Elsevier

Journal of Critical Care

Volume 21, Issue 3, September 2006, Pages 231-235
Journal of Critical Care

Feature—Evolution of HSR
The checklist—a tool for error management and performance improvement

https://doi.org/10.1016/j.jcrc.2006.06.002Get rights and content

Abstract

Levels of cognitive function are often compromised with increasing levels of stress and fatigue, as is often the norm in certain complex, high-intensity fields of work. Aviation, aeronautics, and product manufacturing have come to rely heavily on checklists to aid in reducing human error. The checklist is an important tool in error management across all these fields, contributing significantly to reductions in the risk of costly mistakes and improving overall outcomes. Such benefits also translate to improving the delivery of patient care. Despite demonstrated benefits of checklists in medicine and critical care, the integration of checklists into practice has not been as rapid and widespread as with other fields. This narrative is a guide to the evolution of medical and critical care checklists, and a discussion of the barriers and risks to the implementation of checklists.

Introduction

Human error is inevitable—particularly under stressful conditions [1], [2]. It has been demonstrated that levels of cognitive function are compromised as stress and fatigue levels increase [3], as is often the norm in certain complex, high-intensity fields of work. This can lead to increased errors in judgment, decreased compliance with standard procedures, and decreased proficiency. Areas such as aviation, aeronautics, and product manufacturing, in which safety and precision are paramount in accurate service delivery, have come to rely heavily on simple tools to aid in reducing human error. An important tool in error management across all of these fields is the checklist, a key instrument in reducing the risk of costly mistakes and improving overall outcomes.

A checklist is typically a list of action items or criteria arranged in a systematic manner, allowing the user to record the presence/absence of the individual items listed to ensure that all are considered or completed. A sound checklist highlights the essential criteria that should be considered in a particular area. Checklists can differ from other cognitive aids or protocols in that they lie somewhere in between an informal cognitive aid, such as a Post-It note or a string around your finger, and a protocol, which typically entails mandatory items for completion to lead the user to a predetermined outcome. Checklists can provide guidance to a user and act as verification (a “check”) after completion of a task, without necessarily leading users to a specific conclusion.

Checklists can have several objectives, including memory recall, standardization and regulation of processes or methodologies, providing a framework for evaluations or as a diagnostic tool [4]. However, regardless of the nature of the checklist, the principal purpose of their implementation is commonly error reduction or best practice adherence. Their efficacy as a cognitive aid likely lies in their ability to use the theories of “category superiority effect” or “chunking” where grouping relational or item-specific information in an organized fashion can help to improve recall performance [5], [6]. List instructions are also often better understood and recalled than information in paragraph format [7].

Of the literature available regarding the use of checklists in industry, the focus lies heavily on aeronautics and aviation, manufacturing quality control, and, to an evolving extent, healthcare. This review will highlight the main areas in which checklists are already used most consistently, their specific contributions to that field, and their transition into the healthcare arena.

Section snippets

Aviation

The majority of literature published to date regarding the use of checklists in the workplace focuses on aviation and aeronautics. Primarily because of the high-risk environment in which pilots and astronauts find themselves, these industries have adapted both paper and electronic checklist as tools to help decrease human error.

This profession has recognized the likelihood of human error to occur under daily work conditions. For this reason, all pilots, from Air Force aviators to recreational

Product manufacturing

In industries such as product manufacturing, where the smallest error in the development or production process can endanger the public and increase manufacturing costs, error management is vital. For fields in which a governing regulatory body monitors the quality of the output, checklists are integral in ensuring the proper operating procedures are followed and the standards of quality are upheld.

Although several processes are highly monitored, including automobile or food manufacturing, the

Healthcare

The Institute of Medicine estimates that medical errors cause between 44 000 and 98 000 deaths annually in the United States alone, resulting in US$17 to 29 billion in costs annually [18]. This same report comments on the delay by the healthcare industry in adopting the same rigorous error management precautions and attention to ensuring basic safety as compared to other high-intensity areas such as aviation. The Institute of Medicine is certainly not the first organization or healthcare provider

Critical care

Checklists have slowly begun to make their way into the field of critical care medicine. Checklists may be particularly relevant to critical care, as the complexity of medical conditions seems to be increased in this environment.

Certain procedures or diagnoses that have been targeted for the use of checklists have shown significant improvements in outcome. After the implementation of a checklist to standardize the withdrawal-of-life-support process in two teaching hospital tertiary care

Conclusion

In industries where the welfare of a human being is at risk, checklists can help to ensure that performance and safety standards are met. Where products are manufactured, landings and takeoffs are required, evaluations are performed, or medical procedures are carried out, evidence indicates that checklists may reduce errors, improve safety, and improve outcomes. As patient safety and performance improvement become a stronger focus of the medical profession, the use of simple tools for error

Acknowledgment

The authors would like to sincerely thank Dr Rob Fowler for his input and guidance in the development of this manuscript.

References (34)

  • R.L. Helmreich

    On error management: lessons from aviation

    BMJ

    (2000)
  • United States Air Force Series—OV-10A Bronco Association. Pilots' Abbreviated Flight Crew Checklist—USAF Series: OV-10A...
  • D. Boorman

    Today's electronic checklists reduce likelihood of crew errors and help prevent mishaps

    ICAO J

    (2001)
  • Boorman DJ. Technical fellow—Boeing Commercial Airplane Group. November 2005. Personal...
  • United States Navy. The Naval Safety Center—Aviation Checklists. February 17, 2006 Norfolk,...
  • Liang BA. Flying lessons (Special Report: medical errors). Southern California Physician. May...
  • Civil Air Patrol—USAF. CAPR 60-1 Attachment—IM SAFE Checklist. June 2004 National Headquarters, Maxwell AFB AL...
  • Cited by (463)

    • Employee work habits: A definition and process model

      2024, Human Resource Management Review
    View all citing articles on Scopus
    View full text