Implementation of safety checklists in medicine: not as simple as it sounds

BACKGROUND and objective: Adverse events are documented to affect more than 1 in 25 hospital patients. Medical mishaps and errors are rarely the result of incompetence, poor motivation, or negligence but of challenges on social and cognitive skills such as loss of situation awareness, poor communication, less-than-optimal teamwork, problematic stress management, and memory overload. Realising how prone we as humans are for shortterm memory loss, it is striking how many potentially dangerous medical procedures are based on ‘perfect’ memory. The aims of this thesis were to develop and measure the effect of a pre-induction safety checklist in anaesthesia, explore the personnel’s acceptance and experience with this list, and further examine experiences with checklists in some non-medical high reliability organisations (HROs). HROs are organisations achieving high levels of safety despite facing considerable hazard and operational complexity. Methods: Statistical process control was chosen as a quantitative approach to measure the effect of the pre-induction checklist implementation. Qualitative approaches using focus groups, key informant interviews, Delphi technique, and consensus process were utilized to develop the checklist and examine checklist experiences. Results: During a study period of 13 weeks, the 26-item checklist was used in 502 (61%) of 829 anaesthesia inductions. One or more missing items were identified in 17% (range 4–46%) of these procedures. It took a median of 88.5 seconds (range 52–118) to perform the checklist. Some participants were concerned that patients might have become anxious about possible unpreparedness because there was a ‘need’ for a final check. The participants had, on their own initiative, adopted strategies to reduce this potential burden to the patients. The introduction of the checklist interrupted workflow by disturbing some of the personnel’s own streamlined working habits or by causing redundant checks done by both nurses and physicians. Some participants had experienced negative or ironic comments from colleagues. They emphasised the importance of a supporting and motivating unit leader. Several of the participants had experienced increased confidence in performing challenging cases in unfamiliar places and situations. The participants discovered that the seven various operating theatres in which the checklist was used were not designed and equipped in the same way. This highlighted the need for standardisation if the same checklist should be used in every operating theatre. The interviews with personnel from six HROs generated 84 assertions in checklist development and implementation. Several of the informants underlined the importance of an early assessment if Thesis defended: 19 January 2012. Respondent: Øyvind Thomassen, MD, Department of Anaesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway. Department of Surgical Sciences, University of Bergen, Bergen, Norway. Norwegian Air Ambulance Foundation, Drøbak, Norway. Main supervisor: Jon Kenneth Heltne, Department of Anaesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway. Department of Medical Sciences, University of Bergen, Bergen, Norway. Opponents: Eefje de Vries, PhD, Spaarne Ziekenhuis, Hoofddorp, The Netherlands. Sven Erik Gisvold, Professor, NTNU, Trondheim, Norway. Henning Onarheim, Professor, University of Bergen, Bergen, Norway.