Error prevention using checklists is one strategy used by the aviation industry that was later integrated into healthcare to improve patient safety. The following story provides one such example.
On Wednesday, October 30, 1935, an evaluation flight of the Boeing Model 299 was undertaken at Wright Field, northeast of Dayton, Ohio, USA. The Model 299 was the most technologically sophisticated aircraft of its time and was nicknamed the Flying Fortress because of the extent of its armaments. Major Ployer P. Hill was the pilot, and it was his first f light in the new aircraft. The aircraft appeared to ascend normally, but suddenly stalled, turned on one wing, and crashed, killing two of the aircraft’s five crew, including Major Hill. The investigation into the crash discovered that Major Hill had omitted a crucial step during the preflight preparation; he forgot to release a catch, which on the ground locked the aircraft’s control flaps. Once in the air, this mistake rendered the aircraft uncontrollable.
The crash investigators knew that there was probably no one better qualified to fly the new aircraft than Major Hill — his co-pilot was also highly qualified — yet despite this, the fatal error was still made. The investigators concluded that given the experience of the pilots, further training would not be an effective response to prevent such an event from happening again; a response that is very different from that which often occurs in health care when a mistake is made. Some commentators initially believed that this meant the new aircraft was simply too complicated to fly reliably. A new approach was needed, and it took the form of a simple list of crucial tasks that must be completed before the aircraft could leave the ground. The first aviation checklist had been devised. With the checklist in use, despite the aircraft’s sophistication, the Model 299 (and later versions of it) performed safely for many years. (Webster, 2017, p.178-179).
Checklist integration into healthcare
The use of checklists was eventually integrated into healthcare. An early, well-known checklist was the Surgical Safety Checklist developed by the World Health Organization (WHO). Like aviation, the operating room involves high technology in a complex environment. The surgeon leads and is assisted by a multidisciplinary crew, all of whom must follow key steps to ensure patient safety. The checklist promotes team communication and standardization by reviewing key items before and after the procedure. Studies have shown significant reductions in post-operative complications when the WHO Surgical Safety Checklist is used (Webster, 2017). Checklists seek to ensure the same steps are followed or completed every time. They reduce reliance on memory, which can fail, especially when healthcare workers are distracted, stressed, or multitasking. Checklists also promote teamwork and communication because they get everyone on the same page regarding care information.
Effective checklists
Effective checklists are user-friendly. They’re brief, ideally one page; legible; and able to be read aloud. They include critical steps and designate team role responsibilities (e.g., circulating nurse reviews a time out checklist with the team) (Bernstein, 2017). The best time to review the checklist should be considered when designing it.
Designing an effective checklist involves multidisciplinary staff input, making sure to include those who will be using the checklist. These team members may serve as champions for the checklist during day-to-day operations.
Checklist implementation
Planning for checklist implementation is important. Having potential users practice the checklist during a simulated care situation often generates ideas for checklist improvement, such as how to ensure compliance. During the simulation, the rationale behind the checklist and the evidence supporting it can be reinforced, which helps gain buy-in. Other checklist protocols can also be reviewed, such as being mentally present and referencing the checklist for each item (as opposed to reciting the steps from memory and checking the boxes after).
The next step can be a trial program. The checklist is used by a small group, who evaluate it and determine if it needs modifications. Once trialed, the checklist is ready for widespread use. Finally, checklist compliance may be measured and evaluated to determine if implementation has been successful. An audit can be done during the initial implementation and periodically afterward.
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Copyright by Jeanette Zocco MSN, RNC-OB, C-EFM, C-ONQS
References
Bernstein, P. S., Combs, C. A., Shields, L. E., Clark, S. L., Eppes, C. S. (2017). The Development and Implementation of Checklists in Obstetrics. Society for Maternal-Fetal Medicine Special Report, 2017, pp. B2-B6. doi: 10.1016/j.ajog.2017.05.032
Webster, C.S. (2017). Checklists, Cognitive Aids, and the Future of Patient Safety. British Journal of Anaesthesia, (119)2, pp. 178-181. doi:10.1093/bja/aex193.
Boeing B-17 Flying Fortress. (2021, November 24). Retrieved from https://en.wikipedia.org/wiki/ Boeing_B-17_Flying_Fortress