Checklists in Healthcare

Genie Heitmiller, MD
Society for Pediatric Anesthesia
October 16, 2009

A checklist is a list of action items arranged in a systematic manner that allows the user to record
the completion of the individual items.1 Checklists have been used successfully in aviation and industry,
and healthcare has learned from this success. In aviation, checklists are used for pre-flight checks as well as
for emergency situations, trouble-shooting, and problem solving. The goals of checklists used in healthcare
are primarily error reduction and adherence to best practices in clinical care.
Several examples of the effective use of checklists have been published in recent years. Pronovost
and his colleagues studied the checklist as a tool for the healthcare team to better understand the daily goals
of patient care in the Johns Hopkins Hospital surgical intensive care unit (ICU).2 The daily goals checklist
(Figure 1) was shown to increase the nurses’ and house staff’s understanding of the patient care plan from
10% to 95% over the span of 8 weeks (Figure 2) and reduce length of stay (LOS) by 50%, from 2.2 days to
1.1 days.2

Figure 1. Daily Goals Checklist2

____________________________________________________________________
□ What needs to be done for the patient to be discharged from the ICU?
□ What is this patient’s greatest safety risk? How can we reduce that risk?
□ Pain management and sedation
□ Cardiac - volume status
□ Pulmonary - ventilator (plateau pressure, elevate head of bed)
□ Mobilization
□ Infectious disease - cultures, antibiotic levels
□ Nutrition
□ Medications - can any be discontinued?
□ Tests and procedures
□ Review scheduled labs and x-rays
□ Consultations
□ Communication with primary service
□ Family communication
□ Can any catheters or tubes be removed?
□ Is this patient receiving DVT or peptic ulcer prophylaxis?
____________________________________________________________________________
ICU, intensive care unit; DVT, deep venous thrombosis

Figure 2. Percent of residents (dotted line) and nurses (solid line) per week understanding patient
care goals.2

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In a similar study at Hartford Hospital ICU, the use of a Daily Goals checklist decreased ICU mortality
from 11.4% to 8.3%, decreased LOS to 1.5 days, and decreased the need for mechanical ventilation by 1
day.3 The use of a Daily Goal Communication Sheet in a pediatric ICU study significantly reduced the
number of defects in gastric ulcer prophylaxis from 10% to 3% (p=0.02).4 Thus, a checklist format
communication tool, once implemented, was effective in improving outcomes and reducing defects.
Another study that described the effective use of checklists included a checklist tool as one of five
interventions to reduce catheter-related bloodstream infections (CRBSI) in a 16-bed surgical ICU.5 Those
interventions were:
1. A web-based training module for placement of vascular access devices and lectures from
epidemiologists and infection-control experts to reinforce the evidence-based guidelines and
protocols.
2. Creation of a central venous catheter (CVC) insertion cart that contained all of the supplies needed
to place a sterile CVC.
3. Use of daily goals to ask whether the catheter should be removed.
4. Implementation of a simple checklist tool for CVC insertion to be completed by the bedside nurse.
(Figure 3).
5. Empowerment of the bedside nurse to stop the CVC insertion if the protocol wasn’t being
followed.

Figure 3. Catheter-related Bloodstream Infection Checklist5

Catheter-related Bloodstream Infection

Care Team Checklist

Purpose: To work as a team to decrease patient harm from catheter-related bloodstream infections
When: During all central venous or central arterial line insertions or rewires
By whom: Bedside nurse

1. Today’s date: ______ /______ / ______

month day year

2. Procedure: New line Rewire

3. Is the procedure: Elective Emergent

Yes No Don’t know

Before the procedure, did the physician:
Wash hands immediately prior   
Sterilize procedure site   
Drape entire patient in a sterile fashion   

During the procedure, did the physician:

Use sterile gloves   
Use hat, mask, and sterile gown   
Maintain a sterile field   

Did all personnel assisting with the procedure follow

the above precautions:   

