The checklist--a tool for error management and performance improvement.
TL;DR: This narrative is a guide to the evolution of medical and critical care checklists, and a discussion of the barriers and risks to the implementation of checklists.
About: This article is published in Journal of Critical Care.The article was published on 2006-09-01. It has received 565 citations till now. The article focuses on the topics: Human error & Checklist.
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05 Jun 2013
TL;DR: The knowledge and tools exist to put the health system on the right course to achieve continuous improvement and better quality care at a lower cost, and a better use of data is a critical element of a continuously improving health system.
Abstract: America's health care system has become too complex and costly to continue business as usual. Best Care at Lower Cost explains that inefficiencies, an overwhelming amount of data, and other economic and quality barriers hinder progress in improving health and threaten the nation's economic stability and global competitiveness. According to this report, the knowledge and tools exist to put the health system on the right course to achieve continuous improvement and better quality care at a lower cost.The costs of the system's current inefficiency underscore the urgent need for a systemwide transformation. About 30 percent of health spending in 2009--roughly $750 billion--was wasted on unnecessary services, excessive administrative costs, fraud, and other problems. Moreover, inefficiencies cause needless suffering. By one estimate, roughly 75,000 deaths might have been averted in 2005 if every state had delivered care at the quality level of the best performing state. This report states that the way health care providers currently train, practice, and learn new information cannot keep pace with the flood of research discoveries and technological advances.About 75 million Americans have more than one chronic condition, requiring coordination among multiple specialists and therapies, which can increase the potential for miscommunication, misdiagnosis, potentially conflicting interventions, and dangerous drug interactions. Best Care at Lower Cost emphasizes that a better use of data is a critical element of a continuously improving health system, such as mobile technologies and electronic health records that offer significant potential to capture and share health data better. In order for this to occur, the National Coordinator for Health Information Technology, IT developers, and standard-setting organizations should ensure that these systems are robust and interoperable. Clinicians and care organizations should fully adopt these technologies, and patients should be encouraged to use tools, such as personal health information portals, to actively engage in their care.This book is a call to action that will guide health care providers; administrators; caregivers; policy makers; health professionals; federal, state, and local government agencies; private and public health organizations; and educational institutions.
1,324 citations
TL;DR: Checklists are effective and economic tools that decrease mortality and morbidity in surgery and further research in particular relating to implementation is needed.
Abstract: OBJECTIVE: : A systematic literature review was conducted to assess the effectiveness of, compliance with, and critical factors for the implementation of safety checklists in surgery.
BACKGROUND: : With the aim of increasing patient safety, checklists have gained growing attention. Information about effectiveness, compliance, and critical factors for implementation is crucial for whether and which of the available instruments to use.
DATA SOURCES: : Medline including Premedline (OvidSP), Embase, and Cochrane Collaboration Library, hand search, a search of reference lists of key articles, and tables of content.
STUDY SELECTION: : Electronic databases returned 4997 citations, of which 84 articles were chosen for full-text review. Finally, 22 articles were included in this review.
DATA EXTRACTION: : Data relating to care setting, study methods and design, sample population, survey response rate, type of checklist, aim, effectiveness, compliance, attitudes, and critical factors were extracted from the studies. A random effects meta-analysis of effectiveness data was conducted if 2 or more studies reported a specified outcome.
RESULTS: : With the use of checklists, the relative risk for mortality is 0.57 [95% confidence interval (CI): 0.42-0.76] and for any complications 0.63 (95% CI: 0.58-0.67). The overall compliance rate ranged from 12% to 100% (mean: 75%) and for the Time Out from 70% to 100% (mean: 91%).
CONCLUSIONS: : Checklists are effective and economic tools that decrease mortality and morbidity. Compliance of surgical staff with checklists was good overall. Further research in particular relating to implementation is needed.
265 citations
21 Apr 2020
TL;DR: It is found that AI fairness checklists could provide organizational infrastructure for formalizing ad-hoc processes and empowering individual advocates, and highlight aspects of organizational culture that may impact the efficacy of AI fairnessChecklists.
Abstract: Many organizations have published principles intended to guide the ethical development and deployment of AI systems; however, their abstract nature makes them difficult to operationalize. Some organizations have therefore produced AI ethics checklists, as well as checklists for more specific concepts, such as fairness, as applied to AI systems. But unless checklists are grounded in practitioners' needs, they may be misused. To understand the role of checklists in AI ethics, we conducted an iterative co-design process with 48 practitioners, focusing on fairness. We co-designed an AI fairness checklist and identified desiderata and concerns for AI fairness checklists in general. We found that AI fairness checklists could provide organizational infrastructure for formalizing ad-hoc processes and empowering individual advocates. We highlight aspects of organizational culture that may impact the efficacy of AI fairness checklists, and suggest future design directions.
