suffice. Librarians needed to set their sights on significantly larger cancellation targets to make ends meet. A committee was formed to evaluate our cancellation options.Based on an analysis of the target savings, the subscriptions available for renewal at the end of 2015, and strategies to avoid disadvantaging any particular discipline, the committee recommended cancelling four large multi-disciplinary publisher journal packages – Cambridge, Oxford, Springer, and Wiley – and buying back only the most crucial titles. This was a dramatic proposal by any standard, but especially for Memorial. It was, however, unavoidable.

Abstract This resource contains eight high-fidelity simulation scenarios designed for operating room teams to manage critical events. These scenarios were developed to simulate one of eight critical events for which critical event checklists have been developed. The purpose of this educational module is to allow other facilities to use these scenarios to permit their teams to practice the management of eight specific critical events with and without the use of a critical event checklist. Debriefing templates and scripts are included for the eight scenarios to guide others in the conduct of the debriefing. Evaluations of the performance of the teams are done using two tools, one of which involves the adherence to key processes determined by evidence-based data and expert consensus. The second tool examines the nontechnical skills aspects of the team performance. Included in this resource are the patient's history, physical exam, and laboratory findings, as well as the actual scenario and how it should unfold. Also included are a description of the aids for surgical simulation, PowerPoint orientation presentation, confidentiality forms, mannequin and lab orientation, instructor's guide, citation details for the critical event checklist and the team emergency assessment measure tools, simulation interest group scenario templates, debriefing scripts, and exit questionnaire. The teams that completed these educational sessions had a very positive reaction. On the exit questionnaire, the participants (n = 35) rated the following statements (1 = strongly disagree, 5 = strongly agree): “Managing these simulated scenarios will improve my performance in a similar clinical situation” (Mdn = 5), “The debriefing session helped identify gaps in my practice and to clarify important issues” (Mdn = 5), “The information that I learned about critical perioperative events is relevant and beneficial to my practice” (Mdn = 4), “This session will help me to practice more safely in an ambulatory surgical facility” (Mdn = 4), “Critical event checklists are helpful to deal with critical events in an ambulatory surgical facility” (Mdn = 4), and “Critical event checklists should be available in an ambulatory surgical facility” (Mdn = 5).

There are not enough clinical data from rare critical events to calculate statistics to decide if the management of actual events might be below what could reasonably be expected (i.e. was an outlier).In this project we used simulation to describe the distribution of management times as an approach to decide if the management of a simulated obstetrical crisis scenario could be considered an outlier.Twelve obstetrical teams managed 4 scenarios that were previously developed. Relevant outcome variables were defined by expert consensus. The distribution of the response times from the teams who performed the respective intervention was graphically displayed and median and quartiles calculated using rank order statistics.Only 7 of the 12 teams performed chest compressions during the arrest following the 'cannot intubate/cannot ventilate' scenario. All other outcome measures were performed by at least 11 of the 12 teams. Calculation of medians and quartiles with 95% CI was possible for all outcomes. Confidence intervals, given the small sample size, were large.We demonstrated the use of simulation to calculate quantiles for management times of critical event. This approach could assist in deciding if a given performance could be considered normal and also point to aspects of care that seem to pose particular challenges as evidenced by a large number of teams not performing the expected maneuver. However sufficiently large sample sizes (i.e. from a national data base) will be required to calculate acceptable confidence intervals and to establish actual tolerance limits.