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The Safety Checklist

During my recent stint covering the Neuro ICU I noticed for the first time a checklist posted above each patient bed. The checklist covered the steps to undergo whenever performing an invasive procedure on the patient. I was glad to see that the checklist phenomenon had penetrated my hospital, although the implementation of safety checklists is far from complete.

A recent study published in the BMJ offers support for the efficacy of using checklists to reduce complications and improve patient outcomes. This is a retrospective study looking at mortality and length of stay in Michigan area ICUs, comparing those that had implemented the Michigan Keystone ICU project (including a safety checklist for the placement of central lines) with local ICUs that had not implemented the project. They found a 10% decrease in overall mortality, but the results were not significant for length of stay. Because this was a retrospective study it was not designed to prove cause and effect, but it is highly suggestive of the efficacy of implementing such checklists.

The checklist trend represents a culture change within medicine – and a good one. This change received its greatest boost with the publication of The Checklist Manifesto by Dr. Atul Gawande. He presents a compelling case for the need and efficacy of using checklists in order to minimize error.

He argues that historically medicine has had a culture of quality control through individual excellence and training. This culture still pervades medicine. Each year, for example, I have to go through a long list of safety and other training – the standard response of the powers that be is to institute a new training and certification program for each new regulation or identified safety issue. Training is good, but increasingly there is recognition that it is not adequate.

The problem, Dr. Gawande points out, is that there are areas of our complex civilization that are too complex for mere humans to adequately master. Or you can look at it from the perspective of minimizing error. Training to deal with a complex system can only minimize error to a certain degree. There are inherent human limitations of memory, attention, and consistency that mean that error will be inevitable. In situations where minor mental errors can have catastrophic consequences (like flying planes or performing major surgery) relying on training alone is folly. In such situations the implementation of a simple checklist can significantly reduce error far below what training alone can. It is a lot easier to remember to follow the checklist than to remember each item on the checklist.

There is no question that medicine is a high stakes and complex game. While I am a strong advocate of science-based medicine, we have to recognize its limitations. The opportunities for catastrophic error in medicine are enormous – from prescribing the wrong medication or dose, to forgetting important steps in a complex procedure, to removing the wrong limb. Even minor errors or oversights can have extreme consequences.

In medicine the overarching consideration of any intervention is risk vs benefit. We only use interventions that have potential benefit that is greater than the potential risk (while also understanding that our information is probability-based and imperfect). Often our knowledge is based upon clinical trials which are highly controlled, and therefore do not have the same risk of error that is likely to exist when implemented in the “real” world outside of a clinical trial. In any case minimizing error is key to minimizing risk and optimizing the risk-benefit ratio of medical interventions.

It seems that we have pushed the limits of training. Medicine has become highly technical, specialized, and complex. While extensive training is necessary, it is no longer sufficient to minimize risk. We are now entering the age of the checklist. This is a simple procedure that can significantly improve human performance. The latest study is further evidence in support of this. A 10% reduction in mortality is highly significant.

A related phenomenon, in my opinion, is the movement toward a team approach to patient care, especially in highly complex cases. There is increasing recognition that group intelligence can vastly outperform individual intelligence, and that a group can be smarter than even its smartest member. Complex or high risk cases can benefit from a team of experts, especially with a variety of specialties, collaborating on care. This is nothing new in medicine – tumor boards and multi-disciplinary clinics have been around for decades. But there is movement toward greater reliance on teams than on individual experts.

This is related to the checklist phenomenon in that both trends represent a movement away from over-reliance on the individual and training to minimize error and maximize performance. Both recognize the crushing complexity of modern medicine, and the need to be humble before this complexity.

To broaden the context further, I think these phenomena represent increasing recognition that we need to pay attention in medicine to how our knowledge is implemented, not just to the acquisition of greater knowledge. Pushing the limits of medical knowledge is, of course, incredibly important. But we also have to pay attention to how that knowledge is disseminated, how it is received by the public, how it affects regulation, and how it is implemented by systems and by individuals. We also need better understanding of these processes – we need increased  medical meta-knowledge. We need to learn how to deal with this vast body of scientific information we are rapidly accumulating.

