Standardized Intensive Care. Protocol Misalignment and Impact Misattribution

Guidelines, protocols, and checklists (together called "protocols") can be immensely helpful in the clinical arena. However, clinicians and health care systems relying on protocols must assess whether benefits are being accrued, whether such "benefits" are real, and whether harm can be detected. These concerns are important because protocols (as opposed to drugs or other interventions) are seldom subjected to rigorous testing; instead, they are often implemented on the basis of belief or the results of simplistic "before and after" studies. We describe two concepts, "protocol misalignment" and "protocol misattribution," and discuss how understanding these concepts might help improve outcome and prevent unanticipated harm. Ultimately, applying protocols to the same standards of proof as other interventions might increase insight and help ensure "true" patient benefit.