Can Aviation-Style Checklists Work in Medical Settings? - 8/3/2017

Barbara Burian

Checklists, ubiquitous in high-stakes work domains such as aviation, are increasingly being adopted across diverse medical specialties and settings.  Despite the general success of checklists in aviation, researchers and practitioners are discovering that checklist efficacy is not as high as hoped for within medicine (Prielipp & Coursin, 2015, Grigg, 2015). One of the reasons for this is a mis-match between the checklist and the medical setting in which it is used.

Medical checklists were initially developed as a way to copy the success of aviation checklists in improving flight safety (Bloomstone, 2015; Gawande, 2010; Thomassen et al., 2011; Hales & Pronovost, 2006); consequently, the designs of many medical checklists mirror that used in aviation.  However, this makes them less effective, more cumbersome, and less likely to be accepted by medical personnel because the two work domains have different task structures, team responsibilities, and environmental settings. We compare the two settings in Table 1 (see also Durso & Drews, 2010):

Table 1. Aviation and Medical Settings
  Aviation (Flight Deck) Medicine (Operating Room)
Work Environment Semi-closed Open
Structure Highly ordered and proceduralized Ordered but not so proceduralized
Work Tasks and Flow Medium-to-high level of predictability Medium to low level of predictability
Number of People Involved Typically two Many, number can vary during an event
Specialties and Tasks Performed Same specialty, pilots largely capable of performing the same tasks Different specialties, clinicians trained to perform different tasks
Variability Medium to low variability across aircraft, especially within the same type (e.g., Boeing 777) High variability across patients. 
Equipment Minimal differences in equipment used daily Moderate differences in equipment used daily may occur (such as from one OR to another)
Physical Environment Pilots are seated and stationary, lighting and temperature are typically controllable, vibration is possible, noise is likely Clinicians are standing and may be moving around, lighting and temperature are typically controllable, vibration is unlikely, noise is likely but typically controllable
Critical Events Most are sensed resulting in a diagnosis and alert(s) Sensor data, alerts and visual cues must be manually interpreted to determine diagnosis
Trigger for Critical Event Checklist Use Identification of critical event and completion of immediate actions (if any) No clear-cut trigger exists

Aviation is highly structured, and much of the time it is relatively predictable. In contrast, the medical environment—whether it is an operating room, procedure suite, or clinic—is much more fluid, and unforeseen events happen regularly.  A team of two professionals who have identical training (i.e., pilots) and who work together throughout a procedure (i.e., flight) is much easier to organize through a checklist than a team of many people with varying skills and levels of training, who come and go at different times during a procedure (e.g., surgery).  Additionally, a critical event in the operating room is always mediated by patient-specific factors, such as age, comorbidities, allergies, genetics, and lifestyle. Also, details of physiological events may vary considerably.  In contrast, the variability associated with a specific kind of critical event in a given aircraft type (e.g., Boeing 737) and the responses required are generally far more constrained.  To be effective, a checklist must reflect the reality of the specific environment in which it is used and the task demands encountered.

Furthermore, some medical checklists may be used quite differently than those in aviation because they are needed for different reasons.  For example, when an emergency or abnormal situation occurs in flight, pilots refer to the appropriate checklist in the quick reference handbook (after having completed immediate action items, if any) and work their way through the checklist beginning with the first item on the checklist. Items are accomplished in a “read and do” fashion where each step is read and turn and specified actions are completed one at a time (Burian, 2014).  In medicine, however, when a critical event occurs, the operating room team typically first responds to the situation on their own, using their knowledge and judgment about how to best respond.  Then, as a secondary measure, they may reference the relevant critical event checklist to look for other ideas of what might be tried, make sure they haven’t missed any important steps, or to be reminded of a drug dosage.  We call this type of checklist use “sampling”, because the checklist is not being used to guide the step-by-step response but instead is used as an “idea generator” or reference tool (Burian, Clebone, Dismukes, & Ruskin, 2017).  Medical checklists for critical event responses that are designed and structured as read-and-do-lists do not efficiently support sampling.  (However, they may well support clinicians who do look to them for step-by-step guidance, for example, in unfamiliar situations.)

The demonstrated value that checklists have in high-consequence fields, like aviation, makes their adoption and use in medicine quite enticing.  However, aviation and medicine are very different domains with different types of task requirements and team dynamics; the tools used within each setting must match the specific needs of the users and the operational demands of that domain.  The development and design of such tools is challenging and far more complicated than many realize.  These challenges must be successfully dealt with, however, if the potential of these tools is to ever be fully realized, no matter the domain.

References

Bloomstone J. (2015). Humans fail, checklists don't. J Clin Anesth Manag. 1(1): 1-3.Burian, B. K.  (2014).  Factors affecting the use of emergency and abnormal checklists: Implications for current and NextGen operations. NASA Technical Memorandum, NASA/TM—2014-218382.

Burian, B.K., Clebone, A., Dismukes, R.K., & Ruskin, K. (in press). More than a tick box: Medical checklist development, design, and use. Special Article. Anesth Analg.

Durso F, & Drews F. (2010). Health care, aviation, and ecosystems: A socio-natural systems perspective. Current Directions in Psychological Science. 19(2):71-5.

Gawande A. (2010). The checklist manifesto : How to get things right. New York: Metropolitan Books.

Grigg E. (2015). Smarter Clinical Checklists: How to Minimize Checklist Fatigue and Maximize Clinician Performance. Anesth Analg. 121(2):570-3.

Hales BM, & Pronovost PJ. (2006). The checklist--a tool for error management and performance improvement. J Crit Care. 21(3):231-5.

Prielipp RC, & Coursin DB. (2015). All That Glitters Is Not a Golden Recommendation. Anesth Analg. 121(3):727-33.

Thomassen O, Espeland A, Softeland E, Lossius HM, Heltne JK, & Brattebo G. (2011). Implementation of checklists in health care; learning from high-reliability organisations. Scand J Trauma Resusc Emerg Med.19/1/53:1-7.
 

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