What do checklists bring to healthcare?
A checklist is a staple in any high-reliability industry. Checklists support human memory and serve as a foundation for procedural standardization. Sole dependence on human memory is not at all consistent with high reliability. Humans fall prey to the effects of fatigue, interruptions, complacency, internal emotional responses, and low situational awareness. Our cognitive resources are limited and fragile in the best of circumstances. All of these factors make pure recall a risky proposition—especially when conducting critical safety-sensitive work, where omissions and unintended or misdirected acts of commission can spell disaster.
Therefore, using a checklist allows us to use recognition rather than recall. The information exists in the world so we don’t have to keep it completely in our heads. The point here is that checklists support memory and should be used—they do not supplant it. Individuals in the operational environment must maintain operational knowledge and competence and fully understand the rationale for checklist content.
Checklists also serve as a foundation for the enforcement of agreed-upon standards. This is straightforward and simple. This means that the content presented on a checklist must represent the most current standard operating procedures agreed upon by the organization. If used and followed without exception by those in the operational environment, best practices are followed and behavioral variance, the enemy of high reliability, is eliminated. This brings us to another critical point about the use of checklists. Checklists will not be effective unless their use is fully supported by leadership.
Organizational leaders MUST create a culture of safety that not only embraces, but mandates, the use of checklists for specified tasks. A checklist is a safety tool, and all the safety tools in the world will not reduce operational risk if the culture fails to support them. Bottom line: Checklist use is central to achieving high reliability, and their use is not negotiable.
One more point about checklists. Checklists do not preclude the use of judgment.2 Situations arise where a checklist will move the operator through a process or procedure, but only to a point. Individuals must then use their professional judgement to safely navigate the situation to conclusion. There are also times where blindly following a checklist can lead to problems. Occasionally, conditions in the operating environment require that specific steps on the checklist be carefully considered before execution, and, in rare cases, not completing a prescribed step is the better course of action.
In fact, a well-designed checklist will prompt the user to “consider” certain factors before proceeding. But it is not possible to capture the multitude of possible scenarios that can play out in the real world; therefore, checklists require that users keep their brains in the game.