In the last post we explored the power of checklists in preventing human error. In this post we will look at the practical application of checklists in medical practice. Despite their recognised value in many industries, checklists are unfortunately not applied as widely enough in medicine as they should. One person who has passionately advocated for the widespread use of checklists in medicine is Atul Gawande; in his highly acclaimed book, The Checklist Manifesto, Gawande illustrated the impact of checklists with the positive results of his research into surgical safety checklists. He depicts checklists as means of translating knowledge into a simple, quick, usable, and systematic form, and as tools which buttress the skills of experts. He emphasised that good checklists should be short, precise, practical, and clear, and they should contain few items to conform with the limit of working memory.
Gawande’s major contribution to patient safety is the development of the acclaimed World Health Organisation Surgical Safety Checklist. This checklist is now a key component of surgical operating procedures globally, and Gawande’s own experience of using the checklist conveys the value of this simple tool. Extolling the checklist, Gawande asserted that ‘I have yet to get through a week in surgery without the checklist’s leading us to catch something we would have missed‘, adding that ‘with the checklist in place, we have caught unrecognized drug allergies, equipment problems, confusion about medications’, and ‘mistakes on labels for biopsy specimens’. He further stated that the checklist enabled his team to make better plans and to be ‘better prepared for patients’.
Other practitioners beside Gawande have also reported on the usefulness of the surgical safety checklist; for example, Alex Haynes and colleagues, in a paper titled A surgical safety checklist to reduce morbidity and mortality in a global population, and Thomas Weiser and colleagues, in a paper titled Effect of a 19-item surgical safety checklist during urgent operations in global patient population, both demonstrated how the checklist improved team communication and consistency of care, and reduced the frequency of surgical complications and deaths.
Bradford Winters and colleagues also documented the importance of checklists in their paper titled Clinical review: checklists – translating evidence into practice. There, they asserted that checklists ‘provide unambiguous guidance on what, when, how, and who should do a particular intervention’, and the need for the tasks to be ‘logistically efficient and easily performed‘. In the development of effective checklists, Winters and colleagues stressed the need for them to be designed by a multidisciplinary group who should exhaustively ‘review the existing literature‘ and thoroughly understand ‘the needs and work-place of the users’. Before the checklist is implemented, Winters and colleagues also advocated for ‘rigorous pilot testing and validation‘.
Whilst the surgical safety checklist is symbolic of the value of checklists, Gawande believes that checklists should be applied across the spectrum of medical activities ‘beyond the operating room‘. This is because of his view that all such activities involve risk, uncertainty, and complexity, and he highlighted the scale of this risk when he said ‘there are hundreds, perhaps thousands, of things doctors do that are as dangerous and prone to error as surgery‘. In illustrating the scope of areas where he believes checklists are required, he referred to such tasks as the evaluation of headache, chest pain, lung nodules and breast lumps, and the treatment of heart attacks, strokes, drug overdoses, pneumonias, kidney failures, seizures, and headache. This is why he recommended that all such activities should be committed to checklists, and he urged the medical fraternity to seize the opportunity and do so.
Perhaps as a response to the growing appreciation of checklists, there is evidence showing that they are gaining acceptance in medical practice. Winters and colleagues for example noted several areas where checklists have been applied in medicine with the following objectives:
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- Improving processes of care
- Facilitating bedside teaching
- Assessing the performance of doctors
- Reducing problems with laparoscopic equipment
- Reducing central line-associated bloodstream infections
This wider appreciation of checklists has led to the development of checklists such as:
Whilst checklists are mostly used to prevent mistakes in the performance of procedures, they have a less recognised role in reducing diagnostic error. Highlighting this point in their paper titled Checklists to reduce diagnostic errors, John Ely and colleagues pointed out that diagnostic reasoning is a complex process that ‘often involves sense-making under conditions of great uncertainty and limited time’. They went on to argue that checklists can simplify the process of clinical problem-solving by providing ‘an alternative to reliance on intuition and memory‘. For example, they referred to how checklists prompt physicians ‘to optimize their cognitive approach‘, and to how checklists can help physicians to avoid the commonest cause of diagnostic error – the ‘failure to consider the correct diagnosis as a possibility’.
Further evidence for the role of checklists in reducing the risk of diagnostic error was provided by Mark Graber and colleagues who developed a checklist aimed at reducing the risk of diagnostic mistakes in patients admitted to the emergency room with undiagnosed conditions. Publishing their findings in a paper titled Developing checklists to prevent diagnostic error in emergency room settings, Graber and colleagues reported that ‘both the general and the symptom-specific checklists were judged to be helpful‘, and that the the checklists ‘prompted consideration of additional diagnostic possibilities‘, and ‘changed the working diagnosis in approximately 10% of cases’.
In the next post, we will review the downsides of checklists in preventing human error.
Shortcuts and Pitfalls 