In healthcare, this technique is used in resuscitation procedures. Healthcare workers are trained and recertified, in low and high fidelity simulators, to commence procedures such as Advanced Cardiac Life Support without referring to a checklist. When the patient is not readily revived or responding as expected, the team will refer to their checklists or algorithms to make sure the steps have been executed properly, and that they have not forgotten anything. For this reason, healthcare workers often keep a cognitive aid (a ‘checklist’ of sorts) posted on emergency carts, tucked into pockets or loaded onto mobile devices. ‘Boldface’ checklists can be effective whenever there is a critical sequence to be completed but time is short, or the situation does not enable a physical list to be immediately accessed and used.
If you're a fan of writing in Markdown and using keyboard shortcuts, Checkvist is made for you. It's a web app that lets you create checklists that you can print or share with others, and even set up daily reports. If you need collaborative checklist management, or you want a checklist that integrates with your favorite services like Evernote, try Checkvist.
Lastly, the checklist involves a Time Out: this requires that everything stops and no one interrupts. In an emergency, or under extreme time pressure, it is difficult to get everyone on the team to stop what they are doing and attend completely. The loss of team discussion under time pressure has been described by some centres implementing the Safe Surgery checklist.6 ,13 These are the times when mistakes are most likely to occur, yet paradoxically also when the Time Out portion of the checklist (the briefing to support complex work) is least likely to be performed as intended.
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But the military still bought a few Boeings to experiment with. Some test pilots believed the Boeing bomber was a much more effective warplane and got together to figure out how they could get pilots to fly it. Instead of requiring more training, the test pilots implemented a simple pre-flight checklist. It spelled out all the basic tasks that were needed to fly the plane successfully, like checking to see if the battery switches and radio were on before taking off. By implementing the checklist, pilots flew the Boeing bomber 1.8 million miles without a single accident. Thanks to a “stupidly” simple checklist, the Army ended up ordering thirteen thousand Boeing bombers and the B-17 soared into the annals of wartime history.
In healthcare, we need to get back to the basics with checklists and reserve the tool for processes that are simple, easy to follow, standardised and (perhaps) time critical. Expanding the term to cover briefings and other tools more suited to complex and variable processes is confusing, and may require communication and advanced team skills to implement and sustain. It is appealing to embrace a single tool to improve safety, and checklists have been found to be effective in some settings.16 However, the complexity of quality and safety improvement in healthcare guarantees that solutions will never be singular, straightforward or simple to sustain.
Most companies strive to arrange their best practices in the most convenient way. Checklists work well here. Providing essential information for repetitive tasks in the form of a list proves a company’s consistent approach to any level of activity. As an example, introducing specific rules and policies to new team members is quite practical when done through checklists.
Aviation checklists are designed for modern aircraft that are complicated, not complex; it is usually possible to define a single process path that offers optimum performance for each flight condition. These process paths are flight tested, endorsed (with minor modifications) by airlines when they purchase a new aircraft type, and published in procedural manuals and checklists. There are two categories of checklist used in the cockpit: normal and non-normal (or emergency) procedures.
Introduction of a new tool without full consideration of its purpose, benefits and limitations may actually increase risk to patients, providers and the system as a whole. Overimplementation of checklists may erode respect for long-standing healthcare cognitive aids that are effective, have been iteratively improved, and are well suited to specific purposes. Overreliance on checklists as a safety net can lead to omission of other safety practices that may better support safety through reliability and resilience. Checklists are excellent ‘aides memoire’ and directives to correct procedures, but they are not a panacea.
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Special Unicode Characters in Data Validation Lists: ☐, ☑, ✓, ✔ - This may be my favorite approach. You can include special characters like this in a Data Validation drop-down list. This isn't quite as good as clicking once to fill in a checkbox, but it is great for the mobile Excel apps. The only hard part is remembering how to insert a check mark symbol in Excel. For more information, see my article Using Unicode Character Symbols in Excel.
Checklists seem simple, Gawande says, and are sometimes hard for us to accept as a necessity when we're in high-powered jobs that rely on our skills and knowledge. But humbling ourselves by using a checklist can improve our performance and help us achieve more consistent results. "They remind us of the minimum necessary steps and make them explicit," writes Gawande. "They not only offer the possibility of verification but also instill a kind of discipline of higher performance."
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