Clinical review: checklists - translating evidence into practice

Bradford D Winters, Ayse P Gurses, Harold Lehmann, J Bryan Sexton, Carlyle Jai Rampersad, Peter J Pronovost, Bradford D Winters, Ayse P Gurses, Harold Lehmann, J Bryan Sexton, Carlyle Jai Rampersad, Peter J Pronovost

Abstract

Checklists are common tools used in many industries. Unfortunately, their adoption in the field of medicine has been limited to equipment operations or part of specific algorithms. Yet they have tremendous potential to improve patient outcomes by democratizing knowledge and helping ensure that all patients receive evidence-based best practices and safe high-quality care. Checklist adoption has been slowed by a variety of factors, including provider resistance, delays in knowledge dissemination and integration, limited methodology to guide development and maintenance, and lack of effective technical strategies to make them available and easy to use. In this article, we explore some of the principles and possible strategies to further develop and encourage the implementation of checklists into medical practice. We describe different types of checklists using examples and explore the benefits they offer to improve care. We suggest methods to create checklists and offer suggestions for how we might apply them, using some examples from our own experience, and finally, offer some possible directions for future research.

Figures

Figure 1
Figure 1
Checklist for anesthetic machines [9].
Figure 2
Figure 2
Elements of creating a wise checklist.
Figure 3
Figure 3
Landing procedure checklist for a Boeing 737-800 aircraft. Adapted from the Atlantic Sun Airways CAT B pilot procedures and checklists series [52]. KIAS, knots indicated airspeed.
Figure 4
Figure 4
Daily goals checklist. ABG, arterial blood gas; ABx, antibiotics; AG, aminoglycoside; Bld, blood; BMP, basic metabolic panel; bpm, beats per minute; Card, cardiology; CMP, comprehensive metabolic profile; CXR, chest x-ray; D/C, discontinue; DVT, deep venous thrombosis; EKG, electrocardiogram; eval, evaluation; FIO2, fraction of inspired oxygen; Fluc, fluconazole; GI, gastrointestinal; gtt, drops; GU, genitourinary; Hep, heparin; HOB, head of bed; HR, heart rate; ICU, intensive care unit; ID, infectious disease; KCI SS, potassium chloride sliding scale; LMWH, low-molecular-weight heparin; LOS, length of stay; mgt, management; NDT, nasoduodenal tube; Neuro, neurology; NPO, nil per os (nothing by mouth); OOB, out of bed; OR, operating room; OT, occupational therapy; PaCO2, arterial partial pressure of carbon dioxide; PAN Cx, pan-culture; PEEP, positive end-expiratory pressure; PEG, percutaneous endoscopic gastronomy; PO, per os (by mouth); PPI, proton pump inhibitor; Prealb, prealbumin; PS, pressure support; PSN, patient safety network; Pt, patient; PT, physical therapy; PUD, peptic ulcer disease; pulm, pulmonary; q, every; Resp, respiratory; ROM, range of motion; RR, respiratory rate; RTW, ready to wean; SCD, sequential compression device; SIRS, systemic inflammatory response syndrome; SSI, sliding scale insulin; TEDS, thromboembolic deterrent stockings; TF, tube feeding; TGC, tight glucose control; tol, tolerated; TPN, total parenteral nutrition; WBC, white blood cells.

