PATIENT SAFETY CONCEPTS
The Checklist Movement
Why Laboratories Should Embrace Memory Aids
Corinne R. Fantz, PhD
Checklists are cognitive tools designed to facilitate completing a particular task or tasks using a standardized, systematic approach. Today, people rely on checklists in many places and situations, from grocery stores to space missions. While no one would argue that going shopping is as complex as flying a space shuttle, depending on human recall to complete tasks reliably and accurately is unrealistic. Humans are naturally prone to memory errors that may be exacerbated by stress, interruptions, fatigue, or new situations.
Considering the work environment in our busy clinical laboratories and hospital units, checklists have enormous potential to improve the safety of processes that often involve repetition and always require precision. In fact, many intensive care units around the country have proven that checklists are valuable in healthcare settings. In one example, introducing a simple, five-step memory aid drastically reduced the number of preventable bloodstream infections (1). Based on this success, hospitals are looking to find new opportunities for checklists to improve patient safety in other areas (2).
The Right Culture to Succeed
Although checklists hold great potential for improving reliability in process performance and decreasing errors in healthcare settings, several factors such as culture, design, content, and usability have all played a fundamental role in determining the success of checklists in other industries. One of the biggest barriers to checklist adoption in healthcare is culture.
Take, for example, a technologist who is working in a culture where multitasking is acceptable and possibly even encouraged. She routinely performs instrument maintenance, calls critical values, verifies test results, and covers another station while someone else is on break. Although she may be organized enough to remember all of these tasks without reminders, when fatigued or forced to step out of her routine, the technologist will likely begin to make errors. Task omission in any one of her duties may result in patient harm that otherwise would be avoidable if she were using a memory support tool like a checklist. In this type of setting, checklists would not be effective, as the culture in this laboratory already expects multitasking and oftentimes fails to recognize human limitations. Furthermore, it is important to recognize that staff must have the discipline and self-awareness to use checklists, which might be difficult in this situation.
Designing for Success
Although checklists in healthcare are still in their infancy, the science of designing effective checklists is more mature. Among the most important considerations for creating a checklist is understanding the environmental context where it will be used. For instance, a checklist to ensure samples are tracked and results communicated to the appropriate clinical teams during downtime of a laboratory information system may include reminders displayed in sequential order that are repeatedly referred to throughout the process. A checklist to ensure the proper daily functioning of a core lab may be worked on by multiple staff members who initial tasks as they are completed (Figure 1). A phlebotomy checklist may include a laundry list of items, in no particular order, that are needed for each trip to the hospital units. Still other checklists may require participation of multiple staff members who read and confirm that tasks are completed before moving to the next step, such as powering down an automation line for maintenance.
Designing a reliable checklist is challenging and should include only the information you need to achieve a focused and defined goal. The content of the checklist must support and guide the user without being onerous or time consuming. Too many steps or too much detail in the wrong situation may even cause the user to experience “checklist fatigue.” The list also should reflect institutional policies and procedures, as well as best practices reported in the literature.
Incorporating all these design considerations into a checklist while keeping the content focused on the major goal is not easy. For instance, in the phlebotomy checklist mentioned earlier, if the intent is to decrease waste by ensuring the tray is stocked appropriately, asking phlebotomists to provide documentation for tube expiration dates in their trays could disrupt workflow and cause phlebotomists to either disregard the checklist or increase sample collection turnaround times.
Checks on Checklists
Of course, validating a checklist’s usability in a clinical environment is vital to its success. Whether there are any opportunities to improve the content, structure, or usability with respect to how the list is integrated into the clinical workflow can all be tested in a pilot program. Furthermore, pilot programs allow end-users to provide insight into the readability of the document by selected staff, as well as challenging their responses in a live environment. Depending on the situation, graphics or other visual elements such as a standard color scheme consistent with other laboratory documents may improve the overall effectiveness of the checklist. Staff also can confirm that the nomenclature is correct, appropriate, and consistent for effective communication. As new situations arise, the checklists must be flexible enough to adapt any changes, and no one is better positioned to bring these situations to light than the staff using the checklist.
A Great Tool
These days, many hospitals are embracing the use of checklists as a patient safety concept. In the laboratory, checklists are a great tool for laboratorians because the staff remember to perform specific tasks that if overlooked may lead to patient harm.
In the final analysis, however, the success and overall effectiveness of any checklist is determined as much by the content and structure of the document as by the employee culture. As hospital administrators increasingly recognize the power of healthcare workers, as well as their natural limitations, clinical laboratories have an opportunity to lead the checklist movement and improve patient safety.
- Pronovost P, Needham D, Berenholtz S, Sinopoli D, et al. An Intervention to Decrease Catheter-Related Bloodstream Infections in the ICU. N Engl J Med 2006; 355:2725–2732.
- Hales B, Terblanche M, Fowler R, Sibbald S. Development of Medical Checklists for Improved Quality of Patient Care. Int J Qual Health Care 2008; 20:22–30.
Corinne R. Fantz, PhD, is associate professor of Pathology in the Department of Pathology and Laboratory Medicine at Emory University in Atlanta, Ga. and a member of the Patient Safety Focus Editorial Board. Email: email@example.com