Medication prescribing checklists and the impact on patient safety: A scoping review

Abstract

Objectives

Medication prescribing checklists and the impact on patient safety remain unexplored. This scoping review aimed to identify key elements of these checklists and evaluate their impact on patient safety outcomes.

Methods

We searched PubMed and Embase for studies reporting checklists in medication prescribing practices and the impact on patient safety outcomes as of October 23, 2024. We applied Fisher’s exact test to evaluate the association between checklist effectiveness (based on patient safety outcomes) with study design (randomized controlled trials [RCTs] vs. non-RCTs) and intervention type (bundled intervention vs. checklist-only intervention).

Results

After full-text review, 53 articles met inclusion criteria for data extraction and analysis, including 4 (7.5%) RCTs, 25 (47.2%) quasi-experimental designs, and 24 (45.3%) observational studies. Medication prescribing checklists commonly include elements such as prescription accuracy, drug interaction checks, education, and adherence to guidelines. Twenty-nine (54.7%) studies assessed checklist effectiveness, including 11 with bundled intervention and 18 with checklist-only intervention. Among the 29 effectiveness studies, 25 (86.2%) found the checklist to be effective (23 quasi-experiment studies, one retrospective study, and one RCT), while 4 (13.8%) reported no benefit or inferior outcomes. Barriers to implementation include usability and clinical workflow integration. Notably, studies without an RCT design were more likely to be effective (p = 0.004). The likelihood of effectiveness was not significantly different between studies implementing checklists as part of a bundled intervention and studies with checklists as a single implementation strategy (p = 0.622).

Conclusion

Checklists are an effective tool in improving the safety of medication prescribing practices. However, checklist effectiveness is potentially influenced by several factors such as usability and integration into the workflow. RCTs were more likely to be ineffective than non-RCTs. Further research is necessary to confirm checklist effectiveness and refine their design and implementation strategies.

Introduction

Checklists provide a structed method to ensure that all essential tasks are completed accurately and safely, reducing the risk of overlooked steps due to fatigue, stress, or distriaction.¹ High-risk industries like aviation have long demonstrated the effectiveness of checklists to maintain safe and reliable operations.¹ Healthcare has drawn lessons from aviation and adopted checklists to reduce errors and improve patient safety. Since the successful implementation of the World Health Organization (WHO) Surgical Safety Checklist (SSC), which has been linked to significant reductions in morbidity and mortality, checklist use continues to expand.^2–5

Implementation of successful checklists in healthcare is key as 5–10% of hospitalized patients are exposed to an adverse drug event (ADE), a large majority of which are preventable.⁶ ADEs are categorized into five subtypes: adverse reactions, errors, therapeutic failures, and withdrawal events and overdoses.⁷ Of the inpatients affected by ADEs, medication errors are the strongest risk factor for preventable ADEs with an average of one medication error per day per hospitalized patient.^8–11

The prescribing process is complex and multifaceted, allowing opportunities for errors.¹² A prospective study found errors in 15% of hospital prescriptions.¹³ These errors, such as omission, inappropriate dosage, and incomplete prescription, can significantly impact patient outcomes by leading to adverse events, treatment delays, or suboptimal treatment effects.^14,15 Several contributing factors were identified, including lack of feedback on errors, poor documentation and communication of prescribing decisions, and lack of information about patients’ medication histories from primary care.¹³ With proper implementation and education of the prescribing team, a medication checklist may help curb avoidable prescription errors.

While studies demonstrate potential benefits for checklist in medication prescribing safety, checklist elements vary across studies, the extent of checklist in medication prescribing is unclear, and evidence of their impact on patient safety outcomes is insufficient. Given the diversity in checklist designs and research approaches, a scoping review is necessary to map the existing literature, identify key elements of medication prescribing checklists, and clarify how they impact patient safety. Therefore, the goal of this scoping review was to identify key elements included in medication prescribing checklists in all healthcare settings and their impact on patient safety outcomes.

