Error Prevention Using Checklists

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

After decades of proven use in the aviation industry, checklists were later integrated into healthcare. How could a safety feature from the aviation industry be useful in healthcare? In The Checklist Manifesto, surgeon Atul Gawande highlights the current challenge in medicine: the sheer volume and complexity of knowledge has surpassed human capacity to use it accurately, safely, or consistently- similar to that experienced by pilots with technologically advanced aircraft. The consequence of this is avoidable failures, and the proposed solution- a checklist (Gawande, 2010). 

Checklists aid in integrating scientific evidence by standardizing protocols and essential steps in care processes, thus minimizing human error. They serve as cognitive aids, ensuring critical checks are not missed and safeguarding open communication, coordination, and responsibility among team members. Checklists provide a mental safety net, catching errors that may arise from lapses in memory, inattention, or lack of completeness. In fact, they reduce reliance on memory, which can fail, especially when healthcare workers are distracted, stressed, or multitasking. 

Checklists should, however, leave the management of unpredictable and nuanced situations in the hands of the professionals doing the work (Gawande, 2010). When used effectively, checklists are used for simple yet critical steps, leaving brain space for more complex, critical thinking. In this way, checklists help rather than hinder the work. 

Consistent application of checklists has been shown to improve patient outcomes in many areas. An early, well-known example of this was the central line insertion checklist implemented by ICU teams within Michigan hospitals in the Keystone Initiative. It included five simple steps, tasks such as washing hands and wearing a mask, that are seemingly so obvious. Yet, observation had found these steps were often skipped. Results of this study, published in the New England Journal of Medicine in 2006, showed a 66% reduction in central line infections within three months of project implementation. This work was sustained over several years, saving an estimated 500 patient lives, and 175 million dollars in costs (Gawande, 2010).

Another example of successful checklist integration 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. Studies have shown significant reductions in post-operative complications when the WHO Surgical Safety Checklist is used, including: a 36% decline in the rate of inpatient postoperative complications, a 47% decrease in surgical mortality, a 45% decrease in surgical site infections, and a 25% decrease in unplanned returns to the OR (Haynes et al., 2009; Webster, 2017). While these initiatives demonstrated the undeniable value of cognitive aids, producing similar outcomes at the bedside requires careful attention to how a checklist is designed and implemented into practice. 

Checklist design and characteristics

Simply having a checklist doesn’t mean that people will follow it- two important considerations are design and implementation. Earlier lessons from aviation taught us much about how checklists must be designed to be highly effective. They were developed by veteran pilots who learned by studying thousands of crashes and near misses. Good checklists are specific and practical. They detail the most important steps, including ones that even seasoned staff could miss (Gawande, 2010). They also designate team role responsibilities (e.g., circulating nurse reviews a time-out checklist with the team) (Bernstein, 2017). Designing an effective checklist involves gathering input from those who will be using the checklist, which also helps to ensure buy-in. These team members may also serve as champions for the checklist during day-to-day operations.

Key considerations include:

• Workflow timing: Determine at what point in the workflow the checklist will be used 

• Checklist Type: Based on the situation, decide whether it is a “DO-CONFIRM” or “READ-DO” checklist (Gawande, 2010, p.123)

  • DO-CONFIRM- team members perform steps, typically separately, and then the team pauses to confirm all steps have been completed

  • READ-DO- team members perform the tasks as they cross them off the list

• Length: Keep it short (general recommendation is 5-9 items, the operating memory limit)

• Clarity: Use simple wording 

• Format: Ideally keep it to 1 page (Gawande, 2010)

• Adaptability: One size does not fit all- adjustment based on unique needs of the unit, staff, and available resources may be necessary 

When the checklist design is completed, the focus shifts to creating a rollout strategy that effectively brings the tool to the bedside. 

Implementation strategies

After designing the checklist, careful consideration to how it is rolled out into practice 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 nuances of checklist integration 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). Simulation also allows for muscle memory integration- practicing it with the team allows it to feel right in the moment. 

Before widespread implementation, the checklist can be trialed as a pilot test- with a small group, or a particular shift, to further evaluate and determine if it needs modifications. Once trialed, the checklist is ready for broader use.

These strategies address the logistical components; another key consideration is strong cultural accountability for using the checklist. Without this, checklist integration will not be successful.  Clinical adoption involves empowering staff to hold themselves and one another accountable for following the steps. This concept is called 200% accountability- meaning everyone owns the individual responsibility to do the right thing, at the right time, with the right patient, in the right manner, to ensure the right outcome, AND when workload permits, also holds others accountable to do the same. In practice, this looks like cross-checking one another if a colleague forgets a checklist step or is not following the process correctly, and generally speaking up with safety concerns. When everyone understands this is the expectation, and folks are held accountable for following this, processes are followed and patient safety and positive outcomes are maximized. 

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 to determine compliance with use. This data should be shared with staff transparently. Following a study-and-adjust approach, minor changes can be made as needed. 

This approach represents a successful blueprint for integration- performing the bulk of preparation “up front” with staff input and buy-in, practicing what it will look like, using data to drive change and addressing cultural accountability. 

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. American Journal of Obstetrics and Gynecology, 217(2), B2–B6. https://doi.org/10.1016/j.ajog.2017.05.032

Gawande, A. (2010). The checklist manifesto: How to get things right. Metropolitan Books.

Haynes, A. B., Weiser, T. G., Berry, W. R., Lipsitz, S. R., Breizat, A. S., Dellinger, E. P., Herbosa, T., Joseph, S., Kibatala, P. L., Lapitan, M. C. M., Merry, A. F., Moorthy, K., Reznick, R. K., Taylor, B., & Gawande, A. A. (2009). A surgical safety checklist to reduce morbidity and mortality in a global population. New England Journal of Medicine, 360(5), 491–499. https://doi.org/10.1056/NEJMoa0805019 

Webster, C. S. (2017). Checklists, cognitive aids, and the future of patient safety. British Journal of Anaesthesia, 119(2), 178–181. https://doi.org/10.1093/bja/aex193

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About the Author

Jeanette Zocco, MSN, RNC-OB, C-EFM, C-ONQS, is a leader in perinatal quality and safety with 28 years of experience in obstetrics. She has served as a bedside nurse, charge nurse, clinical nurse leader, perinatal safety nurse, and quality improvement specialist. Currently, she is a perinatal patient safety program manager, supporting quality and safety work for a multi-hospital healthcare system. Jeanette is recognized for developing innovative perinatal quality and safety programs in collaboration with multidisciplinary teams.

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