In the wake of Johns Hopkins’ success in virtually eliminating intensive-care unit bloodstream infections via a simple five-step checklist, the safety scientist who developed and popularized the tool warns medical colleagues that they are no panacea.
“Checklists are useful, but they’re not Harry Potter’s wand,” says Peter Pronovost, MD, PhD, a professor of anesthesiology and critical care medicine at Johns Hopkins University School of Medicine and a patient safety expert. “The science needed to best develop focused, unambiguous and succinct checklists for medicine’s thousands of diagnoses and procedures is in its infancy, and there can be unintended consequences of reliance on simple tools.”
In a review by Pronovost and other Johns Hopkins researchers recently published in the journal Critical Care, the authors say it’s clear that use of aviation-like safety checklists based on scientific evidence can work, and that more hospitals should use them to help prevent errors and reduce costs associated with medical mistakes.
But says Pronovost, whose eponymous checklist is credited with preventing thousands of central-line infections at Hopkins, throughout the state of Michigan and elsewhere, they need to be accompanied by a “change in the culture of arrogance still widespread in medical care.”
Culture change, he says, “insists,” for example, that nurses are empowered to question doctors who don’t follow the steps properly and that every single member of the healthcare team toss out long-held beliefs that infections are an inevitable cost of being in the hospital.
“Just having a checklist on a piece of paper isn’t going to be enough,” he says.
In the Critical Care review, Pronovost and his colleagues took a step back and applied a rigorous scientific analysis of checklists, looking especially for which ones have the potential to work best in varying situations.
For example, some checklists are like grocery lists, a basic catalog of what needs to be accomplished by just one person in order for a process or procedure to be completed properly. In an operating room, the anesthesiologist has a checklist that assists her in making sure that every step is followed to ensure the anesthesia machine is working properly before a patient is put under.
“But that sort of checklist doesn’t work in all cases,” Pronovost says. “Central-line infection checklists work best, for example, when there is what we call a challenge and response, in which one person reads a series of items and a second person verifies that each item had been completed. With the check and balance of another person, the list is more likely to be completed properly.”