Reality Check for Checklists

Can simple solutions ensure the safety of medical procedures? Sociology professor Charles Bosk cautions that the nexus of science, technology and culture in the healthcare setting is anything but simple.

Bosk is lead author of “Reality Check for Checklists,” published in the August 8, 2009 issue of The Lancet, one of the world’s leading medical journals. The authors reflect on the results of the Michigan Keystone ICU project, which dramatically reduced catheter-related bloodstream infections in 103 intensive care units. (The other authors are Peter Pronovost and Christine Goeschel, both from Johns Hopkins University and investigators in the Keystone initiative, and Mary Dixon-Woods from the University of Leicester.)

Press reports called the Keystone project a success story demonstrating that “simple checklists” are the solution to patient safety. But “determining the best way of proceeding in a complex health-care setting is not as straightforward as producing a prompt to remember the milk,” the authors warn. Checklists are not bad, they say. They’re just not a panacea.

"My notion is anything that creates talk among people about how they're doing things is probably good. Anything that makes the work mechanical and reduces the opportunity to build trust, coordination, cooperation and communication is bad. Checklists could go either way." - Charles Bosk

Bosk is the author of Forgive and Remember: Managing Medical Failure, a highly regarded analysis of medical ethics and physician culture, and All God’s Mistakes: Genetic Counseling in a Pediatric Hospital. His latest book, What Would You Do? Juggling Bioethics and Ethnography, is a reflection on more than 30 years as a medical sociologist and an ethnographer of life on the hospital ward. In 2005 he received the Robert Wood Johnson Health Investigator Award for his study of the disconnect between safety theory and safety practice in the American medical system, “Restarting a Stalled Policy Revolution: Patient Safety, System Error and Professional Responsibility.”

Infections related to the placement of catheters in ICU patients are common, costly and sometimes fatal. The cost of caring for an infected patient runs to about $45,000—$2.3 billion for all U.S. patients annually—and bloodstream infections from putting in catheter lines cause an estimated 28,000 deaths each year. The patient-safety interventions adopted by the Keystone initiative reduced these infections by up to 66 percent over 18 months, saving an estimated $75 million and more than 1,500 lives.

The press immediately latched onto one aspect of the results, touting the cure-all qualities of the checklist—steps healthcare workers need to take to execute a procedure correctly and safely. But it’s not quite that simple. Say the “Reality Check” authors, “We propose that widespread deployment of checklists without an appreciation of how or why they work is a potential threat to patients’ safety and to high-quality medical care.”

Checklists in hospitals are not even new, Bosk states. Good physicians have been using them for a long time. “The Keystone study is not about how checklists save us from medical errors," he explains. "It's about, how do you get people who've had a long history of resisting checklists to buy into them? How do you get them to see that they're important?”

Checklists are a useful technical solution, but the bigger challenge for healthcare is getting them into the culture of medical practice. Doctors are socialized to be analytical and decisive, and many believe that checklists undermine their expertise and short circuit the need for swift decision making and action. To improve safety, the authors argue, hospitals need to get both the technical problems and the cultural issues solved—good, evidence-based checklists with solid social networks of healthcare workers who share the same mission.

“Safety gets created in work groups when people have confidence in one another’s judgments, when there’s open communication, when people don’t hesitate to question one another, and when they feel like they have a stake in the success or failure of whatever it is they’re doing,” Bosk maintains. “My notion is anything that creates talk among people about how they’re doing things is probably good. Anything that makes the work mechanical and reduces the opportunity to build trust, coordination, cooperation and communication is bad. Checklists could go either way.”

Airline pilots use checklists to help them take off and land safely, the authors point out, adding that baggage handlers use them too. Many of us know the nightmare stories about how luggage ends up at the wrong airport, if not the wrong country. “Handling baggage that comes in different sizes and shapes, involves complex transfers, and is often in poor condition is a more realistic analogy for use of checklists in achieving patients’ safety than their use in takeoffs and landings.”

Just ticking off a list of reminders won’t transform the safety of medical care. “Nothing threatens safety so much as the complacency induced when an organization thinks that a problem is solved,” the authors conclude. “The answer to the question of what a simple checklist can achieve is: on its own, not much.”