Checking lists, ticking boxes

Although not original, the story makes an interesting introduction to the topic: Boeing's prototype B-17 bomber stalled and crashed in 1935 on its first flight because the elevator control was left locked.¹,² The combination of the loss of life and the potential loss to the firm of the US government procurement demanded an innovative approach – and thus the checklist was born. The B-17 programme went on to build over 13,000 aircrafts. It took over 70 years for the checklist to enter mainstream medicine, with Pronovost's checklist for the prevention of central line infections, which reduced line infection rates from 11% to zero in Johns Hopkins.³ The World Health Organization (WHO)'s surgical checklist was pioneered 7 years ago and is widely used; the UK National Patient Safety Agency (NPSA) recommended its adoption by the NHS in 2009.⁴ Hard evidence of reductions in complications and in-hospital mortality from the use of checklists has been reported from the Netherlands.⁵

In this issue of Clinical Medicine, Braham et al describe the evolution of checklist usage and its adaptation to different circumstances, instancing the NPSA's adaptations of the WHO surgical checklists to obstetric surgery and interventional radiology.⁶ With the NPSA's absorption into the National Health Service (NHS) Commissioning Board Special Health Authority in 2012 (subsequently the NHS Commissioning Board, subsequently NHS England), issuance of checklists by the NHS halted. The year 2014 has, however, been identified as a year for special attention to patient safety by NHS England's safety director, with the launch of a nationwide programme to design patient safety initiatives.⁷ February saw the publication of the report of the NHS Never-Events Task Force Standardise, educate, harmonise: Commissioning the conditions for safer surgery.⁸

Surgery, with its central event of the operation, has perhaps appropriately been the focus for much of the drive towards a more disciplined, less variable and thus less error-prone approach. However, the factors identified by the task force as sources of surgical error – ‘human fallibility, miscommunication, poor coordination of team activity, human–technology interaction and suboptimal management of the environment’ – read equally well as sources of error in hospital medicine. The combination of unsafe systems and unsafe behaviours highlighted as lying behind surgical never-events lie equally behind medical accidents and mismanagement, including absent or inadequate training, particularly in team working and human factors, as well as inadequate staffing. The Task Force pointed to reducing variation by standardisation in the NHS as the first step to preventing never-events – and indeed improving safety in general – and praises and values the surgical checklists as a means to achieve this. It points out, however, that they are not a panacea, and improperly used can degenerate to a despised -tick-box exercise.

In their paper, Braham et al report on the introduction of a local checklist in a medical setting, in the context of a cardiac catheter laboratory performing a wide variety of procedures.⁶ Their initial audit of the effect of using an unmodified WHO Surgical Checklist confirmed that specific modifications to fit the requirements of a cardiac catheter laboratory were essential to obtain buy-in from the staff; indeed the unmodified checklist was rarely completed and on occasions was manifestly incorrectly filled in. A modified checklist designed to be strictly relevant to the environment in which it was being used was substantially more acceptable, and its use may indeed have prevented critical incidents (though the study was not designed or powered to prove that).

It is difficult to imagine that current patient safety initiatives in the NHS will not move increasingly towards mandating the use of checklists, as part of a nationwide move towards standardisation and harmonisation. An appropriately formulated and completed checklist has been shown to safeguard patients; in a medico–legal context one would envisage the same checklist would also safeguard healthcare practitioners. The requirement will be to design such documents so that they are fit for purpose and, if so, they will be welcomed. But much needs to be done to achieve protocols appropriate for the huge number of procedures and scenarios that hospital medicine presents. To state the obvious, it is an area where only clinicians can lead.