Hospital checklists work really well -- except when they're not used

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Cause 1: Good old surgeon chauvinism.


This topic gets me fired up! I do consulting work for industrial control systems and procedures are often poorly documented and many procedures and best practices are not followed correctly. This leads to things like explosions, release of toxic materials, fires, and death in places like refineries and chemical plants.

Paper based procedures and checklists are part of the problem. Electronic procedure management solutions are more effective and more traceable and can be more easily enforced in any operational environment. But more important than that, the new procedures must be enforced from the top down and tied to job performance metrics. You can’t just throw people a tool and expect they will use it, even if they know it’s a good tool. If you’re mired in bad habits, you might need a little more of a kick in the ass.


The clear lesson for hospital leaders is that they cannot just dump a stack of checklists in an operating room — they must observe them being used.

So managers have to actually manage their subordinates instead of just spew directives and then vanish to the pub or the golf course? It sounds like the surgeons aren’t the only ones who need some hand-holding to ensure they do their jobs in a professional and thorough manner…


That reminds me I have to make a list.


I suspect that ‘lapses should be discussed and addressed’ is the area where things can get tricky in terms of organizational incentives.

If you treat checklists as an antidote to the naturally lazy and careless nature of the labor peons(in the same vein as intensive scrutiny and punitive deployment of metrics) they are an easy sell; but mysteriously stop leading to improvements once you run out of laziness and/or hit the good old ‘thermocline of truth’.

If you treat them as essentially the front line of the organization’s sensory and reflex systems; both gathering data about the world and quickly forestalling some basic mistakes, they are more useful but can also lead to conclusions that are harder to sell; and quite possibly harder to candidly discuss with leadership.

I’m guessing that, say, “here’s a year worth of checklist data analyzed to show what corners have to be cut to fit the number of procedures demanded into the time and resources available” is not a team player dataset; even if it is a useful one.

The structure of the ‘checklist’ likely implicitly contributes: a ‘yes/no’ box has the implication that it’s next to a step that can be executed; rather than a step that might deserve a free-response answer like “Not performed because the hospital pharmacy is like a grim parody of the WHO EML and supplies were unavailable” or “declared completed over the objections of the junior member of the surgical team”.


Pilots don’t always like them either, but almost every one can tell you about the guy who didn’t bother and missed that little thing that turned into a a big thing at the worst time possible.

There are certain classes of people that need to ditch the ego, admit they’re not perfect 100% of the time and use the tools proven to make up for that. Doctors who refuse to use checklists should be deemed uninsurable, as they are statistically much more likely to cause a preventable death than those that do use them.


In other words,

Tools are only useful when they serve people. And the management response to tools not serving people is often to make the people serve the tools.




Managers may not actually have the power you imagine over surgeons, who are the rockstars of the hospital.

However, checklists are used in aviation. I wonder how the two cultures are so different in this respect? Perhaps because pilot’s lives are on the line, too? (Not that self-preservation is a guarantee against professional recklessness, though.)


I suspect this is also a really hard thing to teach to people who are already practicing in the field. A big part of the inspiration for Atul Gawande’s work is checklists pilots and others in the aviation industry use. Which they are trained to use from the day they first walk into an air field. I am not going to claim that pilots have never checked something off without actually checking it, but the culture of “go through the checklist every time” is pretty strongly ingrained.

The aviation industry also studies failure extremely carefully. Their whole culture is based around the idea of systems that need to be reliable even though humans are fallible, and they study examples of all the things that go wrong that lead to crashes and loss of life and learn how tools like the checklist, regulations, and requirements are designed based on them. There is even a saying “Aviation regulations are written in blood”.

Surgeons spend way more time learning about what can go wrong with the patient than what can go wrong with the surgeon.


Completing the checklist wasn’t one of the items on the checklist.


Makes sense. We have checklists for our processes where I work as well, and they get pencil whipped all the time. So it’s not just surgeons. But at least when we fuck up someone doesn’t die.

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Peter Pronovost of Johns Hopkins, arguably the foremost leader in Patient Safety says that the CULTURE of the workplace is the key. Martin Makary suggests asking “how good is the communication within the team and UP the organization?”

Some (waaaaay too few) hospitals encourage, support and celebrate even the lowest paid staff to point out errors, missed items, dangers, etc.

But, most don’t.

And, there is NO MANDATED ERROR REPORTING in health care. WTF!?


Get the app (poorly named) PatientAider - it gives YOU checklists for every darn thing you can think of in a health care situation. Like wiping down your hospital room with alcohol YOURSELF, posting your own list of your meds/dosages/timings, having a friend or family member be your advocate, always having a friend or family member at any visit, making lists of questions and asking them and making notes, etc.

YOU must be your best advocate and safety guide. Sad but true.


Hm, that’s not a bad thought. I was just suggesting that the managers who create & disseminate things like these checklists might someday do some supervision, or at least occasional spot-checks, to ensure the surgeons are actually using them. Even if they don’t really have the power to punish them for not doing so, it would seem to be the managers’ responsibility to at least try to get the rules followed.


A checklist that isn’t used is a broken checklist. The correct response to this is not to yell and threaten staff into using the checklist out of fear, it is to investigate why it isn’t being used, what is wrong with its design or content or implementation, and fix that. The thing that is broken is not the human, it is the checklist. This is a matter of workplace culture, as has been pointed out.


I have to say that I am of two minds about this. I despise the de-skilling of many jobs (usually lower paid ones) where essentially everything is by the checklist, with penalties for going off-script.

And personally, I’d probably go squirrely if I had to live by checklists, even though they might make be better at my job.

So I have some sympathy for the deep desire to ditch checklists, even while acknowledging that the vast majority of jobs are probably made more effective by compelling the employees to mindlessly follow sets of simple rules with tiny bits of discretion in the execution of some of the steps.

Still, it feels a bit awkward to decry people escaping checklists that make them better at their job, while steadfastly resisting any attempt to have my job turned into a checklist.

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Just curious, which group creates the checklist: the surgeons or the hospital lawyers getting the ducks lined up for the malpractice suits?

Exactly! I do some quality assurance work and often see the yes/no checklists arbitrarily marked yes because there were extenuating circumstances, and they don’t want to mark no. If checklists are really to be useful in overall improvement, not just rote task accomplishment, there have to be options for indicating WHY things weren’t done, if they weren’t done and work proceeded despite that.

There is definitely a sense of second-guessing, but I love good checklists. They don’t at all reduce the level of skill needed to perform that tracheotomy, they just act as a failsafe to make sure the implement was sanitized beforehand and all that jazz.


To my naïve brain it seems like surgeons should basically be responsible for maintaining the checklist they themselves think they should follow. Then (a) they can’t cop a ‘tude about it, and (b) they have a record in advance of what they are and aren’t responsible for.