Patient Safety at the Center of Error Disclosure: 3 Ways Checklists Help

by Sean Power
November 27, 2013

In 1999, the Institute of Medicine (IOM) reported that anywhere from 44,000 to 98,000 people die in American hospitals because of medical errors. The IOM also found that 90 percent of these deaths are the result of failed systems and procedures.

John T. James, founder of Patient Safety America, recently researched whether the IOM figures from 1999 were still accurate estimates. The study, published in the Journal of Patient Safety, found that between 210,000 and 440,000 patients each year suffer preventable harm—not the 44,000 to 98,000 previously researched by the IOM.

If Mr. James’ figures are accurate—which many critics believe is the case—that would make medical errors the third-leading cause of death in the United States.

Last year, The Huffington Post recently published an article about Alice Brennan, 88, who died as a result of preventable harm, reminding readers that real individuals make up these aggregate statistics, and that hospitals should strive to eliminate medical errors regardless of whether the total is 44,000 or 440,000, or any number in between.

When errors are committed and they result in either a near miss or an adverse event, disclosure to the patient poses legal and ethical questions. Those questions are beyond the scope of this article.

Instead, this post outlines how checklists can help communicate errors with patients.

In a May article on The Doctor Weighs In, I discussed the safety benefits of adopting checklists. Here, I outline the role checklists play in keeping patient safety at the heart of disclosure.

If 90 percent of deaths at hospitals caused by error are the result of systemic and procedural failure, as reported by the IOM in 1999, then checklists can prove useful in both preventing errors and explaining why the error occurred at all.

According to Peter Pronovost, M.D., Ph.D., FCCM (Professor, Departments of Anesthesiology/Critical Care Medicine and Surgery, The Johns Hopkins University School of Medicine and Medical Director, Center for Innovation in Quality Patient):

“To be accountable for patient harms, health care needs valid and transparent measures, knowledge of how often harms are preventable, and interventions and incentives to improve performance.”

Checklists can help strengthen systems and improve compliance to procedures. Here are a few more ways they can help with error disclosure and reporting.

1. Checklists ensure best practices are followed, reducing the likelihood for systemic or procedural failure.

When checklists are followed the chance for error is reduced. Even when things go wrong, checklists provide a resource for explaining the steps that were taken to prevent the error to patients and families. They can also help to illustrate the safeguards in place to prevent or mitigate adverse consequences.

For instance, the PCA Safety Checklist is offered as a free resource by the Physician-Patient Alliance for Health & Safety. It was developed by a multidisciplinary team of experts to minimize adverse events associated with patient-controlled analgesia (PCA).

The checklist sets out to minimize adverse events and maximize patient safety and health outcomes. It reduces the likelihood for systemic or procedural failure as a result of error.

In an article for The Doctor Weighs In, Paul Levy, a former CEO of a large Boston hospital, recently looked at the un-checked checklist, asking how many hospitals would publish reports about protocols not followed. By following checklists, clinicians can ensure they have done everything they could to keep the patient safe.

2. Checklists break down barriers to cultures of safety, further reducing the likelihood for error.

In a webinar with IHI Open School for Health Professionals in 2008, Dr. Pronovost shares his experiences with the first checklist he developed.

On the webinar, Dr. Pronovost candidly recalled that one of the biggest obstacles to implementing the checklist was not a lack of evidence for its recommendations but rather politics and breakdowns in teamwork. These traits are characteristic of a hospital environment that has not fully fostered the “culture of safety” advocated by the IOM in its 1999 report.

Disclosing a poor culture of safety as the cause for error is both difficult to do and beyond the scope of training for caregivers. Checklists can provide a lowest common denominator for caregivers from every discipline and can prevent politics from interfering with patient safety by giving everyone a common language for making decisions.

As Dr. Pronovost explains in the webinar, when the safety checklist was framed with the patient at the center, the politics disappeared. Checklists can therefore help to prevent errors that are caused by difficult-to-explain factors such as poor culture.

