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 termedmistakes 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 todisappointing results. Ethnographic studies of successful and unsuccessful checklist implementation have been instrumental in enhancing understanding of the barriers that can limit checklist utility.
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
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 termedmistakes 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 todisappointing results. Ethnographic studies of successful and unsuccessful checklist implementation have been instrumental in enhancing understanding of the barriers that can limit checklist utility.
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
What's New in Checklists on AHRQ PSNet
STUDY
Implementation of a surgical safety checklist and postoperative outcomes: a prospective randomized controlled study.
Chaudhary N, Varma V, Kapoor S, Mehta N, Kumaran V, Nundy S. J Gastrointest Surg. 2015;19:935-942
STUDY
Perioperative safety in plastic surgery: is the World Health Organization checklist useful in a broad practice?
Biskup N, Workman AD, Kutzner E, Adetayo OA, Gupta SC. Ann Plast Surg. 2015 Feb 7; [Epub ahead of print].
STUDY
Surgical team member assessment of the safety of surgery practice in 38 South Carolina hospitals.
Singer SJ, Jiang W, Huang LC, et al. Med Care Res Rev. 2015 Mar 31; [Epub ahead of print].
STUDY
Sustainability and long-term effectiveness of the WHO surgical safety checklist combined with pulse oximetry in a resource-limited setting: two-year update from Moldova.
Kim RY, Kwakye G, Kwok AC, et al. JAMA Surg. 2015 Mar 25; [Epub ahead of print].
STUDY
Patients' perspectives of surgical safety: do they feel safe?
Dixon JL, Tillman MM, Wehbe-Janek H, Song J, Papaconstantinou JT. Ochsner J. 2015 Mar 12; [Epub ahead of print].
Implementation of a surgical safety checklist and postoperative outcomes: a prospective randomized controlled study.
Chaudhary N, Varma V, Kapoor S, Mehta N, Kumaran V, Nundy S. J Gastrointest Surg. 2015;19:935-942
Perioperative safety in plastic surgery: is the World Health Organization checklist useful in a broad practice?
Biskup N, Workman AD, Kutzner E, Adetayo OA, Gupta SC. Ann Plast Surg. 2015 Feb 7; [Epub ahead of print].
Surgical team member assessment of the safety of surgery practice in 38 South Carolina hospitals.
Singer SJ, Jiang W, Huang LC, et al. Med Care Res Rev. 2015 Mar 31; [Epub ahead of print].
Sustainability and long-term effectiveness of the WHO surgical safety checklist combined with pulse oximetry in a resource-limited setting: two-year update from Moldova.
Kim RY, Kwakye G, Kwok AC, et al. JAMA Surg. 2015 Mar 25; [Epub ahead of print].
Patients' perspectives of surgical safety: do they feel safe?
Dixon JL, Tillman MM, Wehbe-Janek H, Song J, Papaconstantinou JT. Ochsner J. 2015 Mar 12; [Epub ahead of print].
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
Anne Collins McLaughlin, PhD. AHRQ WebM&M [serial online]. October 2010
John Gosbee, MD, MS. AHRQ WebM&M [serial online]. November 2006
Safe Patients, Smart Hospitals: How One Doctor's Checklist Can Help Us Change Health Care from the Inside Out.Pronovost P, Vohr E. New York, NY: Hudson Street Press; 2010. ISBN: 9781594630644.
The Checklist Manifesto: How to Get Things Right.Gawande A. New York, NY: Metropolitan Books; 2009. ISBN: 9780805091748.
Hilligoss B, Moffatt-Bruce SD. BMJ Qual Saf. 2014;23:528-533.
Introduction of surgical safety checklists in Ontario, Canada.Urbach DR, Govindarajan A, Saskin R, Wilton AS, Baxter NN. N Engl J Med. 2014;370:1029-1038.
Treadwell JR, Lucas S, Tsou AY. BMJ Qual Saf. 2014;23:299-318.
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.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.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.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.Pronovost P, Needham D, Berenholtz S, et al. N Engl J Med. 2006;355:2725-2732.
The checklist.Gawande A. The New Yorker. December 10, 2007;83:86-95.
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