Posted in: Public Health, Science and Medicine, Surgical Procedures

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10 thoughts on “The Safety Checklist

  1. tmac57 says:

    Because surgeons need to be highly confident individuals,does this personality trait ever pose a barrier to their acceptance to measures such as a safety checklist?

  2. hat_eater says:

    Like this? :)
    Quote from the above post by Steven Novella: “This approach works, but may rub some physicians the wrong way – those trained in the culture of individualism and personal prowess and responsibility (sometimes referred to within medical circles as the “cowboy” approach – a term meant to be a little derogatory, although simultaneously containing a measure of respect).”

  3. CrookedTimber says:

    I transfered to a new position a couple of years ago that requires many hours each summer flying in small Cessna aircraft around the Rocky Mountains. I was a little unnerved at first when the pilot continually had a laminated checklist on his lap. I was thinking “after thousands of flight hours this guy still has to check how to take off?!” I soon realized (especially after taking beginning flight courses myself) that the checklists were always required for every pilot regardless of experience.
    I think it works wonderfully and may even be more important for those most experienced as that is when complacency can creep in. I’ve tried to incorporate the procedure into other things I do as well. You might be surprised how many times you almost overlook a small but important detail.

  4. Ray Greek MD says:

    As an anesthesiologist and pilot I am a huge fan of checklists.

  5. ConspicuousCarl says:

    Maintaining a constant order of operations, whether written down or not, makes omissions much more obvious than a “wing it” method in which you do things as you think of them.

    Before all of this newfangled CD-burning and mp3 stuff came along, you always heard your favorite songs in the same order as they were recorded on the CD or record, and you knew what was coming next. If you switch to a “best of” or mix CD, you notice that Money for Nothing ended but Walk of Life didn’t come next. You don’t even have to think about it, the brain objects on its own.

    I process stuff at work which can be a total pain in the butt if even a small mistake is made and not found until later. I don’t use a physical checklist, but I get the same benefit by maintaining a methodical and orderly process for each item. My job is much simpler than medicine or even piloting, but I do have multiple details to verify which could be done in any order. I find that a strict regimen makes it harder to forget any one thing.

    Checklists are a good way to ensure that kind of order, in which omissions stand out, when performing longer routines. Checklists may strike the anti-bureaucracy nerve. “I’ve got important stuff to do, I don’t have time for paperwork!” However, a checklist is not so much an extra task as it is a standard of putting on paper the stuff you should be doing anyway. The only real extra activity imposed is having to look at a line of text after each task.

  6. nybgrus says:

    Agreed. In medicine we are taught that you need to get into a routine and approach the same task in the same way every time. It makes it more efficient and less prone to error. This is wonderful for simple tasks (like when I had to do 20 EKGs a night and did them in EXACTLY the same way EVERY time) but for more complicated things get more difficult. The real power of a checklist though is not in maintaining a routine or helping us through the mundane – it is to focus us when we are otherwise inclined NOT to be focused.

    Take for example a routine surgery, say an appendectomy. A good surgeon can do this laparoscopically in as little as 20 minutes. However, you need to ensure that antibiotics are given BEFORE the first incision, along with a whole host of other things. It can be mundane enough a surgery that you gloss over some detail because you don’t need to devote your full mental acuity to performing the surgery. Or because you are tired and have been on call for 24 hours. Or because you are squeezing in the case between trauma surgeries. Or because you got an urgent call from the ICU about your patient. Etc, etc, etc. The checklist then becomes invaluable because it frees your mind to actually focus on those other things! You can be sure that you have done what you need to do for that mundane surgery because the boxes are ticked which gives you clock cycles in your brain to focus on the more pressing and less mundane issues surrounding your boring ol’ appy.

    The pilots that were the heroes in that plane that crashed in the Hudson way back when consistently stated that they did nothing extraordinary – they merely were trained in the very efficient and rapid use of their checklists. Because they ran through it they did not miss a single step of a very complex scenario and thus safely landed the plane.

