Atul Gawande is a famous surgeon from Boston that previously had published books about his profession. His book “Checklist manifesto” is about his interest in working with checklists in the hospital environment and his involvement in the creation and test of the WHO checklist.
Failure can be caused by either having not enough knowledge to be able to perform correctly (ignorance) and through the failure of using the knowledge that we do have (ineptitude).
Much of the failure in hospitals are due to ineptitude by either not being aware of the latest knowledge, forgetting knowledge that one has, or did not take the time for to use it. Checklists, as shown later, are very good at catching failure due to ineptitude.
Checklists in some way have been used to a long time in the hospital through the charts the vital signs: temperature, pulse, blood pressure and respiratory rate. However, those charts have mainly been kept by nurses.
One of the early successful examples of checklists has been done by Peter Pronovost in the John Hopkings hospital ICU (1). By implementing a checklist for the insertion of venous catheter, with the goal of preventing infections. In practice many doctors forgot elements of the procedure and were working less than ideal in respect to sterility. Aspects of this checklist were:
it created more collegial control by nurses to doctors since the procedure was clearly laid out;
there was less possibility to forget steps in the procedure;
the procedure established a clear baseline so no more discussion about how to act was needed anymore. Deviations without reason was prevented.
Results were spectacular with the rate of infections going from 11 in 1000 catheter days to 0 in 1000. The main effect of the checklist was an adherence to a procedure that almost all knew but many forgot to act on.
Work in hospitals have become more and more specialized, leading to more and more people involved with the same patient. No single doctor has an overview of it all. Based on the engineering professions Gawande describes how checklist are used here with the idea in mind that there is no more master builder who can comprehend it all. The involved disciplines need to discuss issues and ensuring this communication and follow up is now the way to guard building process. Beside a detailed activity plan (that is also a sort of checklist) a dynamic checklist is used to ensure the relevant communication takes place and is followed up. Nobody knows all but when the right people share information enough redundancy is created to enhance safety.
From aviation sector it can be learned that:
- normal checklist need pause points where people can focus (for a short time) on handling the checklist;
- some checklists are used in emergency situations;
- the use of checklists needs to be trained, especially since using a checklist feels awkward in the beginning;
- checklists need to be tested extensively in simulation environments since they are often used in high pressure environments.
There are two types of checklist: do-confirm (as a check after the proces: did I do it all) and a ready-do type (check every item using the checklist as lead. (In aviation most checklist are of the ready-go type)
General remarks about what should be on the checklist:
- 5 to 9 items per pause point
- 30 to 90 seconds to finish the process
- simple and exact wording
- 1 page
Not everything that needs to be done has to be on the checklist, some things are not easily forgotten because they are part of the culture or create their own trigger of attention. And of course there needs to be a disciplined process where everyone uses the same checklists, especially in environments where different expertises need to work extensively together.
The final WHO checklist (2) has three pause points: before anesthesia (when the patient is still awake and can be part of the process), before incision (where the team can focus on the major steps and risks of the procedure) and just before the patient is wheeled out of the operating room (to check if everything is ok and all preparation for handover is taken). One of the remarkable facts of the WHO checklist test is that 78% of people involved had at least caught one error by using the checklist.
One of the difficult transitions that medicine as a profession needs to take to accept the use of checklists is the hero culture it now has. Surgeons and other medical professionals have to become more “the same” just as pilots of commercial airliner are more the same since they all are using the same checklists and procedures. One of the bottlenecks in this process is that it is hard to teach professionals that already work in the field the value of checklists since in 999 of the 1000 cases in retrospect it was not needed to check it. However, it is done for the 1 out of 1000 cases where several aspects are such that a risk can become active.
(1) Berenholtz, S. M., Pronovost, P. J., Lipsett, P. a., Hobson, D., Earsing, K., Farley, J. E., … Perl, T. M. (2004). Eliminating catheter-related bloodstream infections in the intensive care unit*. Critical Care Medicine, 32(10), 2014–2020. doi:10.1097/01.CCM.0000142399.70913.2F
(2) Haynes, A. B., Weiser, T. G., Berry, W. R., Lipsitz, S. R., Breizat, A.-H. S., Dellinger, E. P., … Gawande, A. A. (2009). A surgical safety checklist to reduce morbidity and mortality in a global population. The New England journal of medicine, 360(5), 491–499. doi:10.1056/NEJMsa0810119