Use Medical Checklists as Tools, Not Cure-Alls, for Patient Safety Problems

Recent events have put the simple medical checklist in the spotlight.

For instance, the Department of Health and Human Services last summer highlighted work among Michigan hospital ICUs to sharply reduce healthcare-associated infections (HAIs) with checklists. The World Health Organization said it is supporting the global use of surgical safety checklists. And bestselling author Atul Gawande has written about the topic in his new book, The Checklist Manifesto.

But in the midst of these activities come words of caution—brought to you by the team from Johns Hopkins University that helped put the checklist in the medical spotlight: Checklists can be useful and helpful, but they are not a panacea to all patient safety problems.

Use of checklists—or at least familiarity with them—appear common in many hospitals across the country. In the HealthLeaders Media Industry Survey 2010, for instance, 88.8% of quality leaders said their organizations used a checklist system to prevent errors in the hospital operating room, while 11.2% said they did not use such a system [Question 38].

Peter Pronovost, MD, PhD, a professor of anesthesiology and critical care medicine at JHU's School of Medicine, Baltimore, and his staff are credited with preventing thousands of central line infections at Hopkins. This was done partly because of a now well-known five step checklist:

1. Wash hands with soap
2. Clean patient's skin with chlorhexidine antiseptic
3. Put sterile drapes on the entire patient
4. Wear sterile gown and mask
5. Put sterile dressing over the insertion site

Pronovost and his colleagues later assisted a Michigan program that was associated with a 66% reduction in catheter related bloodstream infections in the state’s hospitals, saving more than 1,500 lives and $200 million in the first 18 months alone. Again, the checklist played an important role here.

Writing in the latest issue of the journal Critical Care, they note that checklists "have the tremendous potential to improve patient outcomes by democratizing knowledge and helping ensure that all patients receive evidence based best practices and safe high quality care."

However, in reality, these checklists need to be accompanied by a "change in the culture"—where nurses, for instance, are empowered to question doctors who don't follow the steps properly or where members of a healthcare team toss out long held beliefs that infections are an inevitable cost of being in the hospital. "Just having a checklist on a piece of paper isn't going to be enough," Pronovost said in a statement.

Sean Berenholtz, MD, an associate professor with the departments of anesthesiology, critical care medicine, and health policy and management at Hopkins, and a member of the team that has worked on the development of the checklist, says checklists do appear to be "popping up everywhere."

"Everyone wants to do a checklist. The message becomes that . . . checklists are the simple solution for solving an adaptive problem with a technical solution," he says. "It needs to be embedded in a broader effort to evaluate and address local context. It needs to add value. If providers don't believe in the value of the checklist, they'll just check a box."

Berenholtz says that when implementing checklists, it’s helpful to use the Comprehensive Unit-based Safety Program (CUSP) to help focus efforts to "improve culture and context." This initiative includes steps to:

• Educate providers on the science of safety—to help them understand that "the vast majority of errors aren't the result of one provider...[but] rather it's a whole system that allows that error to occur."
• Use a written survey with staff on how the next patient could be harmed and what can be done to reduce that harm.
• Partner with senior executives to help bridge any gaps between senior leaders and frontline providers.
• Help staff learn from defects or problems.
• Implement teamwork tools (with daily goals) and talk about the whole program that goes along with the checklists.

The eventual goal, the researchers wrote, is that checklists should be created that are "succinct, unambiguous, focused, and ultimately effective, and efficient." And, when ultimately faced with a crisis, "we can react quickly and decisively, knowing that the items we act out from the checklist are well thought out, tested, and will provide us with the results we want."