References

    1. Gawande A. The checklist: if something so simple can transform intensive care, what else can it do? New Yorker. 10 December 2007; Annals of Medicine section. pp. 1–8.
    1. Hales B, Terblanche M, Fowler R, Sibbald W. Development of medical checklists for improved quality of patient care. Int J Qual Health Care. 2008;20:22–30. doi: 10.1093/intqhc/mzm062.
    1. Pronovost PJ, Thompson DA, Holzmueller CG, Lubomski LH, Dorman T, Dickman F, Fahey M, Steinwachs DM, Engineer L, Sexton JB, Wu AW, Morlock LL. Toward learning from patient safety reporting systems. J Crit Care. 2006;21:305–315. doi: 10.1016/j.jcrc.2006.07.001.
    1. Lingard L, Espin S, Whyte S, Regehr G, Baker GR, Reznick R, Bohnen J, Orser B, Doran D, Grober E. Communication failures in the operating room: an observational classification of recurrent types and effects. Qual Saf Health Care. 2004;13:330–334. doi: 10.1136/qshc.2003.008425.
    1. Sutcliffe KM, Lewton E, Rosenthal MM. Communication failures: an insidious contributor to medical mishaps. Acad Med. 2004;79:186–194. doi: 10.1097/00001888-200402000-00019.
    1. Gawande AA, Zinner MJ, Studdert DM, Brennan TA. Analysis of errors reported by surgeons at three teaching hospitals. Surgery. 2003;133:614–621. doi: 10.1067/msy.2003.169.
    1. Degani A, Wiener EL. Cockpit checklists: Concepts, design, and use. Hum Factors. 1993;35:345–359.
    1. Peleg M, Boxwala AA, Ogunyemi O, Zeng Q, Tu S, Lacson R, Bernstam E, Ash N, Mork P, Ohno-Machado L, Shortliffe EH, Greenes RA. GLIF3: the evolution of a guideline representation format. Proc AMIA Symp. 2000. pp. 645–649.
    1. Kendell J, Barthram C. Revised checklist for anaesthetic machines. Anaesthesia. 1998;53:887–890. doi: 10.1046/j.1365-2044.1998.00462.x.
    1. Berenholtz SM, Pronovost PJ, Lipsett PA, Hobson D, Earsing K, Farley JE, Milanovich S, Garrett-Mayer E, Winters BD, Rubin HR, Dorman T, Perl TM. Eliminating catheter-related bloodstream infections in the intensive care unit. Crit Care Med. 2004;32:2014–2020. doi: 10.1097/01.CCM.0000142399.70913.2F.
    1. Pronovost P, Needham D, Berenholtz S, Sinopoli D, Chu H, Cosgrove S, Sexton B, Hyzy R, Welsh R, Roth G, Bander J, Kepros J, Goeschel C. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med. 2006;355:2725–2732. doi: 10.1056/NEJMoa061115.
    1. Makary MA, Holzmueller CG, Thompson DA, Rowen L, Heitmiller ES, Maley WR, Black JH, Stegner K, Freischlag JA, Ulatowski JA, Pronovost PJ. Operating room briefings: working on the same page. Jt Comm J Qual Patient Saf. 2006;32:351–355.
    1. American Society of Anesthesiologists homepage.
    1. Burian B. Proceedings of the Human Factors and Ergonomics Society 50th Annual Meeting: 16-20 October 2006; San Francisco. Santa Monica, CA: Human Factors and Ergonomics Society; 2006. Aeronautical emergency and abnormal checklists: expectations and realities; pp. 101–105.
    1. Swain AD, Guttman HE. Handbook of Human Reliability Analysis with Emphasis on Nuclear Power Plant Applications (NUREG/CR-1278) Washington, DC: Nuclear Regulatory Commission; 1983.
    1. Hayashi I, Wakisaka M, Ookata N, Fujiwara M, Odashiro M. Actual conditions of the check system for the anesthesia machine before anesthesia. Do you really check? Masui. 2007;56:1182–1185.
    1. Colon-Emeric CS, Lekan D, Utley-Smith Q, Ammarell N, Bailey D, Corazzini K, Piven ML, Anderson RA. Barriers to and facilitators of clinical practice guideline use in nursing homes. J Am Geriatr Soc. 2007;55:1404–1409. doi: 10.1111/j.1532-5415.2007.01297.x.