3. When errors do happen, checklists help communicate with patients and families how and why errors occurred, and what systems are in place to prevent failure in the future.

According to the AHRQ Patient Safety Network, components that matter most to patients include:

  • Disclosure of all harmful errors
  • An explanation as to why the error occurred
  • How the error’s effects will be minimized
  • Steps the physician (and organization) will take to prevent recurrences.

Checklists can be particularly useful for communicating the latter three components. By outlining the system in a short summary of recommendations, clinicians disclosing errors can pinpoint what went wrong, how the error’s impact can be minimized, and safeguards in place to prevent recurrences.

Checklists make it more straightforward to communicate errors with patients when they do happen.

11 thoughts on “Patient Safety at the Center of Error Disclosure: 3 Ways Checklists Help

  1. Sean, vey useful article. But the problem with checklists is they are based on outdated so-called best practices such as Six Sigma, and Continuous Improvement ( we need innovative improvements, not slow continuous improvements while patients are dying). We need to use Risk Analysis tools used in safety-critical industries. These tools are described in the ISO 14971 standard for medical devices. Hardly any hospital uses these tools. The Joint commission is now requiring one of these tools called FMEA (Failure Mode and Effects Analysis)

    Dev Raheja
    Author-Safer Hospital Care

    1. I agree, Dev, that checklists have their limitations. I attended a conference last week in Toronto on health quality and one of the panel discussions featured (intentionally) speakers from within and outside the health care industry (one from education, one from hydro). It was interesting to hear their thoughts on the particular challenges of the health care industry. My personal opinion is that if the people using checklists are aware of their benefits and limitations then they have a time and place to be used. I think that’s a statement that most people would agree with–I haven’t met anyone who categorically holds that checklists have no place in health care.

  2. Sean, This is an exceedingly usefl article that points out only too weel the significance of the IOM report on preventable harm and errors that have occurred to patients. I am a professional nurse of 37 years and checklist and the safety pause time of reflection we should all conduct does save lives. In particular for admisinistration of meds, a double check, a clinical side bar a visual checklist all serve as clinical reminders especially in a health care enviornoment where clinicians are decreasing from the work forces. Insyfficient staffing and lack f compentencies still continue to exist that are precursors of patient harm. One does have to take the time and efoort to keep checklistst current with best practice standards just as well do for policy and procedure review. New clinical information is continually being published and one has to take the responsibility to read and inform otheres of practice changes. There are great tools and clinical resoources out there, the PCA Safety Checklist is only one such tool. it is free to use and easy and worthwhile to adopt into practice especially with all the patient risk factors that may lead to harm with use of opioiods.

    I agree with Dev that there needs to be more frquent RCA’s conducted and mini one sas well- use those for the FMEA type performance improvment projects that are now required. You would be astounded in selecting one key issue how many points of failure, environment , comunication and work flow process there really are–that is what we need to tackle.

    It is Thanksgiving and I wish you all a happy and safe one with family and friends but wouldbe amiss if I did not Thank Sean for this article!- it places safety checklist in the forefront of the work that needs to be done to eliminate preventable harm.

    The main role is the safety checklists sets out to minimize adverse events,harm and maximize patient safety but t takes a human component to conduct introspection on all the causes of error. This is time consuming and needs honest accountablility to make a safety checklist functional and working as it should be- “an extra set of eyes”- so well worth the effort towards maximum patient safety.

  3. I made the above comment and forgot to leave my name: Lynn G Razzano RN, MSN,ONCC Clinical Nurse Consultant PPAHS Thank You!

