Checklists are
marvelous tools to ensure completion of important tasks and improve quality and
patient safety. But use of some checklists has not yet met with universal
acceptance (see, for example, our May 2015 Whats New
in the Patient Safety World column The
Great Checklist Debate and our September 1, 2015 Patient Safety Tip of the
Week Smarter
Checklists).
Recently, Singer and colleagues did direct observation of
over 200 surgical procedures at 10 South Carolina hospitals to evaluate
checklist performance and surgeon buy-in (Singer
2016). Few teams completed most or all SSC items and teams more often
completed items considered procedural checks than conversation prompts. In
fact, in only 3% of cases was there full completion of checklists. Clinical
leadership, communication, a summary measure of teamwork overall, and
observers teamwork ratings positively related to overall checklist completion.
Age of the patient and case duration also correlated with completion of more
checklist items. Though shared clinical leadership, open communication, active
coordination, and mutual respect were critical in prompting case-related
conversations, they did not result in completing more procedural checks.
One of the most important uses of checklists in healthcare,
of course, is that used for the surgical or procedural timeout. We use that to
help verify we have the correct patient, are going to do the correct procedure,
and do it on the correct side or site. Despite a focus on avoiding never events
over the past 2 decades, cases of wrong patient, wrong site, wrong side
surgery/procedures continue to occur. Universal Protocol and the surgical
timeout in theory should prevent most such incidents. However, actual
compliance with these is often suboptimal. Weve previously discussed many of
the issues in inadequate timeouts: failure to include all participants, failure
to get active participation of members, failure to have all participants
devote their sole attention to the timeout procedure, failure to consult
primary documents, checkboxes for items not done checked as complete,
checkboxes/documentation completed after the case, skipped items, poor patient
safety culture, and many others.
Education and training have limited ability to improve
compliance with the surgical/procedural timeout. Weve been big fans of using forcing functions or constraints to improve compliance. Such
interventions include things like preventing opening of the surgical trays or
procedure kits until all the items on a timeout checklist have been completed.
Vanderbilt University Medical Center took a similar
approach, with a unique twist, to improving their surgical/procedural timeouts
they created an electronic version of
the timeout in which all steps need to be completed before a case can proceed
(Rothman
2016). Basically, all their ORs are equipped with large LCD screens that
are the equivalent of electronic white boards. Their proprietary software
system makes available all relevant clinical and administrative information.
Projected on the displays before an incision is made is their item-by-item
surgical/procedural timeout. Their process is a forcing function in that documentation of the case cannot proceed until all items have
been checked off as completed. The system currently has 13 questions but an
abbreviated 3-question timeout is used for emergency cases.
Since implementation they have essentially had 100%
compliance with timeouts and they have had no cases of wrong surgery. Given the
rarity of wrong surgery overall, one cannot state with certainty that the
system has prevented wrong surgery but this is a very sound system. It
apparently has been well accepted and has been sustainable. It has been both
time- and cost-efficient to implement.
Take time to read the Rothman article, which has samples of
the displays used in their system. It looks easier than paper-based checklists
and is something most hospitals and ambulatory surgery centers could easily
implement.
In our many columns
on use of checklists in healthcare (and other industries) weve emphasized a
number of factors that are important for promoting their use. Weve discussed
in detail in our May 2015 Whats New in the Patient Safety World column The
Great Checklist Debate and our September 1, 2015 Patient Safety Tip of the
Week Smarter
Checklists some factors that may contribute to a trend toward checklist
fatigue. First and foremost is buy-in from those who will be using
the checklists as tools. And buy-in requires that there be an appropriate culture
of patient safety.
NASA (NASA 2014),
which oversees the ASRS (Aviation Safety Reporting System) has noted that reports
submitted to ASRS indicate that errors related to checklist usage generally
fall into one of these five categories:
NASA also in a subsequent
newsletter (NASA
2015) noted 5 important factors in appropriate use of checklists:
Note also we have in several previous columns noted a
guidance from the UK Civil Aviation Authority that has some excellent
recommendations about the design of emergency checklists used in aviation (UK
Civil Aviation Authority 2006). Many of these design issues are equally
applicable to healthcare checklists.
