The problem with checklists

‘The Problem with…’ series covers controversial topics related to efforts to improve healthcare quality, including widely recommended but deceptively difficult strategies for improvement and pervasive problems that seem to resist solution. Since the seminal studies by Gawande and colleagues1 and Pronovost et al ,2 checklists have become the go-to solution for a vast range of patient safety and quality issues in healthcare. Some see them as a quick and obvious solution to a relatively straightforward problem. For others, they illustrate a failure to understand and address the complex challenges in patient safety and quality improvement. Indeed, successes3 and failures4–6 illustrate an underlying difficulty with understanding precisely why checklists work in some cases but not in others. A recent viewpoint summarises the varying applications of checklists in aviation and healthcare, reflecting upon the dangers of making assumptions about their ‘ubiquitous utility’.7 This provided a timely “The Problem with…”8 opportunity, in which we consider the narratives that often surround the complex challenges faced in designing and implementing a successful checklist, and the science used to explore it. The apparent simplicity of a checklist is understandingly tempting, with some narratives suggesting that their adoption can be used to effectively address what would appear to be intractable, complex and potentially painful systems issues. However, this simple narrative does not always reflect an understanding of the problems needing to be solved, how best to solve them or indeed the intricacies surrounding the implementation, use and impact of such a simple looking tool. More likely, what we face in introducing a checklist is a rather more complex story of gains and losses, procedural interactions and sociocultural balances (see table 1). This ‘simple’ versus ‘complex’ narrative can also be seen in the frequent aviation analogies, which imply that checklists prevented accidents …