    1. Hewson KM, Burrell AR. A pilot study to test the use of a checklist in a tertiary intensive care unit as a method of ensuring quality processes of care. Anaesth Intensive Care. 2006;34:322–328.
    1. Huang HC, Lin WC, Lin JD. Development of a fall-risk checklist using the Delphi technique. J Clin Nurs. 2008;17:2275–2283. doi: 10.1111/j.1365-2702.2008.02337.x.
    1. Makary MA, Mukherjee A, Sexton JB, Syin D, Goodrich E, Hartmann E, Rowan L, Behrens DC, Marohn M, Pronovost PJ. Operating room briefings and wrong site surgery. J Am Coll Surg. 2007;204:236–243. doi: 10.1016/j.jamcollsurg.2006.10.018.
    1. Verdaasdonk EG, Stassen LP, Hoffmann WF, Elst M van der, Dankelman J. Can a structured checklist prevent problems with laparoscopic equipment? Surg Endosc. 2008;22:2238–2243. doi: 10.1007/s00464-008-0029-3.
    1. Pronovost P, Berenholtz S, Dorman T, Lipsett PA, Simmonds T, Haraden C. Improving communication in the ICU using daily goals. J Crit Care. 2003;18:71–75. doi: 10.1053/jcrc.2003.50008.
    1. Lingard L, Regehr G, Orser B, Reznick R, Baker GR, Doran D, Espin S, Bohnen J, Whyte S. Evaluation of a preoperative checklist and team briefing among surgeons, nurses, and anesthesiologists to reduce failures in communication. Arch Surg. 2008;143:12–17. doi: 10.1001/archsurg.2007.21. discussion 18.
    1. Torr J, Iacono T, Graham MJ, Galea J. Checklists for general practitioner diagnosis of depression in adults with intellectual disability. J Intellect Disabil Res. 2008;52:930–941. doi: 10.1111/j.1365-2788.2008.01103.x.
    1. Iacono T, West D, Bloomberg K, Johnson H. Reliability and validity of the revised Triple C: Checklist of Communicative Competencies for adults with severe and multiple disabilities. J Intellect Disabil Res. 2009;53:44–53. doi: 10.1111/j.1365-2788.2008.01121.x.
    1. Clay AS, Que L, Petrusa ER, Sebastian M, Govert J. Debriefing in the intensive care unit: a feedback tool to facilitate bedside teaching. Crit Care Med. 2007;35:738–754. doi: 10.1097/01.CCM.0000257329.22025.18.
    1. Levy MM, Pronovost PJ, Dellinger RP, Townsend S, Resar RK, Clemmer TP, Ramsay G. Sepsis change bundles: Converting guidelines into meaningful change in behavior and clinical outcome. Crit Care Med. 2004;32:S595–S597. doi: 10.1097/01.CCM.0000147016.53607.C4.
    1. Miller GA. The magical number seven plus or minus two: some limits on our capacity for processing information. Psychol Rev. 1956;63:81–97. doi: 10.1037/h0043158.
    1. Lorist MM, Boksem MA, Ridderinkhof KR. Impaired cognitive control and reduced cingulate activity during mental fatigue. Brain Res Cogn Brain Res. 2005;24:199–205. doi: 10.1016/j.cogbrainres.2005.01.018.
    1. Halford GS, Baker R, McCreeden JE, Bain JD. How many variables can humans process? Psychol Sci. 2005;16:70–76. doi: 10.1111/j.0956-7976.2005.00782.x.
    1. Hutchins E. Cognition in the Wild. Cambridge, MA: MIT Press; 1996.
    1. Norman DA. Design principles for cognitive artifacts. Res Eng Des. 1992;4:43–50. doi: 10.1007/BF02032391.
    1. Xiao Y. Artifacts and collaborative work in healthcare: methodological, theoretical, and technological implications of the tangible. J Biomed Inform. 2005;38:26–33. doi: 10.1016/j.jbi.2004.11.004.
    1. Rodriguez-Paz JM, Mark LJ, Herzer KR, Michelson JD, Grogan KL, Herman J, Hunt D, Wardlow L, Armour EP, Pronovost PJ. A novel process for introducing a new intraoperative program: a multidisciplinary paradigm for mitigating hazards and improving patient safety. Anesth Analg. 2009;108:202–210. doi: 10.1213/ane.0b013e31818ca423.