Methods

We conducted a scoping review to comprehensively map the literature on medication prescribing checklists. We developed our search strategy to answer the following questions: For what prescribing practices have medication prescribing safety checklists been implemented? How does the implementation of patient safety prescribing checklists affect patient safety outcomes? This review followed the methodological framework proposed by Arskey and O’Malley and the Preferred Reporting Item for Systematic Review and Meta-analysis for Scoping Review (PRISMA-ScR) (Supplement Table 1).^16,17

Search strategy

The search strategy was built on three key concepts and related terms: medication prescribing, safety, and checklist. Two independent reviewers (YL, TM) searched PubMed and Embase using Table 1 queries for relevant papers as of October 23, 2024.

Table 1.

Search strings and filters for medication prescribing safety checklist publications in PubMed and Embase

PubMed	Embase†
(practice patterns, physicians[MeSH Terms] OR prescribing[Title/Abstract] OR medication administration[Title/Abstract] OR drug prescription[MeSH Terms] OR drug therapy[MeSH Terms] OR dispens[tiab]) AND (checklist[MeSH Terms] OR checklist[Title/Abstract] OR (“prescribing checklist”[Title/Abstract]~2) OR (“safety checklist”[Title/Abstract]~2)) AND (Safety[Title/Abstract] OR Safety Management[MeSH Terms] OR Patient Safety[MeSH Terms] OR Safe[Title/Abstract] OR medication error[Title/Abstract] OR medication errors[MeSH Terms])	(‘prescribing practice’/exp OR ‘prescription’/exp OR ‘clinical practice’/exp OR ‘drug therapy’/exp OR prescribing:ab,ti OR ‘medication administration’:ab,ti OR dispens:ab,ti) AND (checklist/exp OR checklist:ti,ab) AND (safety/exp OR safe:ab,ti OR ‘medication error’:ab,ti)
Filter: English	Filter: English Exclude: papers in Medline, conference abstracts

^†Abbreviations for Embase search: ab-abstract, exp-exploded Terms, ti-title.

Study selection

We included all studies pertaining to medication prescribing checklists and the impact on patient safety outcomes. All study designs and methodologies were included. Any disagreements were resolved by discussion within the two independent reviewers (TM, YL) or with the clinician co-authors (KS, KZ). The following publications were excluded: 1) Study irrelevant to checklists; 2) Surgical safety checklists, unless medication use was reported as an outcome; 3) Checklists that did not include medication prescribing; 4) Narrative reviews; 5) Systematic reviews with only one relevant paper; 6) No description on the development process if the paper focused on checklist development (without implementation or effectiveness results); 7) Comments, editorials, presentations, and conference abstracts. These exclusion criteria ensured the selection of the peer-reviewed primary literature focused specifically on checklists aimed at improving medication prescribing practices.

Data extraction and analysis

Three reviewers (TM, YL, and AR) developed a data extraction table and independently identified the key characteristics of each eligible study. The entire table was then independently reviewed by 2 reviewers (TM, YL) to confirm agreement. The table included detailed characteristics of the studies including, but not limited to, study design, methods, purpose of the checklist, key elements of the checklist, study focus, type of the checklist and interventions, and whether has an impact on patient safety. The study design was categorized as observational (including case study / report, cross-sectional, prospective, and retrospective) or experimental (randomized controlled trials (RCTs) or quasi-experimental studies). The reported purpose of the checklist was categorized as development, implementation, and evaluation of effectiveness. Checklist development refers to the systematic creation and refinement of a checklist through methods such as literature review, expert consultation, consensus techniques (e.g., Delphi process), and pilot testing to ensure checklist validity, clarity, and relevance for guiding clinical decision making. Checklist implementation was defined as the process of integrating a checklist into medication prescribing workflows and ensuring its practical use by healthcare providers through deployment, training, and adaptation to the working environment. We defined a checklist as effective only when objective measures demonstrated an improvement in patient safety outcomes. Studies evaluating perceived effectiveness or assessing practitioners’ knowledge after checklist implementation were not considered effectiveness reports, as they reflect user perceptions rather than directly measuring patient outcomes.

