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Checklists in healthcare.

Poor communication frequently results in adverse outcomes for patients. Nurses use checklists every day as tools to enhance communication between members of the healthcare team and to improve patient care delivery. Nurses have developed many types of checklists to remind the healthcare team of essential information that should be evaluated. For example, the assessment and documentation of vital signs are two of the most important functions that nurses perform. In the 1960s, nurses were credited with the development of a checklist that captured patients' vital signs. The vital signs checklist serves as a reminder for when to assess vital signs as well as a place to document these data points; thus communicating to healthcare providers an overall snapshot of the health and well-being of patients.

Background

The use of checklists began in the aeronautical industry in 1935. Following a terrible plane crash in the U.S. Army Air Corps that killed two of the five crew members, including a senior experienced pilot, the investigation did not reveal any mechanical issues. The crash was attributed to pilot error. The new aircraft being demonstrated was felt to be more complex than previous aircraft and required the pilot to focus on many things at once. Following this crash, test pilots came together and decided that the aircraft was so complex to operate that they could not rely on memory alone and decided to develop a checklist. Gawande (2009) stated, "Pilots learn in flight school that memory and judgment are unreliable and that lives depend on their recognizing that fact" (p.121). Parallels can be drawn to nursing. Nurses must focus on many complex aspects of patient care simultaneously and memory alone may be inadequate.

Much is written about the use of checklists in healthcare literature. In 2001, Dr. Peter Pronovost, a critical care specialist at John Hopkins Hospital, developed a checklist for the insertion of central lines as a tool to help decrease central line infections. A year after the implementation of this checklist, central line infection rates dropped from 11% to 0%. Not believing the data, he followed patients for 15 more months and only two central line infections occurred. Gawande (2009) discusses how Dr. Pronovost calculated that the use of the checklist "had prevented forty-three infections and eight deaths and saved two million dollars in costs" (p. 39) in one hospital alone. Dr. Pronovost and his healthcare team became believers in checklists. His team then developed more checklists and Gawande (2009) noted that they "improved the consistency of care to the point that the average length of patient stay in intensive care dropped by half" (p. 39). In 2003, the Michigan Health and Hospital Association asked Dr. Pronovost to test the use of central line checklists in their hospitals and in 2006 they published the findings in the New England Journal of Medicine. Gawande (2009) noted that "central line infection rates in Michigan's ICUs decreased by 66% and the hospitals' estimated savings were $175 million in costs and more than 1500 lives" (p. 44).

In 2006, the World Health Organization (WHO) began its work on the surgical checklist used in operating rooms today. The WHO realized that the number of surgical cases was exploding with 230 million cases being performed annually, leaving seven million people a year disabled and at least one million dead. Enlisting the help of Dr. Atul Gawande, a patient safety advocate, a general and endocrine surgeon at the Brigham and Women's Hospital in Boston and associate professor at Harvard Medical School, the WHO began its work. Two years into the project, Gawande (2009) noted the results of their efforts demonstrated that the "rate of major complications for surgical patients in all eight hospitals fell by 36 percent after introduction of the checklist. Deaths fell 47 percent" (p. 154). Infections decreased by almost half. Checklists seemed to work.

Current Use

The use of checklists in health care is growing and results are promising. Shinkman (2010) references a study in which "a single major surgical complication costs $13,372, more than the cost of implementing a checklist and the use of a checklist could reduce complication rates by ~10% for a net cost reduction of $8,652 for every complication that is avoided" (para 4). Arriaga et al. (2013) reported that in a simulation based study of operating room crisis, teams missed only 6% of potentially life-saving processes of care when checklists were available compared with 23% of steps missed when there were not checklists immediately on hand.

Nurse managers may find that a checklist is helpful with multiple everyday responsibilities. Nurse managers are in the unique position of being responsible to administration as well as to patients and staff with patient safety being a number one priority for all. Govern (2012) suggests that managers may find it useful to develop a tool that addresses the myriad of responsibilities that includes employee satisfaction and engagement, patient satisfaction, performance improvement, and productivity.

Summary

Checklists, while promising, are not without limitations. Every patient safety issue cannot be solved with a checklist; however, the use of checklists in healthcare has proven successful in preventing many errors as well as generating monetary savings. Checklists may be one tool essential to nursing practice to foster communication, collaboration and teamwork to improve patient care delivery.

REFERENCES

Arriaga, A.F., Bader, A.M., Wong, J.M., Lipsitz, S.R., Berry, W.R., Ziewacz, J.E., Hepner, D.L, Boorman, D.J., Pozner, C.N., Smink, D. S., Gawande, A.A. (2013). Simulation-Based Trial of Surgical-Crisis Checklists. New England Journal of Medicine. Retrieved from www.nejm.org/doi/pdf/10.1056/ NEJMsa1204720

Cosgrove, D., Fisher, M., Gabow, P., Gottlieb, G., Halvorson, G., James, B., Kaplan, G., Perlin, J., Petzel, R., Steele, G., Toussaint, J. (2012). A CEO Checklist for High-Value Health Care. Retrieved from www.iom.edu/CEOChecklist

Gawande, A. (2009). The checklist manifesto, how to get things right. New York; Metropolitan Books.

Govero, E. (2012). New Nurse Manager Checklist for Foundational Success. Nurse Leader, 10(3), 54-56.

Shinkman, R., (2010). Checklist could save hospitals thousands. FierceHealthFinance. Retrieved from www.fiercehealthfinance.com/ node/9019/print

Sibbald, M., DeBruin, ABH., van Merrienboer, JJG. (2013). Finding and fixing mistakes: do checklists work for clinicians with different levels of experience? Advances in health science education; theory and practice. Retrieved from http://psnet.ahrq.gov/ resource.aspx?resourceID=26145
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Publication:Texas Board of Nursing Bulletin
Geographic Code:1U7TX
Date:Oct 1, 2013
Words:1058
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