Implementation of safety checklists in medicine. Not as simple as it sounds
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Background Adverse events are documented to affect more than one in 25 hospital patients. Medical mishaps and errors are rarely the result of incompetence, poor motivation or negligence but challenges on social and cognitive skills such as loss of situation awareness, poor communication, less than optimal teamwork, problematic stress management, and memory overload. Realising how prone we as humans are for short term memory loss, it is striking how many potentially dangerous medical procedures are based on “perfect” memory. The aims of this thesis were to develop and measure the effect of a pre-induction safety checklist in anaesthesia, explore the personnel’s acceptance and experience with this list, and further examine experiences with checklists in some non-medical high reliability organisations (HROs). This is organisations achieving high levels of safety despite facing considerable hazard and operational complexity Methods Statistical process control (SPC) was chosen as a quantitative approach to measure the effect of the pre-induction checklist implementation. Qualitative approaches using focus groups, key informant interviews, Delphi technique, and consensus process were utilized to develop the checklist and examine checklist experiences. Results During a study period of 13 weeks the 26 items checklist was used in 502 (61%) of 829 anaesthesia inductions. One or more missing items were indentified in 17% (range 4-46%) of these procedures. It took a median of 88.5 seconds (range 52-118) to perform the checklist. Some participants were concerned that patients might have become anxious about possible unpreparedness since there was a “need” for a final check. The participants had, on their own initiative, adopted strategies to reduce this potential burden to the patients. The introduction of the checklist interrupted workflow by disturbing some of the personnel’s own streamlined working habits or by causing redundant checks done by both nurses and physicians. Some participants had experienced negative or ironic comments from colleagues. They emphasised the importance of a supporting and motivating unit leader. Several of the participants had experienced increased confidence in performing challenging cases in unfamiliar places and situations. The participants discovered that the seven various operating theatres in which the checklist was used, were not designed and equipped in the same way. This highlighted the need for standardisation if the same checklist should be used in every operating theatre. The interviews with personnel from six HROs generated 84 crucial assertions in checklist development and implementation. Several of the informants underlined the importance of an early assessment if a checklist is the right tool to solve a specific problem. Proximity (defined as ownership and nearness in relation) for all stakeholders, directly or indirectly involved, was claimed to be a key-issue during checklist development. All informants also agreed that the design and length of checklists are vital. Major issues regarding checklist utilisation were: a predefined and agreed upon phraseology, understanding of the background of each point on the list, and to be aware of automaticity. Periodic revisions were described as important for two reasons; firstly to maintain an up-to-date checklist and secondly to build a culture in which the end-user feels that their feedback is valuable for the organisation. Conclusions The introduction of safety checklists in health care is more difficult than it seems at first, and the best approach for achieving success and staff compliance is dependent on several factors. Our findings have provided some new insight in the challenges of developing and implementing checklists.
Paper I: Thomassen O, Brattebo G, Softeland E, Lossius HM, Heltne JK. The effect of a simple checklist on frequent pre-induction deficiencies. Acta Anaesthesiologica Scandinavica 54(10):1179–1184, November 2010. Full text not available in BORA due to publisher restrictions. The article is available at: http://dx.doi.org/10.1111/j.1399-6576.2010.02302.xPaper II: Thomassen O, Brattebo G, Heltne JK, Softeland E, Espeland A. Checklists in the operating room: Help or hurdle? A qualitative study on health workers' experiences. BMC Health Services Reserach 2012, 10:342. The article is available at: http://hdl.handle.net/1956/4628Paper III: Thomassen O, Espeland A, Softeland E, Lossius HM, Heltne JK, Brattebo G. Implementation of checklists in health care; learning from high-reliability organisations. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2011, 19:53. The article is available at: http://hdl.handle.net/1956/5531