To explore potential associations between study characteristics and reported checklist effectiveness, we conducted Fisher’s exact tests to evaluate whether checklist effectiveness varied by study design type (RCT vs. non-RCT), recognizing that RCTs offer greater causal inference while non-RCTs may be more prone to bias. Fisher’s exact test was used due to small sample sizes and cell counts violating the assumption of Chi-squared test.

Results

Study selection and characteristics

The initial search identified 954 records, comprising 582 retrieved from PubMed and 372 from Embase. After title and abstract screening, 822 records were excluded for irrelevance and 3 were excluded for duplication. One hundred and twenty-nine citations remained for full-text screening; 76 studies were excluded after a full-text eligibility assessment. After exclusion, 53 studies were included for data extraction and analysis (Figure 1).

Figure 1.

Flow chart of the study selection process for the scoping review of medication prescribing checklists and the impact on patient safety outcomes.

Table 2 shows the characteristics of the 53 included articles. Year 2023 was the single year with the highest number of publications (n = 10, 18.9%). Geographically, Europe accounted for the largest proportion of studies (50.9%). Three articles (5.7%) adopted a multi-country approach, which focused on checklist development involving authors from multiple countries. The majority (71.7%) of checklist implementations were conducted in hospitals, followed by community pharmacies (15.1%) and outpatient clinics (7.5%). The study designs included 4 (7.5%) RCTs, 25 (47.2%) quasi-experimental designs, and 24 (45.3%) observational studies. Of the 53 reviewed studies, 27 (50.9%) included checklist development, 32 (60.4%) described checklist implementation, and 29 (54.7%) assessed checklist effectiveness on patient safety outcomes.

Table 2.

Characteristics of the 53 included studies on the development, implementation and effectiveness of medication prescribing safety checklists

Variables	Values (n (%)) (N=53)
Year of Publication
2000–2005	1 (1.9)
2006–2010	7 (13.2)
2011–2015	12 (22.6)
2016–2020	18 (34.0)
2021–2023	15 (28.3)
Continent of Publication
North America (US, Canada)a	17 (32.1)
South America	2 (3.8)
Europe	27 (50.9)
Australia	1 (1.9)
Asia	3 (5.7)
Multi-country	3 (5.7)
Setting
Hospital	38 (71.7)
Community pharmacy	8 (15.1)
Outpatient clinic	4 (7.5)
General practice	1 (1.9)
Usability laboratory	1 (1.9)
Unspecified	1 (1.9)
Study design
Observational	24 (45.3)
Case study / report	15 (28.3)
Cross-sectional	3 (5.7)
Prospective	1 (1.9)
Retrospective	5 (9.4)
Experimental	29 (54.7)
RCTb	4 (7.5)
Quasi-experimental study	25 (47.2)
Pre-post studyc	23 (43.4)
Interrupted time series analysis	2 (3.8)
Study focus
Checklist development only	13 (24.5)
Checklist implementation only	6 (11.3)
Checklist effectiveness only	8 (15.1)
Checklist development & implementation	5 (9.4)
Checklist implementation & effectiveness	12 (22.6)
Checklist development, implementation, effectiveness	9 (17.0)

^aThere were no studies in Mexico.

^bRCT: randomized controlled trials.

^cIncluding 6 quality-improvement studies (26.1% of all pre-post studies), as stated by the authors.

Elements of medication prescribing checklists

Detailed characteristics of each included article are shown in Table 3.

Table 3.

