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Development of Medical Checklists for Improved Quality of Patient Care

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Medical ChecklistsHigh intensity fields of work, such as the airline industry and the military, already employ checklists to decrease errors of omission, improper implementation of procedures and protocols, and to decrease human error under stressful conditions. Similar to flight crews and military personnel, healthcare providers must often analyze and manage highly complex conditions under demanding and stressful conditions. Several areas of healthcare in which complex medical situations require rapid systematic approaches to crisis management, such as anaesthesiology and emergency medicine, therefore already make use of the types of checklists and memory-aids shown to be beneficial and life saving in the airline industry. Examples of published checklists currently employed regularly in the medical field include the checklist for diagnosing brain death, the Anaesthesia Gas Machine Checklist, the Checklist for the withdrawal of life support and end-of-life care and the FAST HUG checklist of Clinical Best Practices.

The use of these checklists and memory-aids in clinical pathways has been shown to improve the quality of medical care. Examples include the prediction of successful weaning from mechanical ventilation in ICU patients, adherence to evidence-based best practices and in the improvement of patient safety in many clinical areas.

Checklists are used in both medical and non-medical industries as cognitive aids to guide users through accurate task completion. A checklist is an organized tool that outlines criteria of consideration for a particular process. It functions as a support resource by delineating and categorizing items as a list—a format that simplifies conceptualization and recall of information. Checklists have proven effective in various aspects of performance improvement and error prevention and management.

The development of technical documents, such as checklists, requires a systematic and comprehensive approach, particularly when they are to be implemented in high intensity fields such as medicine. However, there is a relative paucity of published technical instructions for medical checklists. We searched for relevant English-language medical and non-medical literature both to describe where checklists have been demonstrated to improve care and delivery and also, how to develop valid checklists. Within the medical literature, the focus lies with the development of mnemonic devices and checklists outlining current evidence-based best practices, although the checklists themselves are rarely included for publication. Of the literature available in non-medical areas, the focus lies with the design of evaluative checklists and tools for performance measurement, rather than memory aids or goals sheets. Although a small number of strategies for designing effective checklists are referred to in the literature—including utilization of pre-published guidelines, formation of expert panels and repeat pilot-testing of preliminary checklists—a highly effective, standardized protocol for checklist development and design has yet to be developed and validated. To that end, we have performed a narrative review of the most effective methods used in both medicine and other disciplines to design clear and effective checklists, as well as examples of their efficacy in various environments. We also outline available sources of support information. This perspective will delineate the standard components of successful checklists that can be used as a template in the development of case-specific medical checklists.

Medical Checklists 

Although the implementation of checklists has not always directly correlated with significant improvements in patient care and decreases in human error, no published data to date indicate that checklists may contributed to adverse events, such as imposing a burden on the primary care providers, delays in treatment because of lengthy checklists, or errors of omission. Rather, they are largely considered important tools to condense large quantities of knowledge in a concise fashion, reduce the frequency of errors of omission, create reliable and reproducible evaluations and improve quality standards and use of best practices.  However, there are instances in which excessive use of checklists could become a hindrance in the healthcare setting. If each detail of every task were targeted for the development of a checklist, clinicians may experience ‘checklist fatigue’, whereby they become overburdened with completing these lists. Rather than fulfilling their role as a support resource and error management tool, checklist use could begin to unnecessarily complicate processes and decrease reliability by adding a secondary layer of complexity. To suggest strict adherence to checklists in all situations is impractical and to do so could compromise the efficacy of a clinical process or procedure and risk infringing on efficient clinical judgment. Careful selection of checklist topics and consideration of clinical judgement in the content design process can help avoid these potential downfalls.


Checklists can serve as important tools for decreasing medical error and improving overall standards of patient care, particularly during stressful conditions when memory, vigilance and cognitive functions can be affected. The development of effective checklists involves several important steps. Legitimacy of the content will depend on the process for its development, and should include a thorough review and evaluation of the literature, evaluation of current practices and consideration of expert consensus, as well as a thorough validation of the checklist in the target user population prior to implementation of the final document. Checklist development should not be static, but an ongoing process involving expert groups, up-to-date literature, and feedback from the intended users as well as the target audience. When all staff members that might interact with the checklist have been involved in the process of creating and designing the checklist, there is a feeling of ownership of the checklist. The items contained in the final checklist represent a consensus between all members of the team, and improve implementation and uptake of a checklist into daily practice. The lack of literature outlining the methodology and special considerations for developing medical-specific checklists has likely contributed to their continued absence in several key fields of medicine, despite evidence of their fundamental role in error management. Further areas of research in the utilization of checklists should focus on the evaluation of checklist fatigue in healthcare, the impact of checklist usage from the patient perspective, the continued evaluation of outcome improvements and direct tracking of error rates for the respective checklist focus.

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Last Updated ( Wednesday, 11 June 2008 01:24 )  

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