Checklists in healthcare aren’t that hard to find. Dr. Peter Pronovost famously brought central line infections to zero in just three weeks with one (1) The WHO states that their version of a general, pre-operative checklist reduced death rates by 50% (2) . Dr. Atul Gawande wrote a book on the value they can add to medicine. Results like this beg the question why checklists aren’t more ubiquitous in healthcare. I believe that answer to this stems from a fundamental misunderstanding of what checklists actually do. Here I will try and correct that misunderstanding.

 

Telling a highly skilled professional that, when performing a procedure that they do every day, they should reference a written list of the most routine parts so they don’t make a mistake is a hard idea to explain without implying incompetence. And while on the surface it may seem like this is all a checklist is, I assure you, there is more to it.

 

Checklists are not step by step instruction manuals. Whatever procedure a checklist contemplates, I am certain that the user would be able to perform it without using one. Nor are they a method to document or prove that you did your job correctly. They are not cumbersome pieces of paper that interrupt your workflow - we don’t literally check a box next to each item as we go. And most of all, they are not a substitute for judgment or technique, nor do they contemplate matters that require those skills.

 

Checklists increase mental bandwidth.

 

Everything comes at a cognitive cost, even the most mundane and routine items. In complex environments, mishandled routine items can cause harm and adverse outcomes to the same degree as those from a grossly deficient lack of skill. The threat here is that when the workflow at the top of everyone’s minds is so complex, the mundane elements seem paltry by comparison. This means that 1), they take up less bandwidth when your mind is focusing on what it thinks is more important, and 2) the bandwidth they do take up comes at the cost of bandwidth that could and should be used on the complex matters of the case.

 

The more complex an environment, the more things need to go right and in the right order, and the higher the likelihood of a human being forgetting something or making a mistake. As the complexity of the case maxes out the individual’s bandwidth, their ability to focus on higher level items decreases, restricting their bandwidth further as they try to not make any mistakes, and the cycle continues.

 

Cases don’t always go as they’re planned. Interruptions occur. Distractions happen. Deferring a task starts a domino effect where subsequent tasks need to be deferred or accomplished out of order. The deferred task clings for dear life in your working memory, until it either fades away or is recalled.

 

By liberating yourself from having to keep track of whether or not routine yet critical steps have been accomplished, checklists increase bandwidth and allow you to focus on more complex elements of the case.

 

In a complex environment, this should be your number one goal. When an error does happen, we are inclined to think that because of the complex nature of the case, the root cause must lie somewhere within the intricacies of the technique or the experience of the person who made the mistake. Preventable errors, however, are almost always the result of human vulnerability, not clinical skill. Preventable mistakes like retained surgical items, wrong patient surgery, wrong site surgery, failure to administer prophylaxis, failure to have emergency blood supply ready, etc., are all failures of routine steps that could be verified, and not dependent on the skill of the attending.

 

In fact, when we look at aviation incidents or adverse outcomes in surgical cases, the Captain or attending physician is generally not inexperienced. These events happen to experienced, skilled professionals who are highly regarded by their . (Complacency is a threat in and of itself.)

 

The second purpose of a checklist is to trap errors. Regardless of your professional prowess, you will make mistakes. We are not machines, and we are guaranteed to them. It is inherently flawed to rely on the same technique that rendered the error to also correct it. This would be like telling someone who’s looking for a lost item to just remember where they left it. Checklists never forget, and if you use them long enough, they will remind you of things that you have.

 

Checklists not only decrease the probability that critical items will be missed, but they increase the attention that the user can allocate to what their job really is. As the pilot advances the thrust levers for takeoff, a thought pops into his head- “Did I configure the pressurization panel correctly?” If the checklists were done, the he can trust that the aircraft is configured for takeoff correctly, and if a small mistake was made, it wont prevent him from taking off safely. Mid sedation, an anesthesiologist thinks, did I check the medication drawer for the ___? If the checklist was performed, the patient is ready for  anesthesia. The pilot or attending can safely ignore that thought and focus of the critical task at hand.

 

Pilots know to verify the quantity and distribution of fuel on board before we depart. This is hardly a complex part of the job. But its on the checklist anyway. I don’t need to be reminded to check this, the inclusion of this on a checklist isn’t a prompt to do it, it’s to allow me to ensure that, if an inevitable distraction diverted away my attention away at the wrong time and I forgot that I forget to check it, 1) the error will be trapped and I will check the fuel before we leave, and 2) after the dust settles from the distraction, the process of ‘remembering what I have to remember’ doesn’t become another distraction in and of itself.

 

There’s no paperwork involved. Checklists get read aloud, generally by one pilot challenging the other for a response. In the OR, it would probably be the circulating nurse challenging the attending and/or others. When properly implemented, they don’t interrupt workflow. If a checklist is long it may take 25 seconds. Most normal ones take less time. This also creates an opportunity for the group to take a second to stop what their doing, take a step back, reflect on the state of the flight/aircraft/case/patient, and more importantly, communicate. A classic error setup exists where multiple experienced observers note a problem but decline to speak up because of the failure, knowingly or unknowingly, of others to speak up. Checklists open the door for hesitant parties to query things that might not look right.

 

What is the benefit of strictly relying on memory? Any time a waiter has made a mistake with my order, its been someone who did not write my order down and instead tried to memorize it. I still don’t understand what value this adds. I’d much rather they write it down and get it right. When it comes to matters of human life, I feel this logic still stands. Relying on memory for routine, critical things comes at a cognitive cost, and it’s hard to argue that there is a benefit to paying that cost, when a much more reliable method with virtually zero downside can be used.

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1. Gawande, Atul. “A Life Saving Checklist”. The New Yorker. December 2, 2007.

2. Haynes, Alex B., et al. "A surgical safety checklist to reduce morbidity and mortality in a global population." New England journal of medicine 360.5 (2009): 491-499.