In our September 1,
2015 Patient Safety Tip of the Week Smarter
Checklists we noted a study by Russ and colleagues (Russ
2015) that offered the following lessons
for implementing change:
We hope that you will go back and read our September 1, 2015 Patient Safety Tip of the
Week Smarter
Checklists. In particular, pay attention to the interesting perspective by
Eliot Grigg (Grigg
2015) on improving use of checklists and avoiding checklist fatigue and
using technological capabilities to make the checklists more useable. While
Griggs focus was on anesthesia-related checklists, we gave an example of how
we could apply many of his principles to other healthcare checklists.
And, speaking about checklists, The Joint Commission has
just put out The
Joint Commission Big Book of Checklists. It contains lots of downloadable
checklists for a variety of purposes and which you can customize for your own
use.
Some of our prior columns on checklists:
Some of our prior columns
related to wrong-site surgery:
September 23, 2008 Checklists
and Wrong Site Surgery
June 5, 2007 Patient
Safety in Ambulatory Surgery
July 2007 Pennsylvania
PSA: Preventing Wrong-Site Surgery
March 11, 2008 Lessons
from Ophthalmology
July 1, 2008 WHOs
New Surgical Safety Checklist
January 20, 2009 The
WHO Surgical Safety Checklist Delivers the Outcomes
September 14, 2010 Wrong-Site
Craniotomy: Lessons Learned
November 25, 2008 Wrong-Site
Neurosurgery
January 19, 2010 Timeouts
and Safe Surgery
June 8, 2010 Surgical
Safety Checklist for Cataract Surgery
December 6, 2010 More
Tips to Prevent Wrong-Site Surgery
June 6, 2011 Timeouts
Outside the OR
August 2011 New
Wrong-Site Surgery Resources
December 2011 Novel
Technique to Prevent Wrong Level Spine Surgery
October 30, 2012 Surgical
Scheduling Errors
January 2013 How
Frequent are Surgical Never Events?
January 1, 2013 Dont
Throw Away Those View Boxes Yet
August 27, 2013 Lessons
on Wrong-Site Surgery
September 10, 2013 Informed
Consent and Wrong-Site Surgery
July 2014 Wrong-Sided
Thoracenteses
May 17, 2016 Patient
Safety Issues in Cataract Surgery
July 19, 2016 Infants
and Wrong Site Surgery
References:
Singer SJ, Molina G, Li Z, et al. Relationship between
operating room teamwork, contextual factors, and safety checklist performance.
J Am Coll Surg 2016; Jul
25, 2016 [Epub ahead of print]
http://www.journalacs.org/article/S1072-7515(16)30685-8/abstract
Rothman BS, Shotwell MS, Beebe R, et
al. Electronically
Mediated Time-out Initiative to Reduce the Incidence of Wrong Surgery: An
Interventional Observational Study. Anesthesiology 2016; 125(3):
484-494
http://anesthesiology.pubs.asahq.org/article.aspx?articleid=2528136&resultClick=3
NASA. Checklist Checkup. Callback 2014; 410: 1-2 March 2014
http://asrs.arc.nasa.gov/publications/callback/cb_410.html
NASA. A Checklist Checklist.
Callback 2015; 428: 1-2 September 2015
http://asrs.arc.nasa.gov/publications/callback/cb_428.html
Civil Aviation Authority (UK). CAP 676: Guidance on the
Design, Presentation and Use
of Emergency and Abnormal
Checklists. 2006.
http://www.avhf.com/html/library/International_Pubs/CAA_CAP676.pdf
Russ SJ, Sevdalis N, Moorthy K, et al. A Qualitative Evaluation of the Barriers
and Facilitators Toward Implementation of the WHO
Surgical Safety Checklist Across Hospitals in England: Lessons From the
Surgical Checklist Implementation Project. Annals of Surgery 2015; 261(1):
81-91
Grigg E. Smarter Clinical Checklists:
How to Minimize Checklist Fatigue and Maximize Clinician Performance. Anesth Analg 215; 121(2): 57-573
TJC (The Joint
Commission). The Joint Commission Big Book of Checklists. 2016
http://www.jcrinc.com/the-joint-commission-big-book-of-checklists/
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