The power of checklists in preventing human error

In their paper titled Development of medical checklists for improved quality of patient care, Brigette Hales and colleagues defined a checklist as ‘a list of action items, tasks or behaviours arranged in a consistent manner, which allows the evaluator to record the presence or absence of the individual items listed’. We all know how important checklists are in our day-to-day lives, and appreciate that we rely on to-do lists of the tasks that make our lives go round. It is therefore not an exaggeration to say we live by checklists. Hales and colleagues identified the following key factors that make checklists so invaluable:

    • They help to call to mind items, tasks or behaviours that are often overlooked
    • They help to highlight ‘the essential criteria that should be considered in a particular area’
    • They help to standardise processes

The power of checklists rest in their ability to compensate for the recognised inadequacies of human cognition that lead to errors. This was pointed out by Bradford Winters and colleagues in their paper titled Clinical review: checklists – translating evidence into practice; there, they reviewed such deficiencies the unreliability of human memory especially under conditions of stress and fatigue, and when performing complex procedures. John Ely and colleagues, in their paper titled Checklists to reduce diagnostic errors, also pointed to the ‘faulty thinking processes‘ that humans are prone to, and which may lead to error especially in ‘high-reliability‘ industries. In medicine specifically, checklists are invaluable in compensating for the burgeoning amount of medical information that the book, Better doctors, better patients, better decisions, says makes it ‘next to impossible for any one individual to keep up with current medical literature‘.

Checked_tick. Oliver tacke on Flickr. https://www.flickr.com/photos/otacke/12221514614

Checklists come in different forms, and M Peleg and colleagues in their paper titled GLIF3: the evolution of a guideline representation format, identified four principal types, and these are:

    • Static parallel checklists: these are completed by one operator
    • Static sequential with verification checklists: these are carried out by two operators
    • Static sequential with verification and confirmation checklists: these are done by teams
    • Dynamic checklists: this is a flowchart approach to complex decision-making
Checklist. Vormingplus Gent-Eeklo vzw on Flickr. https://www.flickr.com/photos/44514681@N06/26151899419

In their exploration of the advantages of checklists, Hales and colleagues pointed out that they help in the following ways:

    • To ‘condense large quantities of knowledge in a concise fashion
    • To reduce the frequency of errors of omission
    • To create reliable and reproducible evaluations
    • To improve quality standards and use of best practices
    • To enable ‘a consistent standard of care’
    • To act as ‘reminders in clinical care pathways for emergency admissions’
Checklist under magnifying glass. Marco Verch Professional Photographers on Flickr. https://www.flickr.com/photos/30478819@N08/44284465830

Further benefits of checklists were documented by Øyvind Thomassen and colleagues in their paper titled Implementation of checklists in health care; learning from high-reliability organisations. They specifically highlighted the potential of checklists to free the practitioner’s ‘mental capacity to fully attend to operations’, and in this way they serve as ‘an effective tool‘ for improving care processes. Bradford Winters and colleagues, in their paper titled Clinical review: checklists – translating evidence into practice, extended the advantages of checklists to include their ability to reduce communication errors by standardising information and making it accessible to different specialists.

Checklist written with chalk. Marco Verche Professional Photographer on Flickr. https://www.flickr.com/photos/30478819@N08/43278861970

To design effective checklists, Hales and colleagues pointed to certain features that must be taken into consideration. In this regard, they emphasised the importance of checklists having the following characteristics:

    • Accuracy
    • Brevity
    • A ‘correct and consistent writing style relevant to the content’
    • A clear and organised format 
    • A ‘logical and functional order‘.
    • Flexibility to enable the freedom to apply independent judgment
Note with completed checklist. Marco Verche Professional Photographer on Flickr. https://www.flickr.com/photos/30478819@N08/43484501661

In the next post, we will look at the application of checklists in preventing human error.

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