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
Gawande in 2009 introduced a hospital surgery checklist for doctors and nurses as part of a program developed with the World Health Organization. The checklist was designed to ensure basic checks were always completed before surgery. Run through the list, and you'll make sure everyone in on the same page about the surgery to be conducted, aware of who else was on the surgical team, and knows their role in the procedure.
After impressive reductions of catheter-related blood stream infections (CLABSIs) were achieved with the implementation of a checklist bundle, checklists were promoted as evidence medicine should look to this safety solution.19 However, successful reduction of CLABSIs was not due to the checklist alone: multiple interventions addressing ICU safety were implemented at the same time, and it remains unclear what role the checklist specifically played in infection reduction.2 For example, the CLABSI checklist relies on nurse oversight. The changes in nursing behaviour can improve physician performance of line insertion in ways that are unrelated to the checklist: through the ‘Hawthorne’ effect, because the physician knows they are being watched; through empowering nurses and levelling the power gradient between physician and nurse and improving the safety culture; or, through formation of best practice as a habit as physicians insert lines the same way each time.
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