A checklist is an algorithmic listing of actions to be performed in a given clinical setting, the goal being to ensure that no step will be forgotten. Although a seemingly simple intervention, checklists have a sound theoretical basis in principles of human factors engineering and have played a major role in some of the most significant successes achieved in the patient safety movement.
The field of cognitive psychology classifies most tasks as involving either schematic behavior, tasks performed reflexively or "on autopilot," or attentional behavior, which requires active planning and problem-solving. The types of error associated with each behavior are also different: failures of schematic behavior are called slips and occur due to lapses in concentration, distractions, or fatigue, whereas failures of attentional behavior are termed mistakes and often are caused by lack of experience or insufficient training. In health care, as in other industries, most errors are caused by slips rather than mistakes, and checklists represent a simple, elegant method to reduce the risk of slips. Flight preparation in aviation is a well-known example, as pilots and air-traffic controllers follow pre-takeoff checklists regardless of how many times they have carried out the tasks involved. By standardizing the list of steps to be followed, and formalizing the expectation that every step will be followed for every patient, checklists have the potential to greatly reduce errors due to slips.
Current Use of Checklists
Checklists garnered well-deserved publicity as a result of their use in the Keystone ICU project, a multicenter study in which a checklist of evidence-based infection control interventions was implemented to reduce the risk of central line–associated bloodstream infections in intensive care unit patients. This intervention achieved a stunning reduction in line infections, with many ICUs completely eliminating line infections for months at a time. An AHRQ-funded initiative subsequently disseminated the use of the Keystone ICU interventions nationwide, and initial results indicate further sustained success. A similar level of success was achieved through implementation of a surgical safety checklist, which included specific steps during induction of anesthesia, surgical timeout, and transfer of the patient out of the operating room. Remarkable reductions in surgical mortality and morbidity were achieved across a wide range of clinical settings. Further research has investigated the use of checklists to improve safety at the time of hospital discharge, improve transfer of information during in-hospital handoffs, and improve the care of intensive care unit and trauma patients.
Source: Verdaasdonk EG, Stassen LP, Hoffman WF, van der Elst M, Dankelman J. Can a structured checklist prevent problems with laparoscopic equipment? Surg Endosc. 2008. Available at: http://dx.doi.org/10.1007/s00464-008-0029-3
Checklists are a remarkably useful tool in improving safety, but care must be taken not to overemphasize their importance: they cannot solve every patient safety problem, and even when checklists are appropriate, certain co-interventions may be necessary to maximize their impact. The success of checklists in preventing central line infections and improving surgical safety resulted from the strong evidence base supporting each of the individual items in the checklist, and therefore checklists may not be successful in areas where the "gold standard" safety practices have yet to be determined. Successful implementation of a checklist requires extensive preparatory work to maximize safety culture in the unit where checklists are to be used, engage leadership in rolling out and emphasizing the importance of the checklist, and rigorously analyze data to assess use of the checklist and associated clinical outcomes. An emerging issue is whether adherence to evidence-based checklists should be elective: a New England Journal of Medicine editorial by two safety leaders recommended that providers be held accountable for failing to use such checklists. Finally, only certain types of errors can be prevented by checklists: errors in clinical tasks that involve primarily attentional behavior (such as diagnostic errors) require solutions focused on training, supervision, and decision support rather than standardizing behavior. These issues were discussed in detail in a recent commentary by some of the authors of the Keystone ICU study.