Hospital Checklists Need a Reality Check, According to Penn Collaborative Study

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Media Contact:Jordan Reese | jreese@upenn.edu | 215-573-6604August 17, 2009

PHILADELPHIA –- A team of sociologists and health-care researchers is calling for greater understanding of how hospital and medical checklists can be used to improve patient safety. Furthermore, say the authors of a commentary in the journal The Lancet, widespread deployment of medical checklists without an appreciation of how or why they work is a potential threat to patient safety and to high-quality care.

According to the authors, the real threat to safety arises when a hospital thinks it has solved a problem by handing the workers a checklist and telling them to use it. The reality is that getting the checklist is just the beginning. The key, say the authors, is getting people motivated to cooperate.

“The big challenge is how to get staff to use checklists consistently,” said co-author Charles Bosk, a professor of sociology in the School of Arts and Sciences at the University of Pennsylvania and senior fellow in Penn’s Center for Bioethics. “They’re not a magic pill. A checklist isn’t something a hospital can swallow and expect care to get better, safer or cheaper.”

Bosk studies patient safety with funding from the Robert Wood Johnson Foundation and Veterans Affairs Health Services Research and Development Service.

The mistake most commonly made when introducing checklists is to assume that a checklist can solve a cultural problem. It is a mistake, the authors contend, to think that you can get workers to use checklists just by insisting on it. A widely cited study that thrust medical checklists into favor involved using a five-step checklist to minimize the risk of patients getting catheter-related bloodstream infections. When the program was implemented in 103 intensive care units in Michigan for 18 months, infection rates dropped by 66 percent, resulting in estimated savings of $200 million and 2,000 lives. The program was implemented in many countries.

The authors say that the popular study fails to prove the efficacy of medical checklists as much as it shows the need to create incentives for people to cooperate. This includes using audit and feedback to create reputational and social incentives and having advocates within the organization who act as champions.

“The science of checklist implementation is in its infancy and needs much more attention,” said Mary Dixon-Woods, professor of medical sociology at the University of Leicester.

In the article, Bosk points out that simply having checklists in a hospital does not stop errors from occurring. He recounts the example of a 17-year-old girl who died in 2003 when she was given an organ transplant with a mismatched blood type.

“That error happened even though there were checklists for checking blood type,” he said.

The article also indicates that checklists work well for some types of problems in health care but not others. For example, aviation checklists help pilots complete take-off and landing safely. It’s less well known that checklists are also used for baggage handling, too, and there they don’t work so well.

“Checklists can be a really good way of making health care safer,” said Peter Pronovost, a critical-care physician, professor and director of the Quality and Safety Research Group at the Johns Hopkins School of Medicine. Pronovost leads the World Health Organization’s evaluation work to improve patient-safety measurement and leadership.

“There’s no doubt about that. They work by improving recall, prompting people to do all the necessary steps, and by making clear the minimum expectations. But they have to be used wisely,” Pronovost said.

“Reality checklist for checklists,” by Bosk, Dixon-Woods, Pronovost and Christine Goeschel of Johns Hopkins, who also leads quality and safety projects with the Agency for Healthcare Research and Quality and the National Patient Safety Agency, is published in current issue of The Lancet.