Detailed characteristics of the 53 included studies on the development, implementation and effectiveness of medication prescribing safety checklist

Study	Study design	Checklist purpose	Checklist key elements	Study focus	Checklist alone or bundled intervention	Checklist effective?a
Pape32 (2005)	Pre-post study	To ensure correct medication administration.	Prescription accuracy, allergy checks, education, documentation	Implementation, effectiveness	Symbols and signage	Yes
Garbutt18 (2008)	Pre-post study	To minimize prescribing errors using standard practices.	Prescription accuracy, patient information, routine checks, order writing process, verbal orders	Development, implementation, effectiveness	Grand rounds, interactive education, active and passive reminders	Yes
Rosenberg33 (2008)	Pre-post study	To ensure timely surgical antibiotic prophylaxis.	Antibiotic review, prescription accuracy, dose, reason for non-administration	Implementation, effectiveness	Checklist alone	Yes
Mertz58 (2009)	Pre-post study	To ensure timely IV-to-oral antibiotic switch.	Antibiotic review	Effectiveness	Checklist alone	Yes
Pham19 (2009)	Case study / report	To ensure proper patient selection for abatacept therapy.	Contraindications, adverse events, patient information	Development	N/Ab	N/A
Lewinski34 (2010)	Cross-sectional	To detect drug-related problems in pharmacy services.	Prescription accuracy, compliance, adverse events, contraindications, drug interactions	Development, implementation	Checklist alone	N/A
Vries59 (2010)	Pre-post study	To optimize surgical antibiotic prophylaxis timing.	Informed consent, equipment checks, communication, follow-up	Effectiveness	Checklist alone	Yes
White20 (2010)	Interrupted time series	To verify ambulatory infusion pump settings	Prescription accuracy, equipment checks, double-check discrepancies, patient information, safety prompt	Development, implementation, effectiveness	Checklist alone	Yes
Lépée21 (2012)	Interrupted time series	To enhance prescription review during ward rounds.	Patient information, prescription accuracy, antibiotic review	Implementation, effectiveness	Checklist alone	Yes
Linden48 (2012)	Case study / report	To guide assessment, decision-making, and treatment planning.	Drug interactions, medical history, response/tolerability, patient acceptance	Development	N/A	N/A
Stocker60 (2012)	Pre-post study	To enhance antibiotic therapy practices.	Infection check, therapy adjustment, follow-up	Development, implementation, effectiveness	Checklist alone	Yes
Colborne61 (2013)	Pre-post study	To ensure VTE risk assessment and prophylaxis	Adverse events, organ function evaluation	Effectiveness	Checklist alone	Yes
Patapovas49 (2013)	Pre-post study	To screen for safety risks in drug therapy	Drug interactions	Development, implementation	Education, poster	N/A
Schneider22 (2013)	Cross-sectional	To ensure appropriate emergency contraception supply.	Patient information, medical history, adverse events	Implementation, effectiveness	Checklist alone	N
Sedlmayr56 (2013)	Retrospective	To flag high-risk patients for inappropriate medications.	Adverse events, alternative drugs, supportive procedures	Implementation	Regular safety training, information posters, computerized decision support	N/A
Villafranca35 (2014)	Pre-post study	To improve medication error detection.	Prescription accuracy, administration	Development, implementation, effectiveness	Checklist alone	Yes
Weiss23 (2014)	Randomized controlled trial	To reduce ICU antibiotic overuse.	Antibiotic review, patient information, prescription accuracy, dose, safety prompts	Implementation, effectiveness	Presence of non-care physician to prompt for antibiotic treatment questions	N
Bungard62 (2015)	Case study / report	To assess eligibility for novel anticoagulants.	Contraindications	Development	N/A	N/A
Keiffer36 (2015)	Pre-post study	To improve medication double-check processes.	Allergy checks, prescription accuracy, therapy adjustments, drug interactions, communication, monitor	Implementation, effectiveness	Quality committee, education, medication double check, distraction-free zone, medication bar coding.	Yes
Warholak50 (2015)	Case study / report	To prevent inappropriate prescriptions.	Drug interactions, administration	Development	N/A	N/A
Dobish63 (2016)	Case study / report	To identify critical stop points in chemotherapy preparation	Equipment checks, administration, dose	Development, implementation	Chemotherapy preparation worksheets	N/A
Urfer24 (2016)	Pre-post study	To improve clinical decision-making in prescribing.	Prescription accuracy, adverse events, monitoring, patient information	Effectiveness	Checklist alone	Yes
Warren64 (2016)	Case study / report	To ensure methotrexate prescribing aligns with guidelines	Medical history, contraindications, baseline labs, response, tolerability, monitoring	Development	N/A	N/A
Byrne37 (2017)	Pre-post study	To enhance discharge prescription accuracy.	Prescription accuracy	Implementation, effectiveness	Checklist alone	Yes
Daalen53 (2017)	Randomized controlled trial	To reduce hospital stays and inappropriate antibiotic use.	Prescribing accuracy, therapy adjustments, antibiotic review, documentation	Implementation, effectiveness	Education, feedback on baseline antiobiotic use, reminders	Yes
Desnoyer38 (2017)	Case study / report	To detect inappropriate medications in internal medicine.	Prescription accuracy, drug interactions	Development	N/A	N/A
Pires12 (2017)	Case study / report	To ensure compliance with medication prescription guidelines.	Compliance, patient information, prescription accuracy	Development	N/A	N/A
Ruthirago44 (2017)	Pre-post study	To enhance guideline adherence and patient outcomes.	Education, compliance	Effectiveness	Checklist alone	Yes