    Medicine has a tradition of being the field of individual expertise. There was, in fact, a time when I physician could know most, if not all, of the medicine surrounding his/her field. That was because the knowledge was very limited and patient outcomes were unsurprisingly poor (relative to today’s standards). As knowledge grows it becomes impossible for one human being to encompass the full breadth and depth of knowledge and it is important to acknowledge that – but the “cowboy” attitude of medicine is a hard one to ditch.

    From Gawande’s book: ICU’s were studied and it was impressive. The error rate was often BELOW 1%. That means that as humans, we have achieved an ability to be on the ball 99% of the time. Which is massively impressive. Now put that in perspective – the average ICU patient receives ~120 interventions per day (everything from serious invasive stuff to hanging a bag of saline). That means that, on average, more than 1 mistake per patient per 24 hours is made, even at a BETTER THAN 99% accuracy. One can imagine that most of those mistakes are very small and inconsequential (delaying saline by 30 minutes, accidentally giving 30cc extra saline, etc) but some will not be. And btw, an extra 30cc of saline CAN be a very big deal in the ICU. Now multiply that by all the ICU patients in the US and by 365 and suddenly you have a large number of people suffering serious adverse affects in a (nearly) perfectly working system. There must be a better way… and I think Gawande persuasively argues for the checklist (and a less hierarchical, more team based approach, which includes nurses and other allied health – not JUST doctors).

  7. akg2011 says:

    As I was reading this I was reminded of an anecdote I’ve used many times… I’m a software development manager, and programmers, being the creative bunch they are, hate checklists, feeling that they are somehow demeaning and that they stifle creativity.

    We had a family friend who was a 747 pilot and I would periodically ask whether he was on board when flying. I never did see him, but on one occasion was invited to sit in the cockpit from the time we were sitting at the terminal until we leveled off (obviously pre 9/11). As part of the pre-flight checklist, either the pilot or co-pilot held a checklist with about 10 items printed in large print. He would hold his finger against each item in turn, read it out, the other would point to the appropriate dial and read out the value, they would then agree that it matched and move on to the next item.

    Given that there were only 10 items in the list, and that they checked them before every flight, what was the chance that they *didn’t* know the list by heart?

    The moral was that checklists aren’t a workaround for stupidity, but as Steve said, people make mistakes. And as others have said, having checklists actually frees you up to be creative, focus on the important stuff, etc.

  8. Monkey Man says:

    1. When I had surgery a dude came up to me and asked me if my left was the bad one. I said yes and he marked an x on it. I thought, wow that was really not a confidence booster. There are millions of things technology can forward thinking can do for medicine, the fact that we’re only now seeing the “checklist revolution” that has led to countless saved lives in the last several years is also not very encouraging… ONWARD SCIENTIAN SOLDIERS

  9. nimonik says:

    Checklists do save lives, that is why we are building the largest database of medical (and other) checklists and making them available free of charge.

    We are looking for great medical checklists, please contact us if you are interested in checklists on iPad or iPhone.

    Our current database is here:

    https://www.nimonikapp.ca/checklists

    And our iPad tool is here:

    http://www.nimonik.ca/features/ehsq-reporter-for-ipad-iphone-and-ipod-touch/

    Thanks!

    Jonathan

  10. morningperson says:

    My recently inspired dental hygiene appointment checklist:

    Health History review/update
    Chief Complaint evaluation
    Xrays &/or periochart
    Oral Cancer Screening
    Restorative needs screening
    Perio evaluation/ cleaning
    -polish
    -floss
    -mn ant.
    -mn post
    -mx
    Dr. exam
    Fluoride
    Schedule next appt.

    This website is wonderful! I’ve also created lists for starting the day & changing the rooms between patients. I’m just exploring the SBM wesite now, but am looking for articles regarding the Dr. Oz anti xrays show http://palmbeachsmiles.blogspot.com/2011/01/dont-get-dental-advice-from-dr-oz.html and your article on his “journey to the Dark Side” made me feel better that I’m not alone with my rapidly diminishing opinion of him.

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