After the procedure:

Was a sterile dressing applied to site   

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 The control ICU in this study was a 15-bed cardiac ICU, where only the first intervention
(education) was implemented to enhance provider awareness of the evidence-based guidelines for CVC
insertion and maintenance. During the intervention period, the CRBSI rate in the surgical ICU (study ICU)
dropped from 11.3 per 1000 catheter days to zero in the final quarter of the study. This was sustained for
the following year. The cardiac ICU (control ICU) CRBSI rate dropped from 5.7 per 1000 catheter days to
1.6 per 1000 catheter days. The authors estimated that the intervention prevented 43 CRBSI, 8 deaths, and
nearly $2 million in additional costs per year. Use of a checklist resulted in changes in systems as well as in
behavior of individual surgical teams.
In 2008, the World Health Organization (WHO) launched a Safe Surgery Saves Lives program
with a Surgical Safety Checklist (Figure 4) in an effort to improve safety of surgical care around the world.

Figure 4. 2008 WHO Surgical Safety Checklist6

Eight hospitals were selected to participate as pilot sites for this program. Selection was based on
geographic distribution within WHO regions with the goal of representing diverse socioeconomic groups:
Amman, Jordan; New Delhi, India; Seattle, WA; Ifakara, Tanzania; Manila, Philippines; Toronto, Canada;
London, England; Auckland, New Zealand. Baseline data were collected on 3733 consecutive patients that
included demographics, procedure, type of anesthetic, complications, and safety data currently in place.
Routine use of pulse oximetry, verbal confirmation of patient identification and surgical site, routine
administration of prophylactic antibiotics, a standard plan for vascular access for high blood loss cases, and
formal team briefing (preoperative) and debriefing (post-procedure). After implementation of the checklist,
data were collected on 3955 consecutive patients. The rate of any complication at all sites dropped from
11% to 7% after the checklist was introduced (p<0.001). The total in-hospital death rate dropped from 1.5%
to 0.8% (p=0.003), the overall rates of surgical site infection dropped from 6.2% to 3.4% (p<0.001), and
unplanned re-operation dropped from 2.4% to 1.8% (p<0.001).7 This checklist was revised in 2009 (Figure
5).

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 Figure 5. 2009 World Health Organization Surgical Safety Checklist6

Surgical Safety Checklist

Before induction of anaesthesia Before skin incision Before patient leaves operating room

(with at least nurse and anaesthetist) (with nurse, anaesthetist and surgeon) (with nurse, anaesthetist and surgeon)

Has the patient confirmed his/her identity, Confirm all team members have Nurse Verbally Confirms:
site, procedure, and consent? introduced themselves by name and role. The name of the procedure
Yes Confirm the patient’s name, procedure, Completion of instrument, sponge and needle
Is the site marked? and where the incision will be made. counts
Yes Has antibiotic prophylaxis been given within Specimen labelling (read specimen labels aloud,
the last 60 minutes? including patient name)
Not applicable Whether there are any equipment problems to be
Yes addressed
Is the anaesthesia machine and medication Not applicable
check complete? To Surgeon, Anaesthetist and Nurse:
Yes Anticipated Critical Events What are the key concerns for recovery and
Is the pulse oximeter on the patient and To Surgeon: management of this patient?
functioning? What are the critical or non-routine steps?
Yes How long will the case take?
Does the patient have a: What is the anticipated blood loss?
Known allergy? To Anaesthetist:
No Are there any patient-specific concerns?
Yes To Nursing Team:
Difficult airway or aspiration risk? Has sterility (including indicator results)
No been confirmed?
Yes, and equipment/assistance available Are there equipment issues or any concerns?

Risk of >500ml blood loss (7ml/kg in children)? Is essential imaging displayed?

