Checklist Confusion

One technique for improving health care quality and avoiding mistakes, particularly popular in hospitals, is the use of checklists for various procedures and activities.  Use of a checklist implies that there is a best way to conduct a certain procedure and that if the steps on the checklist were followed in all cases, quality would get better.  An article in the journal Nature finds that this may not be the case.   (Nature Article)   The authors give the example of the World Health Organization checklist for surgical safety, a set of 19 tasks.  A pilot study in 8 hospitals appeared to show that death rates fell by half and some complications by a third following introduction of the checklist.  The United Kingdom National Health Service then mandated that all its hospitals use the surgery checklist and thousands of surgical units around the world began to use this or a similar checklist.

Alas (and honestly, this can’t be unexpected), in wider use the pilot results could often not be replicated.  A study looking at 200,000 procedures in 101 hospitals in Ontario, Canada, for example found no significant reductions in mortality or complications.  Some experts believe this is due to implementation differences or other factors, not the checklist itself.  Poor study design in some of the “successful” trials may also be to blame for the early hoopla.  The same inconsistencies have been found with other checklists, such as those to reduce catheter infections.  Some research finds that checklists may breed familiarity and just going through the steps by rote, without careful attention.  Many health care workers find the lists poorly written, redundant, inappropriate in some cases, and not supported by data.  It seems the checklists need to be carefully constructed and how they are introduced and how staff is trained to use them may be crucial in their success.  Like most things, certainly in health care, just the idea that something is going to make a big difference isn’t enough.