Shephard51 (2017)	Pre-post study	To improve safety in immunosuppressant use.	Counseling, drug interactions, contraindications, monitoring: adverse events	Effectiveness	Checklist alone	Yes
Sinnott45 (2017)	Case study / report	To optimize medication management with peer support and structured reviews	Indication, drug interactions, compliance, adverse events, risk reduction, treatment simplification	Implementation	Action planning, social environment restructuring, social support, and self-incentives	N/A
Shea39 (2018)	Pre-post study	To evaluate antiretroviral prescribing accuracy.	Prescription accuracy, administration, drug interactions	Development, implementation, effectiveness	Order-entry/verification system modifications and pharmacist education.	Yes
Bain46 (2019)	Pre-post study	To improve discharge process for insulin therapy.	Compliance, self-administration ability, equipment checks, follow-up	Development, implementation, effectiveness	Posters in ward areas; detailed medication reconciliation.	Yes
Cardoso65 (2019)	Case study / report	To standardize nursing care and prevent adverse events	Admission, administration	Development	N/A	N/A
Doris66 (2019)	Retrospective	To ensure safe prescribing and monitoring of dabigatran.	Indication, dose, organ function check, and adverse events	Implementation	Checklist alone	N/A
Kanjia25 (2019)	Pre-post study	To improve compliance with safe APAP administration.	Prescription accuracy, patient information, dose, documentation, and handoff	Development, implementation, effectiveness	Checklist alone	Yes
Whittam67 (2019)	Case study / report	To ensure safe rituximab infusion.	Indication, emergency/elective use, dose, contraindications, informed consent, contraindications, immunizations, baseline labs, medical history	Development	N/A	N/A
Alley40 (2020)	Pre-post study	To facilitate communication with prescribers.	Initial screening, safety trigger, prescription accuracy, communication, action plans, follow-up	Development, implementation	Online continuing education course	N/A
Evans26 (2020)	Case study / report	To guide dapagliflozin prescribing.	Prescription accuracy, patient information, contraindications, medical history	Development	N/A	N/A
Chen55 (2021)	Retrospective	To enhance opioid safety while ensuring pain management	Medication and risk factor review, education	Implementation	Checklist alone	N/A
Marzal-Alfaro27 (2021)	Case study / report	To guide pharmacist responsibilities in CAR-T therapy.	Patient information, treatment logistics, bridging therapy, adverse events, response, follow-up	Development	N/A	N/A
Correll (2022)	Case study / report	To guide clozapine initiation, monitoring, and management.	Patient information, therapy initiation, maintenance, adverse events	Development	N/A	N/A
Hayes29 (2022)	Pre-post study	To improve antibiotic stewardship in community pharmacies.	Patient information, antibiotic review, education	Implementation, effectiveness	Community pharmacy e-learning, posters, patient facing info leaflets	Yes
Lem52 (2022)	Cross-sectional	To assess patient suitability for treatment.	Patient information, medical history, drug interactions	Implementation	Training document	N/A
Aimar54 (2023)	Pre-post study	To reduce prescribing errors and optimize inpatient care.	Indications, prescribing process	Implementation, effectiveness	Education of junior doctors and ward staff; electronic prescribing system	Yes
Grischott47 (2023)	Randomized controlled trial	To review unnecessary chronic medications in elderly patients.	Patient complaint, treatment goals, medication review, adverse events, dose, alternative drugs, compliance, communication	Implementation, effectiveness	Discharge letters sent to primary care physicians	N
Harvey68 (2023)	Case study / report	To identify candidates for IV-to-oral antibiotic switch	Antibiotic review, clinical symptoms, biomarkers, administration	Development	N/A	N/A
Hayes30 (2023)	Retrospective	To educate and empower staff in antibiotic stewardship.	Patient information, antibiotic review, education	Implementation	Antimicrobial stewardship (AMS) e-Learning and the Antibiotic Guardian pledge	N/A
Kapoor41 (2023)	Randomized controlled trial	To ensure safe transition of care for DOAC patients.	Prescription accuracy, affordability, education, access to expertise, documentation, transition of care, monitoring	Effectiveness	Checklist alone	N
Martínez57 (2023)	Prospective	To help pharmacists identify medications for deprescribing.	Adverse events, dose, follow-up deprescription criteria	Development, implementation	Reconcile home treatment with electronic medical records	N/A
Nishida42 (2023)	Retrospective	To minimize inappropriate medication use and polypharmacy.	Administration, prescription accuracy, response, drug interactions, swallowing issues, organ function, monitoring	Development, implementation, effectiveness	Multidisciplinary review of medication list	Yes
Segebrecht69 (2023)	Pre-post study	To integrate first-line non-opioid therapies into prescribing	Alternative drugs, physical therapy referral, pain clinic referral prior to prescribing	Effectiveness	Checklist alone	Yes
Wat43 (2023)	Pre-post study	To verify chemotherapy prescriptions safely.	Regimen details, diagnosis match, organ function/labs, allergies, dose, medical history adverse events, prescription accuracy	Development, implementation, effectiveness	Checklist alone	Yes
White31 (2023)	Pre-post study	To assess warfarin-to-DOAC transition eligibility	Drug interactions, patient information contraindications, insurance coverage and copay details.	Implementation, effectiveness	Checklist alone	Yes