    1. Sean, I fully agree. The checlists are necessary. Thanks Lynn for pointing out that we need “extra set of eyes” to make safety fully functional. FMEA tells us where we need extra set of eyes depending on the ctriticality of the harm. I have been doing FMEAs for over 25 years with several industries. I usually find at least 50 harmful scenarios on a process like surgery that we did not even consider. FYI: We need a checklist for young doctors. A Johns Hopkins research revealed that only 4% recent medical graduates look at the patients while communicating. The same may be true about recent nursing graduates.
      Dev Raheja
      Author-Safer Hospital Care

  4. Thanks Sean for your reply and feedback! Thanks Dev for responding as well. I totally concur with FMEA directing us on the extra set of eyes depending on the critical nature of the potential harm and harm analysis. Your vast and extensive experience with conducting FMEAs are right on target with pointing out at least potential of 5o harmful scenarios and selecting the FMEA working team and there specific analysis of how they may have impacted the harm event either via inefficient work flow processes, human communication, environmental factors all of which combined caused a harmful event. I have conducted FMEAs in the healthcare environment and they are very timeconsuming and need a strong champion, which I have no doubt you have been in your years of experieince.

    A FMAE Checklist would be great to develop as I don’t think everyone does the analysis and contstruct in the same consistent critical thinking manner. Your idea of a checklist for young MD’s /Recent Nursing grads looking at their patients while communicating is a great one! This is the absolute way we can visually conduct a thorough physical assessment as well as identifying gaps in the patient’s ability to be a “good “historian. Both parties need to be “engaged ” in the level of understanding of critical conditions that may cause potential harm or interventions need tobe developed to avert problems- Looking at a patient and having visually maintaining eye contact is the way I was trained. This needs to be placed back on track as continuous and ongoing assessment throughout the continuum of care is a necessary function and task never to be ignored or there’s is likely and “oops” that could havew been prevented!

    Thanks Sean and Dev for your great comments Best regards Lynn Razzano RN,MSN,ONCC

    1. Lynn, thanks for your inputs. If someone does develop a checklist for recently graduate doctors and nurses, please let me know at You made a good point: Both parties (care givers and patients) need to be “engaged ” in the level of understanding of critical conditions that may cause potential harm or interventions need to be developed. Unfortunately, according to Gallup organization of wide range of industries, less than 30% employees are engaged who are willing to walk an extra mile (from my book “Safer Hospital Care.”). Same ssems to be true of patients. Even the patients need a checklist in their own proactive treatment.
      Dev Raheja
      Author-Safer Hospital Care

  5. Sean,

    I like the post and the solid feedback.

    In your post you noted – “the biggest obstacles to implementing the checklist was not a lack of evidence for its recommendations but rather politics and breakdowns in teamwork.” I would like to add to this a lack of full accountability. Our checklists are linked to performance evaluations. We have been using checklists for more than five years. With nearly 40,000 patient encounters on a monthly basis and approximately 4,000 tasks in four locations, checklists help ensure the simple stuff get done. As most of you may know, the paper checklist has its drawbacks; so we created an application, which significantly improved compliance and overall operations. We are in the process of redesigning the desktop application for mobile and tablet devices. I will update you guys when we have a firm release date for the new version. I would love to get this group’s feedback.

  6. I totally agree with the addition of lack of full accountablity as a huge contributing factor as a major obstacle to implementing checklists. I agree wholeheartedly that checklists should be linked top performance evaluations and annual competencies that are reuired to be maintained and current. A checklist is just as you say helps to ensure the simple stuff gets done and paves the way to deal with complex work processes. It is a check and balance assurance.
    I applaud the creation of a checklist application for mobile and tablet devices this ensures keeping pace with the new technology and promotes the use of the checklist for patient safety no matter where the clinician is in “Real Time” I would be interested in reviewing when finalized as I would be able to offer Clinical feedback as well as if it is user friendly for a clinician to utilize and save time. My e-mail is :
    I value you adding comments and replying to Sean’s great article. I hope others with do as well-clinically sharing is so critical in this Health Care environment!

    Thanks Lynn Razzano, RN,MSN,ONCC

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