TAKE-HOME POINTS
■ Checklists can be an effective tool to guard against memory lapse and promote attention. They can also be used as a vehicle to update practices and comply with standards of care.
■ Improved team performance and better communication and collaboration are beneficial aspects of their use.
■ In the hectic world of modern health care, a simple checklist is not only easier to implement but more likely to be completed.
■ Checklists cannot solve every patient safety problem. They are effective only when discrete tasks can be identified and evidence-based support exists for the listed items.
■ Checklists can address certain types of errors but cannot account for errors that occur as a result of inadequate or improper training or lack of experience.
The scene is an operating room—nearly any operating room in the United States. The patient is awake on the table; the team is assembling around the suite to begin surgery. The surgeon commands, "Put him under, let's do this." An advocate for the patient speaks up. "What about the checklist?" "Excuse me?" the surgeon asks. "The safe surgery checklist," suggests the advocate, displaying the checklist card. "I've had 10 cases today," groans the surgeon. "All the more reason to take the necessary precautions," replies the advocate, "it will only take a minute." "One minute," replies the surgeon.
"John Carter, here for a right cadaveric renal allograft." Correct.
"Does the patient have a known allergy?" No.
"Does anesthesia anticipate a difficult airway?" No.
"Is the risk of bleeding higher than 500 cc?" "I sure hope not, ok, let's put him under," replies the surgeon.
"Let's take our time and introduce the room." Each team member introduces themselves and states their role in the surgery.
"Any concerns from the surgical team?" "Only that you are wasting my time," snaps the surgeon.
"Any nursing concerns?" "We don't have any reperfusion solution," says the scrub nurse. "We won't be needing it," says the surgeon. "I'll have some sent up," offers the circulating nurse.
"Were antibiotics given in the last 60 minutes?" "Just starting them now."
The surgery begins. Near the end of surgery, the clamps are removed but the kidney fails to pink up. A renal artery thrombus has formed. The kidney needs to be removed, the thrombosed artery cleared, and the kidney reattached. In the interim, the kidney is bathed in reperfusion fluid. The fluid would not have been in the operating room had the checklist not been followed, which would have led to potentially serious complications. The scene closes with the surgical intern asking where he can get a copy of the checklist.
Although this scenario could happen in any operating room, it was played out as an episode of ER that aired in March 2009. The patient's advocate was the character surgeon Peter Benton. The scene illustrates several important points about using checklists: First, checklists don't need to be complicated or take very long to complete. Second, use of checklists can save lives and prevent medical errors. Third, although it was exaggerated for television, routine use of checklists needs to be fully embraced in order to be effective. This article addresses each of these points.
SIMPLE IS BETTER
In the past year, two books written for the general public have promoted the use of checklists as a way to improve patient safety and efficiency in health care.1,2 The authors, Atul Gawande, MD, MPH, and Peter Pronovost, MD, PhD, are experienced in designing and implementing checklists, and they persuasively demonstrate how checklists can reduce errors, improve patient care, and save money. Checklists can be an effective tool to guard against memory lapse and promote attention. They can also be used as a vehicle to update practices and comply with standards of care. Some of the most beneficial aspects of the checklists are improved team performance and better communication and collaboration.
The Agency for Healthcare Research and Quality (AHRQ) defines a checklist as an algorithmic listing of actions to be performed in a given clinical setting; the goal being to ensure that no step will be forgotten.3 Many organizations that conduct routine functions that could lead to a catastrophic disaster if an error were to occur regularly use checklists to minimize risk and improve performance. Major building construction projects, nuclear power facilities, and the military routinely employ simple yet often very elaborately connected safety systems, of which checklists are the foundation. When discussing safety, other industries are often compared to the aviation industry, which has regularly used checklists for routine and emergency procedures for decades.
Checklists as a tool for improving safety and preventing errors were introduced to military aviation in the 1930s. After a highly trained and experienced test pilot crashed the remarkable new Boeing Model 299, later known as the B-17, aviation experts realized aircraft were becoming too complex to operate safely without standardized procedures. Unlike aircraft of earlier generations, the number and complexity of procedures meant that operating procedures could not be committed to memory and performed consistently without an aid. Checklists were a simple and effective solution that outlined specific tasks for each crew member to complete at various times throughout the flight and while on the ground.4 After implementation of the new checklist for the Boeing Model 299, pilots logged 1.8 million miles of air travel without an accident.5
Gawande stated that medicine has now entered its B-17 phase.5 Many routine functions in health care have become wrapped in system complexity, and a simple checklist is an ideal method for ensuring that the most important steps are not forgotten. In 2009, Gawande and his colleagues with the Safe Surgery Saves Lives Study Group published the results of their study on the impact of using a surgical safety checklist, which was conducted at eight hospitals.6 The checklist was the model for the one used in the ER episode described above. The entire checklist comprises 19 items that are performed during three different phases of surgery: (1) before induction of anesthesia, (2) before skin incision, and (3) before the patient leaves the operating room. The complete checklist can be found at the World Health Organization's Web site7 (Figure 1).
Pronovost investigated using checklists to reduce the incidence of catheter-related infections in the ICU.8 The study was conducted through the Michigan Health and Hospital Association Keystone Center for Patient Safety and Quality and became known as the Keystone ICU project. Its checklist included only five main items and was launched at more than 100 Michigan hospital ICUs in October 2003. These items are evidence-based and recognized by the CDC as having the greatest impact on reducing infection, but they also have the lowest barriers to implementation:
• Wash hands with soap and water
• Clean the patient's skin with chlorhexidine antiseptic
• Use full-barrier precautions during insertion
• Avoid using the femoral site, if possible
• Remove the catheter as soon as it is no longer necessary
In the hectic world of modern health care, a simple checklist is not only easier to implement but more likely to be completed.