257 citations
Cites background or methods from "The checklist--a tool for error man..."
...One participant, when shown an example of a surgical checklist [47], noted that “it would be really nice to have some sort of a checklist or something that can tell us about easy pitfalls to fall through....
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...In aviation and medicine, checklists often serve as memory aids [16, 47]....
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...Despite initial success stories involving medical checklists [47, 48, 59], many studies (e....
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...These moments, referred to as “pause points” in the medical literature [47], differed slightly for different participants, but most participants identified moments for each stage where they were already pausing development and deployment and could potentially undertake checklist items....
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...In medicine, when surgical checklists were introduced, nurses felt more empowered to raise safety concerns before and during surgery, and were more likely to be listened to by surgeons [17, 47, 59]....
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TL;DR: Some of the cognitive and system-based sources of detection and interpretation errors in diagnostic radiology are described and potential approaches to help reduce misdiagnoses are discussed to create sustainable improvement in diagnostic errors.
Abstract: OBJECTIVE: In this article, we describe some of the cognitive and system-based sources of detection and interpretation errors in diagnostic radiology and discuss potential approaches to help reduce misdiagnoses. CONCLUSION: Every radiologist worries about missing a diagnosis or giving a false-positive reading. The retrospective error rate among radiologic examinations is approximately 30%, with real-time errors in daily radiology practice averaging 3-5%. Nearly 75% of all medical malpractice claims against radiologists are related to diagnostic errors. As medical reimbursement trends downward, radiologists attempt to compensate by undertaking additional responsibilities to increase productivity. The increased workload, rising quality expectations, cognitive biases, and poor system factors all contribute to diagnostic errors in radiology. Diagnostic errors are underrecognized and underappreciated in radiology practice. This is due to the inability to obtain reliable national estimates of the impact, the difficulty in evaluating effectiveness of potential interventions, and the poor response to systemwide solutions. Most of our clinical work is executed through type 1 processes to minimize cost, anxiety, and delay; however, type 1 processes are also vulnerable to errors. Instead of trying to completely eliminate cognitive shortcuts that serve us well most of the time, becoming aware of common biases and using metacognitive strategies to mitigate the effects have the potential to create sustainable improvement in diagnostic errors.
257 citations
Cites background from "The checklist--a tool for error man..."
...Diagnostic checklists have been shown to be effective in reducing errors in other fields of medicine, such as emergency medicine and anesthesiology [58–62]....
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TL;DR: The authors of the WHO Surgical Safety Checklist drew lessons from the aviation experience to create a safety tool that supports essential clinical practice and discusses the differences that exist between aviation and medicine that impact the use of checklists in health care.
Abstract: The World Health Organization's Patient Safety Programme created an initiative to improve the safety of surgery around the world. In order to accomplish this goal the programme team developed a checklist with items that could and, if at all possible, should be practised in all settings where surgery takes place. There is little guidance in the literature regarding methods for creating a medical checklist. The airline industry, however, has more than 70 years of experience in developing and using checklists. The authors of the WHO Surgical Safety Checklist drew lessons from the aviation experience to create a safety tool that supports essential clinical practice. In order to inform the methodology for development of future checklists in health care, we review how we applied lessons learned from the aviation experience in checklist development to the development of the Surgical Safety Checklist and also discuss the differences that exist between aviation and medicine that impact the use of checklists in health care.
253 citations
Cites background from "The checklist--a tool for error man..."
...The use of medical checklists to improve the safety and reliability of clinical practice has gained increased attention and there are emerging discussions in the literature on strategies to develop checklists for health care [17, 18]....
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References
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01 Jan 2000
TL;DR: Boken presenterer en helhetlig strategi for hvordan myndigheter, helsepersonell, industri og forbrukere kan redusere medisinske feil.
Abstract: Boken presenterer en helhetlig strategi for hvordan myndigheter, helsepersonell, industri og forbrukere kan redusere medisinske feil.
16,469 citations
TL;DR: Medical staff reported that error is important but difficult to discuss and not handled well in their hospital and barriers to discussing error are more important since medical staff seem to deny the effect of stress and fatigue on performance.
