In 2006, Peter Pronovost, professor at Johns Hopkins University School of Medicine’s Departments of Anesthesiology and Critical Care Medicine and Surgery, and his colleagues published a landmark article in the New England Journal of Medicine, which showed that use of a simple checklist slashed the rate of catheter-related bloodstream infections in Intensive Care Units (ICUs) to virtually zero.1 In the first 15 months of implementing the checklist, an estimated 1500 lives and US$175 million in costs were saved. This checklist consisted of only five steps, each previously proven to help lower the rate of infection (and that every doctor and nurse knew they should do but failed to perform on every occasion):
- Hand washing with soap and water;
- Wearing a sterile hat, mask, gown and gloves;
- Cleaning the patient’s skin with chlorhexidine antiseptic;
- Avoiding inserting the catheter around the groin region if possible; and
- Removing unnecessary catheters.
Pronovost, with the help of colleagues, went on to replicate the success of the central-line safety checklist with other checklists that addressed pain management2 and mechanical ventilation.3 Adding to the evidence that checklists can help to improve patient safety, Hayes et al. reported that implementation of a Surgical Safety Checklist on an international scale resulted in lower death rates and complications of surgery.4
Checklists are a valuable tool to improve the completeness and consistency in which critical steps in a procedure are performed. Unlike many other interventions in healthcare today, they cost hospitals next to nothing to implement and have the potential to save lives and improve clinical outcomes, thereby reducing the economic burden of healthcare. So should hospitals have checklists for everything? Probably not, and here’s why.
Social and Cultural Issues
Many physicians perceive checklists as “cookbook medicine” or “template care”. What’s more, their compliance to the checklists would be monitored, and perhaps even ensured through prompting/reminders, by nurses. Arrogance in the medical fraternity remains a major barrier to the widespread adoption of checklists.
For the central-line safety checklist project, Pronovost and his colleagues encountered resistance not only among the doctors, but also hospital executives. We suspect the same people might have been more enthused if presented with, say, a novel antibiotic that promised to reduce the rate of central line infections by 50%. (Pronovost’s safety checklist cut the catheter-related infection rate by up to 66%.)
Checklists Alone Are Not the Answer
Despite their utility, checklists are not the panacea for all the problems in healthcare. Checklists are better suited for some situations than others. For instance, unlike the central-line safety checklist, checklists used for screening developmental problems have been shown to miss large proportions of children with mental retardation and language difficulties.
Also, inattention to adaptive work – work which requires new learning when both the problem and solution are unclear – and indiscriminate use of checklists lead to dissatisfaction among already busy clinicians, and may be counterproductive. In fact, Pronovost warns against having an excessive number of checklists: “Creating too many checklists—especially those that are not proven to improve patient safety—or using checklists where they are not truly needed can be distracting and time-consuming and over-reliance on them can lead to a false sense of safety.”
See the article by Hales et al. for tips on developing and implementing checklists.5
Checklists can help to improve quality of care and patient safety. However, they must be used judiciously and in conjunction with an open, inclusive and iterative approach that focuses on goals to translate evidence into practice.
- Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med 2006;355:2725-2732. [Erratum, N Engl J Med 2007;356:2660.]
- Edrek MA, Pronovost J. Improving assessment and treatment of pain in the critically ill. Int J Qual Health Care 2004;16:59–64.
- Pronovost PJ, Rinke ML, Emery K, Dennison C, Blackledge C, Berenholtz SM. Interventions to reduce mortality among patients treated in intensive care units. J Crit Care 2004;19:158-64.
- Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AHS, Dellinger E, et al. Surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 2009;360:491-9.
- Hales B, Terblanche M, Fowler R, Sibbald W. Development of medical checklists for improved quality of patient care. Int J Qual Health Care 2008;20(1):22-30.
- Gawande A. The Checklist Manifesto: How to Get Things Right. New York: Metropolitan Books, 2009.
- Gawande A. The Checklist. The New Yorker, 10 Dec 2007, available at: http://www.newyorker.com/reporting/2007/12/10/071210fa_fact_gawande (Accessed 29 April 2010).