Safety Checklists Hold Potential But Healthcare Industry Needs to Reexamine Fundamentals, According to BMJ Viewpoint

By Sean Power

Discussion about safety checklist efficacy needs to review the fundamental principles of checklist uses, according to Dr. Robyn Clay-Williams, Australian Institute of Health Innovation, Macquarie University, Sydney, and Dr. Lacey Colligan, Division of Quality and Value, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire, USA, in a BMJ Quality & Safety Viewpoint.

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Dr. Clay-Williams and Dr. Colligan summarized some of the current dialogue around safety checklist efficacy:

  • Success requires cultural and organizational change efforts
  • Results can be confounded by both technical and non-technical variables, and
  • Local contexts can impact outcomes.

Healthcare safety checklists have been tried on six continents to varying degrees of success. By examining why checklists might work and how they can be better implemented, the authors suggest healthcare professionals may be able to fulfill the original promise of checklists.

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Below we have highlighted some passages from the Viewpoint that stood out as particularly important when it comes to patient safety and quality.

Safety Checklists for Normal Procedures

According to the authors:

“‘Normal’ checklists are effective whenever there are advantages to standardizing performance, time is not critical, the series of tasks is too long to be committed to memory (or there are likely to be interruptions to execution of the task that might interfere with memory retrieval), and the environment enables a physical list to be accessed and used.”

Safety Checklists for Emergency (Non-Normal) Procedures

“Despite notable exceptions (such as ‘choking’ under pressure), procedural memory retrieval is less affected by stress than declarative or episodic memory retrieval. For this reason, aircrew practice time critical emergency procedures regularly to aid in forming the correct ‘habits’. However, as soon as time permits, the checklist is used to confirm that the steps were executed as required.”

WHO Surgical Safety Checklist

“Checklists are suited to verification of procedures for linear processes; whereas briefings are suited to support execution of complex processes that may require appropriate adaptation and variation. Briefings are important because surgical outcomes are complex and emergent, and optimal performance of surgical procedures may require flexibility to accommodate the unexpected, however briefings should be instituted separately from the checklist. If briefings are too closely coupled to checklist completion, teams may miss the cognitive shift required to move from linear or procedural work to complex or adaptive work.

“Each clinician’s role in the checklist should be formalized for the surgical setting, so that when tempo is high, steps are not missed. Third, compliance requires that boxes be ticked. This means that at least one team member will be occupied with completing the checklist and thereby not be available for other tasks.

“When it comes to checklist implementation, it is important to recognize that aviation checklists are integral to the normal workflow. The aircraft does not stop while the checklist is completed, and the timing of checklist completion is arranged so that it does not conflict with other essential flight activities. To that end, the checklist does not impose an additional burden or workload, but is actually perceived by aircrew as something that makes the flight easier. In contrast, the Time Out is performed before the case can begin, so essentially stands independently of the workflow. To that end, the Time Out is likely to be seen as something additional, and, unless it results in obvious time-saving downstream, will be perceived as an increase in workload. This mixture of purpose between checklist and briefing, in combination with implementation issues, may explain the range of outcomes as well as the range of enthusiastic to skeptical opinions about the mandated use of checklists in surgery.”

Checklist Completion as a Metric for Determining Compliance

“Using ‘compliance with checklist’ audits as a measure of safety or quality, however, is problematic, as high checklist compliance is no guarantee that the task is well-executed, or that patient safety culture is high.”

The viewpoint contains other insights that are worthy of consideration. Those using the Physician-Patient Alliance for Health & Safety PCA Safety Checklist, OB VTE Recommendations, and Stroke VTE Safety Recommendations may find value in reading the full viewpoint and reflecting on how these assumptions manifest themselves in their own healthcare setting.

Read the full article here.

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