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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 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.

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
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.
STUDY
The surgical safety checklist and teamwork coaching tools: a study of inter-rater reliability.
Huang LC, Conley D, Lipsitz S, et al. BMJ Qual Saf. 2014;23:639-650.
 
Editor's Picks for Checklists
From AHRQ WebM&M
Human Factors Engineering Can Teach You How to Be Surprised Again.
John Gosbee, MD, MS. AHRQ WebM&M [serial online]. November 2006
What Makes a Good Checklist.
Anne Collins McLaughlin, PhD. AHRQ WebM&M [serial online]. October 2010
 
From AHRQ PSNet
JOURNAL ARTICLE
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.
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.
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.
Measurable outcomes of quality improvement in the trauma intensive care unit: the impact of a daily quality rounding checklist.
DuBose JJ, Inaba K, Shiflett A, et al. J Trauma. 2008;64:22-29.
Reality check for checklists. Classic icon
Bosk CL, Dixon-Woods M, Goeschel CA, Pronovost PJ. Lancet. 2009;374:444-445.
Transition of care for hospitalized elderly patients—development of a discharge checklist for hospitalists.
Halasyamani L, Kripalani S, Coleman E, et al. J Hosp Med. 2006;1:354-360.
Patient handover from surgery to intensive care: using Formula 1 pit-stop and aviation models to improve safety and quality.
Catchpole KR, de Leval MR, McEwan A, et al. Paediatr Anaesth. 2007;17:470-478.
NEWSPAPER/MAGAZINE ARTICLE
The checklist. Classic icon
Gawande A. The New Yorker. December 10, 2007;83:86-95.
BOOK/REPORT
The Checklist Manifesto: How to Get Things Right. Classic icon
Gawande A. New York, NY: Metropolitan Books; 2009. ISBN: 9780805091748.
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.
 
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Last Updated: October 2012