checklists: the good, the bad, and the preventably ugly€¦ · checklists: the good, the bad, and...
TRANSCRIPT
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Checklists: The good, The bad,
and the preventably ugly
Della Lin, M.D. AHA-NPSF Patient Safety Leadership Fellow
Estes Park Institute Senior Fellow HRET Senior Fellow
June 2016 [email protected]
“Reality Check for Checklists”
• The emphasis on checklists is Hitchcockian “McGuffan”, a distraction from the plot that diverts attention from how safer care is really achieved.”
Bosk, C et. Al. The Lancet Vol 374 August 8, 2009
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“A checklist does not replace or interfere with your judgment or critical decision-
making” Daniel Boorman
Boeing Checklist Designer
Why Checklists?
Rank Order of Error Reduction Strategies
Forcing functions and constraints
Automation and computerization
Standardization and protocols
Checklists and double check systems
Rules and policies
Education/ Information
Be more careful, be vigilant
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The intent of checklists is to turn the brain on…
N Engl J Med 2006;355:2725-32;
BMJ 2010;340:c309.
Heralding the Checklist
Median and Mean CRBSI Rate
0
1
2
3
4
5
6
7
8
9
Bas
eline
Inte
rven
tion 0-
34-
67-
9
10-1
2
13-1
5
16-1
8
19-2
1
22-2
4
25-2
7
28-3
0
31-3
3
34-3
6
Time (months)
CR
BS
I R
ate
Median CRBSI Rate Mean CRBSI Rate
• Wash Hands
• Use Chlorhexidine
• Full Barrier Drape
• Avoid Femoral Site
• Remove Unwanted Lines
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Surgical Safety Checklist
The Mindful Intent of the Surgical Safety Checklist
• The Team will… – Effectively communicate
– Exchange critical information
– Anticipate risk
– Prevent harm
– Ensure accuracy
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Significant Reduction in Death and Complications
6.2%
3.4%
11.0%
7.0%
1.5%
0.8%
0.0%
2.0%
4.0%
6.0%
8.0%
10.0%
12.0%
Surgical Site
Infections
All
Complications
Death
Before
After
NEJM January 29, 2009, 360:491-8
P<0.001 P<0.001 P=0.003
Further data on checklists
• “functioning as well-coordinated team:
– 69%-> 92%
• OR nurse turnover
– 23%-> 7%
• “synthesis of the existing body of evidence suggests a relationship between checklist use in surgery and fewer postoperative complications”
World Health Organization Gillespie,B et. al. Anesthesiology; 120:1380-9. 2014
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But if it were YOU…
• 78.6 % : “The checklist helped prevent errors in the operating room”
• 93.4% “If I were having an operation, I would want the checklist to be used”
Haynes et. al. BMJ Qual Saf 2011;20:102
SURPASS Checklists Reduce Surgical Complications and Mortality
• The Surgical Patient Safety System: de Vries EN et. al. Effect of a comprehensive surgical safety system on patient outcomes.
15.4%
10.6%
1.5%0.8%
0%
2%
4%
6%
8%
10%
12%
14%
16%
One or more
complications
Mortality
Before After NEJM 2010;363:1928-37.
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www.projectcheck.org http://emergencymanual.stanford.edu
Teams Testing in Simulation improved performance with use of Checklists
6%
23%
Arriaga,A et. Al. NEJM 368: 246-53. 2013
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When checklists are GOOD, it is in the context of high
performing teams
Formula for Perfect Teams?
• Google Project Aristotle
– Psychological Safety
– Dependability
– Structure/Clarity
– Meaning of Work
– Impact of Work
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Using Checklists as a tool for a high performing team
Catchpole,K et. al Ped Anes 17:470-478 2007
Baseline Mean ± 95% CI
Post- Intervention Mean ± 95% CI
Technical Errors 5.42 ± 1.24 3.15 ± 0.71
Information omissions 2.09 ± 1.14 1.07± 0.55
Duration 10.8 ± 1.6 9.4 ± 1.29
> 1 error 39% 11.5%
Checklists have a critical role when…
• Key steps shouldn’t be omitted
• Unnecessary variation can be removed
• We want to reduce fatigue.. improve mental capacity
• Used as a tool for situational awareness
… in the context of a high performing team
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When checklists don’t work…
“Implementation of surgical safety checklists was not associated with significant reduction in operative mortality or
complications”
Urbach DR et. al. (2014). Introduction of surgical safety checklists in Ontario, Canada. The New England Journal of Medicine, 370 (11), 1029-38
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Checklists don’t work, when there is no ability to adapt
Surgical Safety Checklist
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When “checklists” can get ugly
When they turn the brain “off”
• When the intent is for compliance instead of commitment
• When the team mindlessly “thinks” • They are being evidence-based
• They are having a conversation
• The roles are accounted for
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“improper checklist use can adversely affect patient safety”
– 94% participation
– 85% completion
– 54% accuracy
J Am Coll Surg 2013;217:867-873
• “weak type of safety barrier...”
• “… when compliance with the checklist is flawed and other safety checks are omitted because they are thought of as being handled by the checklist– then we have a new safety threat because we have induced a false sense of safety into the … system”
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Checklists are dangerous… … when the mental model is that a
“checklist” is a “crutch”
( read.. lame and unenlightened)
Anthes, Emily Nature Vol 523 July 30, 2015
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Coaching Tools from Safe Surgery 2015
Huang LC, et al. BMJ Qual Saf 2014;23:639–650.
UK CUT tool found wide variation
Russ, S et. al J Am Coll Surg 2015;220:1-11.
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WHOBARS tool from New Zealand
Devcich DA, et al. BMJ Qual Saf 2015;0:1–9.
Checklists
• The Good: A tool for high performing teams… MINDFUL
• The Bad: A tool mandated without local adaptation for individuals/teams… UNMINDFUL
• The Ugly: Assuming “compliance” is sufficient feedback for success … MINDLESS