Checklists

We all know how important checklists are in our day-to-day lives. We cannot survive the day without a to-do list reminding us of the tasks that make our lives go round. It is clearly not an exaggeration to say we live by the checklist.

Airline safety

But checklists perform far more important roles than reminding us to buy the milk, or to pick junior after football practice. Checklists are central to the maintenance of safe practice in many industries. Checklists are best celebrated in aviation where they are indispensable to airline safety.

The Checklist Manifesto

Despite their recognised value, checklists are not applied widely enough in medicine. One person who has passionately addressed this shortcoming is Atul Gawande in his highly acclaimed book, The Checklist Manifesto. In this book, the author explored the positive impact of checklists based on his own research into surgical safety. His view of checklists is quite instructive, for example when he says:

• Checklists translate knowledge into a simple, usable, and systematic form
• Checklists are quick and simple tools aimed to buttress the skills of expert professionals.
• Good checklists could become as important for doctors and nurses as good stethoscopes

 

The WHO surgical safety checklist

Gawande’s major contribution to patient safety is the development of the acclaimed WHO Surgical Safety Checklist. This simple tool is now a key component of surgical operating procedures globally.

 

Gawande’s own experience of using the checklist shows how important this tool is. He says:

• I have yet to get through a week in surgery without the checklist’s leading us to catch something we would have missed
• With the checklist in place, we have caught unrecognized drug allergies, equipment problems, confusion about medications, mistakes on labels for biopsy specimens
• We have made better plans and been better prepared for patients

Beyond the operating room

Atul Gawande made the important observation that checklists have potential applications “beyond the operating room“. He said “…there are hundreds, perhaps thousands, of things doctors do that are as dangerous and prone to error as surgery“. He gave several examples of these such as the evaluation of headache, chest pain, lung nodules and breast lumps. He also pointed to the treatment of heart attacks, strokes, drug overdoses, pneumonias, kidney failures, seizures, and headache.

Addressing Gawande’s challenge

Gawande appreciates that all medical activities involve risk, uncertainty, and complexity. His simple recommendation is to commit them all to checklists. He urges the medical fraternity to seize the opportunity and do this. Apart from Anaesthesia which is probably ahead of the curve, there are only few medical checklists such as:

• Ward Round Considerative Checklist developed by Gordon Caldwell.
• Pediatric Symptom Checklist
• The KIDS SAFE Checklist for Pediatric Intensive Care Units
• Checklist for Prevention of Central Line Associated Blood Stream Infections 
• Heart Failure Checklist

 

Neurology checklists

Gawande’s vision of a checklist-led approach to medicine, encompassing the spectrum of clinical practice, is indeed challenging. As a neurologist who is keen on patient safety, I was intrigued by this perspective, and I wondered if it was possible to commit the whole of neurology to checklists. In taking up the challenge, I imagined a neurology checklist application that is practical, comprehensive, easy to search, evidence-based, and up-to-date. After five years of collecting and distilling articles, reviews and guidelines, and after months of engagement with software developers, the dream is becoming reality. In my next blog post I will describe the outcome of the journey and discuss how simple checklists may unlock excellent neurological practice.