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
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.
Checklists let you put tasks in order so you can accomplish the most important things first. Once you have put things in writing though, you might feel pressured to complete the tasks in order. This can slow you down. Some people work better when they can jump from task to task and let their emotions guide them. A checklist might impede their emotion. However, if you truly need to finish certain tasks before moving to new ones, a checklist will keep you focused and on-track.
Though Gawande admits he didn't expect to see the checklist make much difference in his own surgeries, he followed it to avoid hypocrisy and was surprised by the results. The checklist saved a life in at least one case, where a mistake by Gawande led to a critical need for blood while the mistake was corrected. Thanks to the checklist, extra blood had been prepared ahead of time, despite Gawande's confidence in performing a surgery he'd done successfully many times before.
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.
Checklist compliance is increasingly monitored in healthcare.5 Often, institutions conduct internal audits of checklist compliance in anticipation of regulatory inspections. Using ‘compliance with checklist’ audits as a measure of safety or quality, however, is problematic, as high checklist compliance is no guarantee that the task is well-executed,18 or that patient safety culture is high.20 In addition, some of the benefits that have been found to be associated with checklist usage, such as enhanced team building and nurses speaking up, are likely to be negated if compliance audits lead to sanctions.
Healthcare safety activists have looked to checklists to solve a myriad of problems, particularly with the current iteration of checklists that have been imported from aviation. Large-scale implementations with conflicting outcomes suggest that these tools are not as simple or effective as hoped. Scholars debating the efficacy of checklist implementation in healthcare have identified important reasons for varying results: that success requires complex, cultural and organisational change efforts, not just the checklist itself2; that results may be confounded by a mix of the technical and socioadaptive elements,3 and that local contexts may either augment or undermine the implementation's outcomes.4
The crux of this problem is while the world around us is becoming more and more complex, we’re still stuck with a brain that hasn’t changed much in 100,000 years. Sure, we’ve figured out ways to off-load memory storage to books and computers so we can know more; we just haven’t figured out a good way to overcome our evolved biases, cognitive flaws, and intrinsic forgetfulness. And so, despite owning a brain brimming with ever more knowledge, we continue to make stupid mistakes.
I started to brain storm other areas that checklists could be beneficial. In the construction industry, Gawande explains that checklists are used so that key points are discussed between those in different aspects of the building process. For research, are there things that you always need to talk about with other experimenters or your supervisor when it comes to a study? Maybe a checklist can help there too. Also, when editing manuscripts or proofs, you could have a structured set of points to assess such as, “check to make sure data in tables/figures is correct” or “make sure reference list is up to date”. These all seem so basic, but if taking the time to go over them and know that once you’ve handed in the manuscript that these things have definitely been checked, it could prevent you from having to submit an erratum due to something like an improper figure.
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