^aChecklist effectiveness: We defined a checklist as effective only if objective measures demonstrated improved patient safety outcomes. Studies evaluating perceived effectiveness or practitioner knowledge were not considered effectiveness reports.

^bN/A: not applicable

Published medication prescribing checklists generally consisted of multiple key elements including verification of patient information,^12,18–31 prescription accuracy,^{12,18,20,21,23–26,32–43} guideline compliance,^{12,34,44–47} checks for potential drug interactions,^{31,34,36,38,39,42,45,48–52} and maintaining appropriate documentation.^25,32,41,53 Tools such as the TARGET Antibiotic Checklist and Direct Oral Anticoagulant (DOAC) Eligibility Checklist aid in high-risk medication management,^29–31 while perioperative and hospital-based checklists, such as the variable rate intravenous insulin infusion (VRIII) checklist,⁵⁴ optimize inpatient care. Additionally, some checklists highlighted the importance of education.^{29,30,32,41,44,55}

We identified 19 articles (35.8%) that included a checklist as part of bundled intervention, among which 11 (57.9%) assessed checklist effectiveness. The most common bundled interventions are educational posters on medication prescribing safety,^29,46,49,56 medication safety training sessions with case reviews,^52,56 and updates to the electronic prescribing system.^54,57 Some bundled interventions also included computerized decision support and patient information leaflets.^29,56

Checklist impact on patient safety

Among the 29 (54.7%) studies assessing the impact of the checklist on patient safety outcomes, 25 (86.2%; 23 quasi-experiment studies, one retrospective study, and one RCT) found the checklist effective (Table 3). Checklists significantly improved physician adherence to guidelines and clinical outcomes and reduced medication errors.^29,36,39,44 In addition, checklist altered prescribing behaviors and promoted safer practices.⁶⁹ Segebrecht et. al incorporated a checklist derived from Centers for Disease Control and Prevention’s opioid prescribing recommendations.⁶⁹ Following the integration of this checklist into the electronic medical record, opioid prescribing decreased by 38.4% per month.