    1. Surowiecki J. The Wisdom of Crowds: Why the Many Are Smarter than the Few and How Collective Wisdom Shapes Business, Economics, Societies and Nations. 1. New York, NY: Random House; 2004.
    1. Gurses AP, Seidl KL, Vaidya V, Bochicchio G, Harris AD, Hebden J, Xiao Y. Systems ambiguity and guideline compliance: a qualitative study of how intensive care units follow evidence-based guidelines to reduce healthcare-associated infections. Qual Saf Health Care. 2008;17:351–359. doi: 10.1136/qshc.2006.021709.
    1. Oberauer K, Kliegl R. Simultaneous cognitive operations in working memory after dual-task practice. J Exp Psychol Hum Percept Perform. 2004;30:689–707. doi: 10.1037/0096-1523.30.4.689.
    1. Nielsen J. Usability Engineering. San Diego, CA: Academic Press; 1993.
    1. Strauss A, Corbin J. Basics of Qualitative Research: Techniques and Procedures for Developing Grounded Theory. 2. Newbury Park, CA: Sage Publications; 1998.
    1. Wicker P, Smith B. Checking the anaesthetic machine. J Perioper Pract. 2006;16:585–590.
    1. Brockwell R. The anesthesia machine: what's new besides the name? ASA Newsletter. 2006. p. 70.
    1. O'Grady NP, Alexander M, Dellinger EP, Gerberding JL, Heard SO, Maki DG, Masur H, McCormick RD, Mermel LA, Pearson ML, Raad II, Randolph A, Weinstein RA. Guidelines for the prevention of intravascular catheter-related infections. Centers for Disease Control and Prevention. MMWR Recomm Rep. 2002;51:1–29.
    1. Pronovost PJ, Berenholtz SM, Goeschel C, Thom I, Watson SR, Holzmueller CG, Lyons JS, Lubomski LH, Thompson DA, Needham D, Hyzy R, Welsh R, Roth G, Bander J, Morlock L, Sexton JB. Improving patient safety in intensive care units in Michigan. J Crit Care. 2008;23:207–221. doi: 10.1016/j.jcrc.2007.09.002.
    1. El-Khatib MF, Bou-Khalil P. Clinical review: liberation from mechanical ventilation. Crit Care. 2008;12:221. doi: 10.1186/cc6959.
    1. Pronovost PJ, Berenholtz SM, Goeschel CA, Needham DM, Sexton JB, Thompson DA, Lubomski LH, Marsteller JA, Makary MA. Creating high reliability in healthcare organizations. Health Serv Res. 2006;41:1599–1617. doi: 10.1111/j.1475-6773.2006.00567.x.
    1. Koppel R, Metlay JP, Cohen A, Abaluck B, Localio AR, Kimmel SE, Strom BL. The impact of computerized physician medication order entry in hospitalized patients--a systematic review. JAMA. 2005;293:1197–1203. doi: 10.1001/jama.293.10.1197.
    1. Eslami S, de Keizer NF, Abu-Hanna A. The impact of computerized physician medication order entry in hospitalized patients--a systematic review. Int J Med Inform. 2008;77:365–376. doi: 10.1016/j.ijmedinf.2007.10.001.
    1. Windle J, Van-Milligan G, Duffy S, McClay J, Campbell J. AMIA Annual Symposium Proceedings. Omaha, NE: University of Nebraska Medical Center; 2003. Rapid deployment of physician order entry using web-based, disease-specific order sets; p. 1079.
    1. Wrona S, Chisolm DJ, Powers M, Miler V. Improving processes of care in patient-controlled analgesia: the impact of computerized order sets and acute pain service patient management. Paediatr Anaesth. 2007;17:1083–1089.
    1. Donaldson NE, Rutledge DN, Ashley J. Outcomes of adoption: measuring evidence uptake by individuals and organizations. Worldviews Evid Based Nurs. 2004;1(Suppl 1):S41–51. doi: 10.1111/j.1524-475X.2004.04048.x.
    1. Titler MG. Methods in translation science. Worldviews Evid Based Nurs. 2004;1:38–48. doi: 10.1111/j.1741-6787.2004.04008.x.
    1. Atlantic Sun Airways CAT B pilot procedures and checklists series.

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