Abstract: OBJECTIVES: To survey operating theatre and intensive care unit staff about attitudes concerning error, stress, and teamwork and to compare these attitudes with those of airline cockpit crew. DESIGN:: Cross sectional surveys. SETTING:: Urban teaching and non-teaching hospitals in the United States, Israel, Germany, Switzerland, and Italy. Major airlines around the world. PARTICIPANTS:: 1033 doctors, nurses, fellows, and residents working in operating theatres and intensive care units and over 30 000 cockpit crew members (captains, first officers, and second officers). MAIN OUTCOME MEASURES:: Perceptions of error, stress, and teamwork. RESULTS:: Pilots were least likely to deny the effects of fatigue on performance (26% v 70% of consultant surgeons and 47% of consultant anaesthetists). Most pilots (97%) and intensive care staff (94%) rejected steep hierarchies (in which senior team members are not open to input from junior members), but only 55% of consultant surgeons rejected such hierarchies. High levels of teamwork with consultant surgeons were reported by 73% of surgical residents, 64% of consultant surgeons, 39% of anaesthesia consultants, 28% of surgical nurses, 25% of anaesthetic nurses, and 10% of anaesthetic residents. Only a third of staff reported that errors are handled appropriately at their hospital. A third of intensive care staff did not acknowledge that they make errors. Over half of intensive care staff reported that they find it difficult to discuss mistakes. CONCLUSIONS: Medical staff reported that error is important but difficult to discuss and not handled well in their hospital. Barriers to discussing error are more important since medical staff seem to deny the effect of stress and fatigue on performance. Further problems include differing perceptions of teamwork among team members and reluctance of senior theatre staff to accept input from junior members.
1,510 citations
TL;DR: Although operating theatres are not cockpits, medicine could learn from aviation and aviation has developed standardised methods of investigating, documenting, and disseminating errors and their lessons.
Abstract: Pilots and doctors operate in complex environments where teams interact with technology. In both domains, risk varies from low to high with threats coming from a variety of sources in the environment. Safety is paramount for both professions, but cost issues can influence the commitment of resources for safety efforts. Aircraft accidents are infrequent, highly visible, and often involve massive loss of life, resulting in exhaustive investigation into causal factors, public reports, and remedial action. Research by the National Aeronautics and Space Administration into aviation accidents has found that 70% involve human error.1
In contrast, medical adverse events happen to individual patients and seldom receive national publicity. More importantly, there is no standardised method of investigation, documentation, and dissemination. The US Institute of Medicine estimates that each year between 44 000 and 98 000 people die as a result of medical errors. When error is suspected, litigation and new regulations are threats in both medicine and aviation.
#### Summary points
In aviation, accidents are usually highly visible, and as a result aviation has developed standardised methods of investigating, documenting, and disseminating errors and their lessons
Although operating theatres are not cockpits, medicine could learn from aviation
Observation of flights in operation has identified failures of compliance, communication, procedures, proficiency, and decision making in contributing to errors
Surveys in operating theatres have confirmed that pilots and doctors have common interpersonal problem areas and similarities in professional culture
Accepting the inevitability of error and the importance of reliable data on error and its management will allow systematic efforts to reduce the frequency and severity of adverse events
Error results from physiological and psychological limitations of humans.2 Causes of error include fatigue, workload, and fear as well as cognitive overload, poor interpersonal communications, imperfect information processing, and flawed decision making.3 In both aviation …
1,312 citations
"The checklist--a tool for error man..." refers background in this paper
...Under these circumstances, the checklist becomes flight protocol, and completion of a checklist frommemory is considered a protocol violation or pilot error [8]....
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...The Institute of Medicine is certainly not the first organization or healthcare provider to draw comparisons between these industries, nor are they the first to express their opinion that healthcare is behind in adopting these simple policies [1,8,13]....
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TL;DR: The Intensive Care Delirium Screening Checklist can easily be applied by a clinician or a nurse in a busy critical care setting to screen all patients even when communication is compromised, and helps to identify delirious patients.
Abstract: Objective: Delirium in the intensive care unit is poorly defined. Clinical evaluation is difficult in the setting of unstable, often intubated patients. A screening tool may improve the detection of delirium. Method: We created a screening checklist of eight items based on DSM criteria and features of delirium: altered level of consciousness, inattention, disorientation, hallucination or delusion, psychomotor agitation or retardation, inappropriate mood or speech, sleep/wake cycle disturbance, and symptom fluctuation. During 3 months, all patients admitted to a busy medical/surgical intensive care unit were evaluated, and the scale score was compared to a psychiatric evaluation. Results: In 93 patients studied, 15 developed delirium. Fourteen (93%) of them had a score of 4 points or more. This score was also present in 15 (19%) of patients without delirium, 14 of whom had a known psychiatric illness, dementia, a structural neurological abnormality or encephalopathy. A ROC analysis was used to determine the sensitivity and specificity of the screening tool. The area under the ROC curve is 0.9017. Predicted sensitivity is 99% and specificity is 64%. Conclusion: This study suggests that the Intensive Care Delirium Screening Checklist can easily be applied by a clinician or a nurse in a busy critical care setting to screen all patients even when communication is compromised. The tool can be utilized quickly and helps to identify delirious patients. Earlier diagnosis may lead to earlier intervention and better patient care.
1,122 citations