Updated 02/12/2020
A recent literature review of the evidence regarding whether surgical checklists affect outcomes comes to no firm conclusion ... the evidence is mixed. A previous Canadian study published in the NEJM, showed little or no impact to surgical checklists and in his accompanying editorial Lucian Leape, noted patient safety expert, stated that checklists that are not used or implemented poorly always fail to have an impact.
So why do high reliability organizations, pilots , safety experts and the World Health Organization continue to tout the need for checklist adoption? Atul Gawande has written an entire text "The Checklist Manifesto" on the topic, emphasizing checklist utility.
Two major issues will affect the utility and effectiveness of checklist adoption, as well as their use and impact on outcomes.
First, the inability to see benefit from checklist use is not inherent to the list or the process itself but the more important question of how we create sustained changes in human behavior and adopting checklist use. The literature is evolving regarding successful use of implementation science. The business world talks about change management. Behavioral psychologist, economists and neurocognitive researchers struggle to achieve sustained changes in human behavior so it comes as no surprise that checklists won’t help if they are never used.
Kahneman has shown our flawed decision making regarding behavioral economics in "Thinking Fast and Slow", but the poor rationale appears in all spheres of life. Type one decisions are instinctive and intuitive and type 2 decisions are more reasoned and deliberative. Checklists can be dismissed by many if a knee jerk type one decision is made rejecting the utility. The natural consequence of flawed decision making is flawed behaviors that follow. The wrong decision on using the checklist will lead to no benefit to patient safety. Research continues on specific techniques to achieve the goal of making good decisions and influencing behaviors. Some focus on creating intrinsic motivation to cause change like using a checklist. Others rely on education or typical carrots and sticks approaches. More are moving to neurocognitively aware methods using
heuristic techniques,
progressive participatory dialectic techniques,
exaggeration,
gamification
closed loop data collection with real-time feedback
video and simulation training.
( See work of Itiel Dror) Using the right implementation tools above can make checklists use and outcome better.
Dan Ariely author of "Predictably Irrational" has clearly stated that typical didactic education doesn't work. He is absolutely right! The time for sending out a checklist, writing a new policy or listening to a PowerPoint lecture is over. Please do create and promulgate your checklist but then take the opportunity to learn the science of changing human behavior and start on a path to safer behaviors and sustained improvements. Using the techniques described above is a good start to creating sustained changes in our behavior.
Second, the use of checklists is significantly influenced by the presence of of a culture of safety within the institution or workplace setting. Much has been researched and published on the importance to patient safety and outcomes especially in hospitals of maintaining a culture of safety. Without an underlying culture of safety with open communication, reporting and resolution of safety issues, the adoption of checklists and many other efforts to enhance safety will be ineffective.
Checklists can be useful if implemented correctly in a setting of a robust culture of safety and using the correct behavioral change techniques. First, powerpoint lectures or policy changes alone will not be enough to adopt checklists or make them effective. Second, promoting a culture of safety starting with something as simple as a culture of safety survey could start you on a path to a safer patient environment.
References
https://www.sciencedirect.com/science/article/pii/S1532046416301186
N Engl J Med 2014; 370:1063-1064 DOI: 10.1056/NEJMe1315851
https://qualitysafety.bmj.com/content/20/4/338.short
https://sigmapubs.onlinelibrary.wiley.com/doi/abs/10.1111/j.1547-5069.2009.01330.x
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Nicolas Argy, M.D., J.D.
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Health/Business Consultant/Educator, Patient Safety, Quality, Risk Management, Public Health Advocate,