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Checklists
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Background

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 are a remarkably useful tool in improving safety, but they are not a panacea. As checklists have been more widely implemented, it has become clear that their success depends on appropriately targeting the intervention and utilizing a careful implementation strategy.

Errors in clinical tasks that involve primarily attentional behavior—such as diagnostic errors or handoff errors—may require solutions focused on training, supervision, and decision support rather than standardizing behavior, and thus may not be an appropriate subject for a checklist. An effective checklist also requires consensus regarding required safety behaviors. 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.

When a checklist is appropriate, safety professionals must be aware that implementing a checklist is a complex sociotechnical endeavor, requiring frontline providers to not only change their approach to a specific task but to engage in cultural changes to enhance safety. 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. Failure to engage in appropriate preparatory and monitoring before and after checklist implementation may explain why checklist use in real-world settings is often poor, contributing to disappointing results. Ethnographic studies of successful and unsuccessful checklist implementation have been instrumental in enhancing understanding of the barriers that can limit checklist utility.

Surgeons experienced 50% fewer positioning errors with laparoscopic procedure equipment when they used a structured checklist. 73% experienced wrong positioning in the control group, compared to 30% using a checklist. checklist. 40% experienced wrong settings and connections of equipment in the control group, compared to 23% using a checklist. 87% experienced one or more incidents with equipment in the control group, compared to 50% using a checklist.

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

Controversies

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.

 
What's New in Checklists on AHRQ PSNet
REVIEW
Effect of using a safety checklist on patient complications after surgery: a systematic review and meta-analysis.
Gillespie BM, Chaboyer W, Thalib L, John M, Fairweather N, Slater K. Anesthesiology. 2014;120:1380-1389.
STUDY
A qualitative evaluation of the barriers and facilitators toward implementation of the WHO surgical safety checklist across hospitals in England: lessons from the "Surgical Checklist Implementation Project."
Russ SJ, Sevdalis N, Moorthy K, et al. Ann Surg. 2014 Jul 28; [Epub ahead of print].
STUDY
Reducing the rate of catheter-associated bloodstream infections in a surgical intensive care unit using the Institute for Healthcare Improvement Central Line Bundle.
Sacks GD, Diggs BS, Hadjizacharia P, Green D, Salim A, Malinoski DJ. Am J Surg. 2014;207:817-823.
STUDY
Compliance with a time-out procedure intended to prevent wrong surgery in hospitals: results of a national patient safety programme in the Netherlands.
van Schoten SM, Kop V, de Blok C, Spreeuwenberg P, Groenewegen PP, Wagner C. BMJ Open. 2014;4:e005075.
NEWSPAPER/MAGAZINE ARTICLE
Surgical checklists unused in 10% of hospitals, CMS data shows.
Clark C. HealthLeaders Media. July 24, 2014.
STUDY
The WHO surgical safety checklist: survey of patients' views.
Russ SJ, Rout S, Caris J, et al. BMJ Qual Saf. 2014 Jul 18; [Epub ahead of print].
REVIEW
Effectiveness of the surgical safety checklist in correcting errors: a literature review applying Reason's Swiss cheese model.
Collins SJ, Newhouse R, Porter J, Talsma A. AORN J. 2014;100:65-79.
 
Editor's Picks for Checklists
From AHRQ WebM&M
What Makes a Good Checklist.
Anne Collins McLaughlin, PhD. AHRQ WebM&M [serial online]. October 2010
Human Factors Engineering Can Teach You How to Be Surprised Again.
John Gosbee, MD, MS. AHRQ WebM&M [serial online]. November 2006
 
From AHRQ PSNet
BOOK/REPORT
Safe Patients, Smart Hospitals: How One Doctor's Checklist Can Help Us Change Health Care from the Inside Out. Classic icon
Pronovost P, Vohr E. New York, NY: Hudson Street Press; 2010. ISBN: 9781594630644.
The Checklist Manifesto: How to Get Things Right. Classic icon
Gawande A. New York, NY: Metropolitan Books; 2009. ISBN: 9780805091748.
JOURNAL ARTICLE
The limits of checklists: handoff and narrative thinking.
Hilligoss B, Moffatt-Bruce SD. BMJ Qual Saf. 2014;23:528-533.
Introduction of surgical safety checklists in Ontario, Canada. Classic icon
Urbach DR, Govindarajan A, Saskin R, Wilton AS, Baxter NN. N Engl J Med. 2014;370:1029-1038.
Surgical checklists: a systematic review of impacts and implementation.
Treadwell JR, Lucas S, Tsou AY. BMJ Qual Saf. 2014;23:299-318.
Systematic review of safety checklists for use by medical care teams in acute hospital settings—limited evidence of effectiveness.
Ko HCH, Turner TJ, Finnigan MA. BMC Health Serv Res. 2011;11:211.
Effect of a 19-item surgical safety checklist during urgent operations in a global patient population. Classic icon
Weiser TG, Haynes AB, Dziekan G, et al; Safe Surgery Saves Lives Investigators and Study Group. Ann Surg. 2010;251:976-980.
Reality check for checklists. Classic icon
Bosk CL, Dixon-Woods M, Goeschel CA, Pronovost PJ. Lancet. 2009;374:444-445.
A surgical safety checklist to reduce morbidity and mortality in a global population. Classic icon
Haynes AB, Weiser TG, Berry WR, et al; for the Safe Surgery Saves Lives Study Group. N Engl J Med. 2009;360:491-499.
An intervention to decrease catheter-related bloodstream infections in the ICU. Classic icon
Pronovost P, Needham D, Berenholtz S, et al. N Engl J Med. 2006;355:2725-2732.
NEWSPAPER/MAGAZINE ARTICLE
The checklist. Classic icon
Gawande A. The New Yorker. December 10, 2007;83:86-95.
 
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Last Updated: August 2014