Two studies reported the partial effectiveness of checklists. Daalen et.al found that an antibiotic checklist improved prescribing appropriateness, but did not reduce hospital stay.⁵³ Shephard et. al introduced a checklist for systemic medications monitoring to an oral medicine clinic, which improved tuberculosis risk assessment compliance from 5% to 50% at 6 months.⁵¹ However, compliance declined to 4% at 12 months, demonstrating challenges in sustaining improvement over time.

Among the 29 studies assessing checklist effectiveness, 4 (13.8%) found no benefit or inferior outcomes: 3 (10.3%) found no improvement on patient safety, and 1 (3.4%) showed worse performance than face-to-face prompting. In a cluster RCT, Grischott et. al examined a checklist-guided medication review at hospital discharge among older patients with polypharmacy and found no improvement in readmissions or health-related outcomes.⁴⁷ Kapoor et. al found that a bundled intervention including a checklist did not reduce clinically important medication errors (CIMEs) in an RCT.⁴¹ Schneider et.al showed that a paper-based checklist did not improve pharmacy advice regarding emergency contraception.²² Weiss et. al compared an unprompted electronic checklist within the electronic health record (EHR) with face-to-face prompting, where a non-care providing resident physician joined intensive care unit (ICU) rounds and initiated antibiotic discussions.²³ Face-to-face prompting was superior to an unprompted EHR-based checklist at reducing empirical antibiotic utilization.

Table 4 illustrates the relationship between checklist effectiveness, study design (RCT vs. non RCT, including quasi-experimental and observational studies), and intervention type (bundled intervention vs. checklist-only intervention). Interestingly, studies without an RCT design were more likely to be effective (p = 0.004). The likelihood of effectiveness was not significantly different between studies implementing checklists as part of a bundled intervention and studies with checklists implemented as a single implementation strategy (p = 0.622).

Table 4.

Association between study design (RCT vs. non-RCT) and intervention type (bundled intervention vs. checklist-only intervention) and checklist effectiveness

Effectiveness	RCTa	Non-RCTe	Total	P-value	Bundled intervention	Checklist only	Total	P-value
Effective	1	24	25	0.004	9	16	25	0.622
	3.45b	82.76	86.21		31.03	55.17	86.21
	4.00c	96.00			36.00	64.00
	25.00d	96.00			81.82	88.89
Ineffective	3	1	4		2	2	4
	10.34	3.45	13.79		6.90	6.90	13.79
	75.00	25.00			50.00	50.00
	75.00	4.00			18.18	11.11
Total	4	25	29		11	18	29
	13.79	86.21	100.00		37.93	62.07	100.00

^aRCT: randomized controlled trial

^bPercentages among total studies

^cPercentages by row

^dPercentages by column

^eNon-RCT studies including quasi-experimental and observational studies

Discussion

This scoping review provides a comprehensive analysis of medication prescribing checklists and the impact on patient safety. We identified 53 studies and found that checklists could improve patient safety. However, checklist effectiveness is potentially influenced by various factors such as usability and integration into clinical workflows, and checklist effectiveness is associated with the robustness of study design.

