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.
The way I prepared for these tests was to take lots of practice exams under the same time constraints as the real deal. Professors often post their old law exams online so I used those. The most important part of these practice sessions was the review afterward. I’d look at my answer and compare it to the professor’s answer key. It allowed me to see which issues I missed and any analysis I forgot to include. After two or three practice exams I began to see patterns in my failures. I’d make the same mistakes over and over again, and it was often due to overlooking stupid stuff.
Clinicians have long relied on an analogous form of decision support such as lists or algorithms for differential diagnosis. When a patient presentation is unusual (non-normal but not emergent), differential diagnosis lists (whether in old-fashioned textbooks or new-fashioned handhelds) support clinical performance by serving as a cognitive aid. The practice of reviewing a complete differential helps overcome anchoring and confirmation biases and can be a forcing function to ensure that every critical, and treatable aetiology is ‘ruled out’. Unlike non-normal checklists that are built into cockpit workflow, differential lists are often not well-integrated into clinical workflow and this may undermine their use.12
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When it comes to checklist implementation, it is important to recognise that aviation checklists are integral to the normal workflow. The aircraft does not stop while the checklist is completed, and the timing of checklist completion is arranged so that it does not conflict with other essential flight activities. To that end, the checklist does not impose an additional burden or workload, but is actually perceived by aircrew as something that makes the flight easier. In contrast, the Time Out is performed before the case can begin, so essentially stands independently of the workflow. To that end, the Time Out is likely to be seen as something additional, and, unless it results in obvious time-saving downstream, will be perceived as an increase in workload. This mixture of purpose between checklist and briefing, in combination with implementation issues, may explain the range of outcomes as well as the range of enthusiastic to skeptical opinions about the mandated use of checklists in surgery.14–16
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