The downsides of checklists in preventing human error

We have so far seen that checklists are effective in preventing human error. Checklists however do have some drawbacks, and one of these was flagged up by Matthew Sibbald and colleagues in their paper titled Checklists improve experts’ diagnostic decisions. In this article, the authors described how checklists may increase the cognitive load of experts and thereby give rise to the phenomenon of ‘expertise reversal‘. To reduce the risk of this, Sibbald and colleagues advised experts not to use checklists in the ‘initial interpretation stage of diagnostic decisions’, but to apply them later in the ‘verification stage‘. They went on to illustrate the effectiveness of this approach in their study of experts interpreting electrocardiograms (ECGs). In another paper titled Finding and fixing mistakes: do checklists work for clinicians with different levels of experience?, Sibbald and colleagues also showed that novices benefit more from checklists than experts.

To do list. justworks on Flickr.

Another potential disadvantage of checklists is the time and effort that is invested in applying them. Referring to this in their paper titled Investing in the use of a checklist during differential diagnoses consideration: what’s the trade-off?Keng Chew and colleagues highlighted the need to consider this trade off when designing checklists. A related potential drawback of checklists is ‘checklist fatigue’, a concept that was discussed by Brigette Hales and colleagues in their paper titled Development of medical checklists for improved quality of patient care. There, they referred to the risk of practitioners becoming overwhelmed when ‘each detail of every task were targeted for the development of a checklist’. They added that a profusion of checklists may ‘unnecessarily complicate processes and decrease reliability by adding a secondary layer of complexity‘. To avoid this pitfall, they advocated a ‘careful selection of checklist topics’, and the application of clinical judgement in determining the content of the checklists.

To-Do List on a Post-It Sticker. Justin Levy on Flickr.

Øyvind Thomassen and colleagues, writing in a paper titled Implementation of checklists in health care; learning from high-reliability organisations, also explored another potential shortcoming of checklists, and this is the risk of lack of acceptance by the end users. There are various reasons why checklists may be underused, and these were reviewed by Bradford Winters and colleagues in their paper titled Clinical review: checklists – translating evidence into practice. Despite their ‘tremendous potential to improve safety and quality and reduce the costs of health care’, Winters and colleagues listed the factors which limit their use to include ‘the paucity of scholarly research to identify where to use checklists, how to build and implement them and assess their effectiveness at improving patient outcomes, and whether or how checklist use is sustained over time’.

To do list. Marco Verch Professional photographer on Flickr.

A final potential pitfal of checklists is that they may not prevent diagnostic error in certain circumstances. For example, John Ely and  Mark Graber, in their paper Checklists to prevent diagnostic errors: a pilot randomized controlled trial, reported that checklists did not help reduce the diagnostic error arising from premature closure. For this and other reasons, Henry Ko and colleagues, in their paper titled Systematic review of safety checklists for use by medical care teams in acute hospital settings-limited evidence of effectiveness, argued for caution in assessing the benefits of checklists in improving patient safety.

One done. Daniel Kulinsky on Flickr.

We have now completed our review of the use of checklists in preventing human error. In the next post, we will look at medication safety in preventing human error.

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