HAVE YOU THOUGHT ABOUT WHAT AIRLINE PILOTS DO TO ENSURE AIRCRAFT SAFETY BEFORE DEPARTURE, IN THE AIR AND WHILE LANDING? They use checklists. Highly skilled professionals in incredibly complex situations use checklists.
The increasing intricacy of health care, along with a focus on evidence-based practices, has led physicians and other healthcare professionals to examine multiple facets of a patient’s health status. Yet numerous studies illustrate the lack of quality patient care. Checklists can serve as important tools for decreasing medical error and improving standards of patient care, particularly during stressful conditions when memory, vigilance and cognitive functions can be affected.(1)
An innovative method is necessary in order for our healthcare system to eliminate mistakes and control patient care. Dr. Atul Gawande, a surgeon at Brigham and Women’s Hospital, professor at Harvard Medical School and at the Harvard School of Public Health, completed research with the World Health Organization (WHO) in 2007 regarding the safety of surgeries around the globe. The team of experts developed a safe surgery checklist that drastically decreased morbidity and mortality. (To download the WHO Surgical Safety Checklist, go to www.who.int/patientsafety/safesurgery/ss_checklist/en/
). Rates of complication fell from 10.3 percent before the introduction of the checklist to 7.1 percent after its introduction among high-income sites and from 11.7 percent to 6.8 percent among lower-income sites.(2) This checklist is an extremely simple and effective tool for surgical teams to reduce common mistakes.
Although the environment of physical medicine is significantly different from that of surgery, all health care is ultimately about patients. Crucial aspects specific to physical medicine include orthopedic tests, neurologic exam, functional movements, imaging, labs and considering other causes of common conditions. The surgical checklist includes basic steps for the surgical team to follow, while a physical medicine checklist incorporates routine procedures into a concise and quick format. A physical medicine checklist has been developed, somewhat derived from the WHO surgical safety checklist, to facilitate appropriate evaluation and treatment of physical medicine patients (see Figure 1). Chiropractic physicians, physical therapists, athletic trainers, orthopedic surgeons and other healthcare professionals can use the items included in this checklist. It is designed to assist with every patient encounter, to simply remind clinicians of standard and expected management procedures.
Integrated Health Care
Patient outcomes are likely to improve with consistent communication among experts in their fields. Interprofessional communication is essential nowadays, especially with the interplay among genetic predisposition, environmental context and lifestyle choices.(5) A more efficient method of managing complex issues in health care comes from learning how interconnectedness is more crucial than separate pieces of a system.(6,7,8) The basis of a quality medical checklist should encompass checkpoints of major importance, while still providing clinicians with the freedom to use their own judgment.(1) It is clear that more research is required, but the capability of physicians is the factor that must persevere. Capability is defined as the extent to which individuals can adapt to change, generate new knowledge and continue to improve their performance.(8) This concept is especially significant, as research suggests that between 44,000 and 98,000 patients die each year from preventable errors in the United States.(9)
Aviation employs checklists to assist even veteran pilots during times of stress. Aviation checklists, similar to medical checklists, form a cognitive net to catch flaws inherent in all of us.(3) The difficulty of compliance and coherence, with any form of standardization, is clearly related to the cultural autonomy associated with the medical profession. The advancements in multidisciplinary healthcare teams illustrate that inclusivity is becoming the norm.
Possible Negative Effects
There is a danger of checklists becoming a minimum that certain physicians will not strive to overcome. The risk is associated with an increase in simplicity and reliance on the checklist, which should be used as an adjunct as opposed to an absolute.(12) The use of checklists in medicine can have profound effects, considering that humans can only retrieve about seven pieces of information from our memories, and this becomes increasingly unreliable once stress and fatigue are introduced.(12) Therefore, a checklist can counteract the unpredictable environments that clinicians experience. Health care, as a science, has intensely developed evidence-based practices but has failed to fully incorporate the human-ness of treating a person’s health. Brennan et al. describe this dilemma as the problems of moving forward without evidence and the hazards of waiting for evaluation of common-sense approaches.(13)
Numerous studies have shown that complications occur not only in the operating room but also in the peri-operative periods. A medical team developed a multidisciplinary checklist called the Surgical Patient Safety System (SURPASS) and measured pre- and post-intervention in several hospitals. The authors determined that complication rates fell from 27.3 per 100 patients to 16.7 per 100 patients after SURPASS implementation.(18) There was also a significant reduction of in-hospital mortality rates following checklist employment, although the realization of a surgical checklist involves many individuals and requires substantial time and effort to accomplish.(18) Continuing the argument of complex systems and the use of straightforward measures as solutions, another study was conducted using intensive care unit (ICU) length of stay and staff perceptions via a daily form. The use of the daily goals form, as indicated by staff, improved communication, clarified work goals and allowed all staff to feel they were playing a more active role in patient care.(16) Using basic rules to solve complex issues shows that resolutions do not always need to be expensive and time-consuming.
