Could checklists support teams in stressful situations?

We welcome Grieg et al’s debate article about checklists.¹ Any activity that supports GPs in delivering safe, effective care in time-critical situations is greatly welcomed. However, we would like to take the opportunity to encourage practitioners to adopt a more critical approach when considering the use of checklists.

As Greig et al suggest, the rise of checklists in health care has largely followed their use in the aviation industry, where they provide a safety layer that protects against classic human failings like forgetting, particularly when working under pressurised conditions. But differences between health care and aviation present a challenge for this cognitivist way of understanding checklists.² For example, patient complexity makes healthcare delivery much less amenable to standard operating procedures than aviation. Managing healthcare emergencies relies on seamless functioning of multiple staff members across a wide range of roles — from GPs to practice nurses to receptionists — rather than just pilots and cabin crew. Practice treatment rooms and equipment vary from place to place much more than standardised aeroplane cockpits do. This means that checklists may not always be effective, may not transfer well between contexts, or may work in different ways than expected.³

We remain convinced about the potential usefulness of checklists, particularly in pressurised, infrequently occurring situations such as emergencies. However, faced with the complex, contextualised nature of health care, we recommend qualitative, sociocultural research to develop a deeper understanding of how they can be made to work effectively and in what contexts. We also recommend road testing of checklists — a process that may be supported by the emerging field of in-situ simulation⁴ to ensure that they work within the realities of real-world general practice.