In praise of the checklist for error prevention

Complex and life-dependent systems often fail in their reliance on experience and professionalism alone


This article was originally posted May 31, 2010. It has been updated with new information.

A case for checklists. Leaving the cardiac monitor/defibrillator in the emergency department was a simple mistake. The crew had more than 50 years of combined experience in EMS, and according to their director, they were the best of the best – the kind of medics you wanted to see when you had the big one. But on this night, something had interrupted their routine. The medic taking the stretcher out to the rig thought the medic finishing the report in the ED was bringing the monitor, while the medic finishing the report thought the medic taking the stretcher had gotten it.

What’s more, just as the medic was making up the stretcher pushed it into the ambulance, a car squealed to a stop outside and a frantic woman jumped out asking for help with her husband. As the stretcher medic was helping to move the gasping husband into a wheelchair and the report-writing medic was coming out of the ED, their unit was paged for a man down call.

From stocking the ambulance to preventing infections, checklists prevent dangerous errors. (Photo/courtesy https://directorsblog.health.azdhs.gov)
From stocking the ambulance to preventing infections, checklists prevent dangerous errors. (Photo/courtesy https://directorsblog.health.azdhs.gov)

It wasn’t until they arrived on the scene of the cardiac arrest that they discovered the mistake.

Checklists prevent errors

Anybody who has worked in a busy EMS system can understand how this mistake happened. However, it could have been prevented with a simple checklist. If, before pulling the shifter into drive on the ambulance, the crew had connected with each other and gone through a 15-second pre-departure checklist, they would have discovered the missing monitor.

The problem is, "We don’t like checklists," writes Atul Gawande in a fascinating book titled "The Checklist Manifesto."

"It somehow feels beneath us to use a checklist, an embarrassment. It runs counter to deeply held beliefs about how the truly great among us – those we aspire to be – handle situations of high stakes and complexity. The truly great are daring. They improvise. They do not have protocols and checklists.”

Paramedic chieds, managers and supervisors in emergency services know this well. Who hasn’t struggled with trying to convince crews to complete rig checks at the beginning of a shift?

If you ask EMS crews (especially the experienced) about this issue, they will say they don’t need a checklist because they have enough experience to know what they need to do and when to do it. Because checklist battles seem unwinnable, many mangers give up trying. But as the true story above illustrates, complex and life-dependent systems often fail in their reliance on experience and professionalism alone.

As a surgeon, Harvard professor and great writer, Gawande has spent years studying how humans get things right while performing complex processes in stressful and unpredictable situations. His findings, presented in riveting stories of surgery, crashing airplanes, resuscitation, skyscraper building and financial investments, show that the simple, lowly checklist produces dramatic results.

Dropping infection rates with a checklist

In a story about central IV line infections in ICUs, Gawande demonstrates that merely requiring the ICU staff to go through a five-point checklist dropped infection rates to almost zero:

1. Wash hands 

2. Clean patient’s skin

3. Drape patient

4. Wear a mask

5. Cover site after insertion

As it turns out, checklists are more than checklists. When used in teams and within a culture of expectation and accountability, their impact is more than the sum of the items checked off. Checklists change important human factors, they create a pause, no matter how brief, for taking stock. Checklists temper our heroic notion that we are infallible. They continually bring a certain gravitas or sobriety to what may become routine or ordinary, and they remind us that life-and-death consequences may be only one forgotten moment or caridac monitor away.

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