Checklists improved adherence to guidelines and reduced medication errors.^29,36,39,44 However, several barriers limited their effectiveness. Delivery method (electronic vs paper-based) may affect ease of access and integration with the EHR, while lack of awareness and briefing reduced adoption.⁵⁶ Some checklists were narrow in scope, focusing only on specific medications (e.g., critical care drugs), which reduces their usefulness in more complex prescribing scenarios.⁵⁶ Initial compliance improvement may decline over time, potentially due to the Hawthorne effect (behavior improves when people know they are being observed) and checklist fatigue.⁵¹ Over time, established staff may stop referring to checklists and rely on recall, while new staff may lack training, further weakening sustained implementation and effectiveness. In addition, the intended improvement through checklist use was limited by insufficient communication between healthcare professionals, such as pharmacists and providers,⁴¹ or primary care physicians (PCPs) and hospital physicians (HPs).⁴⁷ Embedding checklists into broader communication strategies is essential to support consistent use, improve coordination, and enhance patient safety.

Most studies (86.2%) in this review found that checklists were effective in improving patient safety. However, checklist effectiveness was significantly associated with study design, with RCTs less likely to report positive outcomes than non-RCTs. This discrepancy may reflect potential biases in observational studies or quasi-experimental studies, where factors such as the Hawthorne effect could overestimate checklist impact. That said, our findings should be interpreted with caution, as only four RCTs were included in this review, limiting the robustness of this comparison. In addition, RCTs are highly controlled and usually have stricter inclusion/exclusion criteria than non-RCT studies. Notably, two of the three RCTs reporting ineffectiveness had a small study population,^23,47 including one with under-recruitment during COVID-19, which led to reduced statistical power and potential false-negative results. In another RCT, the control group received partial checklist support, potentially underestimating the full checklist benefit.⁴¹ Given these limitations, additional studies with larger sample sizes and robust designs are needed to further validate and refine our findings.

Our review highlights that while checklists are valuable tools for improving patient safety, their effectiveness is highly dependent on how they are implemented. For example, real-time checklists coupled with face-to-face prompt were more effective than unprompted electronic checklists, especially in complex clinical scenarios requiring intricate decision-making.²³ This suggests that checklists alone may not be sufficient to drive behavioral change unless they actively engage clinicians in real-time decision processes. On the other hand, checklists are more scalable than assigning a dedicated clinician to prompt others. To maximize checklist effectiveness, checklists should be designed to support clinical decision-making (not replace) and ideally be integrated into the clinical environment to prompt meaningful reflection and action.

Furthermore, many studies implemented checklists as part of bundled interventions, including educational tools, training sessions, and updates to the electronic prescribing system. However, bundled interventions did not show a significant association with improved checklist effectiveness. This may be due to low physician engagement, often driven by poor usability and poor integration into daily workflows as integrating multiple interventions into daily workflows can be challenging. Physicians reported using medication safety measures in fewer than 10% of critical orders.⁵⁶ However, physicians expressed a higher intention to use these tools if usability and workflow alignment improved.⁵⁶ This emphasizes that regardless of whether checklists are implemented independently or within bundles, their effectiveness depends on the integration into clinical routines and their ability to facilitate real-time decisions.

Limitations

The study has several limitations. First, the inclusion of published studies limited to PubMed and Embase can lead to bias, as unpublished studies may be more likely to have negative findings. Second, this scoping review did not assess the quality of included studies. Given that many studies have small sample sizes in a single center, our findings should be interpreted with caution. Third, this scoping review described checklist effectiveness using summary statistics rather than performing meta-analyses, limiting the ability to provide quantitative conclusions. Finally, grouping diverse quasi-experimental studies together may mask differences in methodological robustness and may lead to misclassification.

Conclusion

Checklists can be an effective tool in improving medication prescribing practices and patient safety. However, checklist effectiveness is potentially influenced by several factors such as usability and integration into the workflow. Our findings highlight the need for further research of larger sample sizes and longitudinal studies to confirm checklist effectiveness and refine their design and implementation strategies.

Key points.

Background

• The elements of medication prescribing checklists vary across studies.

• Evidence of their impact on patient safety is limited.

Findings

• Checklists can be effective in improving medication prescribing practices, such as prescription accuracy and guideline compliance, and ultimately enhancing patient safety.

• Checklist effectiveness may depend on factors like usability and integration into the clinical workflows.