No Yes
Yes, and two IVs/central access and fluids Not applicable
planned

This checklist is not intended to be comprehensive. Additions and modifications to fit local practice are encouraged. Revised 1 / 2009 © WHO, 2009

Not all checklists have been as effective as the ones discussed above. Pre-anesthesia checkout
checklists that have been in place for over 20 years have not been reliably used or understood by anesthesia
providers. Studies comparing the Food and Drug Administration (FDA) checklist8,9 with the user’s own
checkout method showed no difference in finding machine faults.10,11 In addition, the FDA checklist was
less applicable to advancing technology in anesthesia equipment. To address this issue, the American
Society of Anesthesiologists (ASA) Sub-committee on Equipment and Facilities published
recommendations in 2008 for pre-anesthesia checkout that listed 15 items to be completed at the beginning
of each day, and of these, eight items to be completed prior to each procedure.12 These checklist items are
intended to replace the existing FDA recommendations. The daily checkout is shown in Figure 6. Studies
to determine the effectiveness of this guideline are yet to be published.

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 Figure 6

Automated electronic checklists are part of the most up-to-date anesthesia machine software
technology. In aviation, electronic checklists have been shown to reduce errors by an additional 46% when
compared to paper checklists.13 Similar to aviation, anesthesia is moving toward electronic checkouts
supplemented with machine prompts for checks of items such as suction and monitoring equipment.
Checklists must be used judiciously. Overuse can lead to checklist fatigue and cries of “Not
another checklist!” Checklist development should always include the users, and an evaluation trial should
be conducted before implementation to determine its usefulness and impact.
In conclusion, effective checklists may be used as tools to reduce errors, enhance best-practice
compliance and improve outcomes.

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References

1. Hales BM, Pronovost PJ. The checklist: a tool for error management and performance
improvement. J Crit Care 2006; 21:231-235.
2. Pronovost P, Berenholtz S, Dorman T, Lipsett PA, Simmonds T, Haraden C. Improving
communication in the ICU using daily goals. J Crit Care 2003; 18:71-75.
3. Checkoffs play key role in SICU improvement. Healthcare Benchmarks Qual Improv 2003;
10:113-5.
4. Schwartz JM, Nelson KL, Saliski M, Hunt EA, Pronovost PJ. The daily goals communication
sheet: a simple and novel tool for improved communication and care. Jt Comm J Qual Patient
Safety 2008; 34:608-613.
5. Berenholtz SM, Pronovost PJ, Lipsett PA, Hobson D, Ersing K, Farley JE, Milnovish S, Garrett-
Mayer E, Winters BD, Rubin HR, Dorman T, Perl TM. Eliminating catheter-related bloodstream
infections in the intensive care unit. Crit Care Med 2004; 32:2014-2020.
6. http://www.who.int/patientsafety/safesurgery/en/
7. Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AS, Dellinger EP, Herbosa T, Joseph S,
Kibatala PL, Lapitan MCM, Merry AF, Moorthy K, Reznick RK, Taylor, B, Gawande AA; Safe
Surgery Saves Lives Study Group. A surgical safety checklist to reduce morbidity and mortality in
a global population. N Engl J Med 2009; 360:491-499.
8. Anesthesia Apparatus Checkout Recommendations, 1986. Federal Register. 1986; 52:5583-5584.
9. Anesthesia Apparatus Checkout Recommendations, 1993. Federal Register. 1994; 59:35373-
35374.
10. Manley R, Cuddeford JD. An assessment of the effectiveness of the revised FDA checklist.
AANA J 1996; 64:277-282.
11. March MG, Crowley JJ. An evaluation of anesthesiologists’ present checkout methods and the
validity of the FDA checklist. Anesthesiology 1992; 75:724-729.
12. Subcommittee of ASA Committee on Equipment and Facilities. Recommendations for the pre-
anesthesia checkout procedures (2008).
13. Boorman D. Today’s electronic checklists reduce likelihood of crew errors and help prevent
mishaps. ICAO J 2001; 1:17-36.

Additional references:

Charlton JE. Checklists and patient safety. Anaesthesia 1990; 45:425-426.

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