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.
Reinforcement and sanctions surrounding tasks may distract performance from the intent of the checklist. In healthcare, there is often a need to adapt the procedure to the patient or the context. Recent findings show that the WHO checklist, for example, is often implemented differently within single organisations, depending on context. Clinicians may be discouraged from acting in a manner that is best for the patient if they perceive that they may be censured for not following the procedure ‘to the letter’.
When ideas are translated from one industry to another, the assumptions underlying the original concepts may be lost or diluted. As checklists are increasingly imposed through a variety of professional and regulatory mandates in North America,5 Europe6 and elsewhere,7 perhaps it is time to review the fundamental principles of checklist use, including why they might work and how we can implement them better.
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