Improving Patient Outcomes
It is evident that checklists serve their purpose in the operating room: Surgeons, nurses, anesthesiologists and other members of the surgical team communicate more efficiently, which facilitates safer procedures and a cohesive team mentality. Even though physical medicine is not a team of medical professionals working together in an operating room, effective communication is still vital for optimal patient care. Chiropractic physicians, physical therapists, orthopedists, primary care physicians, psychologists and other healthcare professionals must regularly discuss diagnoses and treatment options for mutual patients. That inevitably develops a greater interdisciplinary understanding and respect.
Checklists can provide an inexpensive and unpretentious tool for improving patient outcomes. The specific procedures included in a checklist should be common to the end users and able to be employed in many conditions. Checklists have become a simple solution to complex situations in many fields. Medical care has slowly begun to adopt the idea that physicians do not know every detail associated with health care. With this in mind, a few reminders of daily patient-related tasks should not interfere with the public persona or personal beliefs of a physician.
The stigma of checklists in health care was radically debunked with the WHO surgical safety checklist. For checklists to become a reality in patient management, healthcare professionals must begin to use them and reflect on their benefits. The physical medicine checklist allows practitioners to use their clinical expertise while not leaving out the mundane. The physical medicine checklist could be incorporated into an electronic medical records system, posted in patient charts or even displayed in treatment rooms. The checklist was developed with physical medicine practitioners in mind and incorporates aspects essential to basic evaluation and management. From airplane cockpits to surgery suites, a checklist is an example of how different professions can utilize similar practices to focus on safety.
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.
2. Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AS, Dellinger EP, & et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med
3. Gawande AA. The checklist manifesto: how to get things right. 1st ed. New York: Metropolitan Books;2009.
4. Lingard L, Espin S, Rubin B, Whyte S, Colmenares M, Baker GR, & et al. Getting teams to talk: development and pilot implementation of a checklist to promote interprofessional communication in the OR. Qual Saf Health Care
5. Plsek PE & Greenhalgh T. The challenge of complexity in health care. BMJ
6. Wilson T & Holt T. Complexity and clinical care. BMJ
7. Plsek PE & Wilson T. Complexity, leadership, and management in healthcare organizations. BMJ
8. Fraser SW & Greenhalgh T. Coping with complexity: educating for capability. BMJ
9. Sexton JB, Thomas EJ, & Helmreich RL. Error, stress, and teamwork in medicine and aviation: cross sectional surveys. BMJ
10. Thomassen O, Espeland A, Softeland E, Lossius HM, Heltne JK, & Brattebo G. Implementation of checklists in health care; learning from high-reliability organizations. Scand J Trauma Resusc Emerg Med
11. McIntyre N & Popper K. The critical attitude in medicine: the need for a new ethics. BMJ
12. Winters BD, Gurses AP, Lehmann H, Sexton JB, Rampersad CJ, & Pronovost PJ. Clinical review: checklists - translating evidence into practice. Crit Care
13. Brennan TA, Gawande A, Thomas E, & Studdert D. Accidental deaths, saved lives, and improved quality. N Engl J Med
14. Erdek MA & Pronovost PJ. Improving assessment and treatment of pain in the critically ill. Int J Qual Health Care
15. Bergmann TF & Peterson DH. Chiropractic technique: principles and procedures. 3rd ed. Missouri: Elsevier;2011.
16. Pronovost P, Berenholtz S, Dorman T, Lipsett PA, Simmonds T & Haraden C. Improving communication in the ICU using daily goals.J Crit Care 2003;18:71-5.