The checklist, your friend or foe?

The use of checklists in medicine, especially emergency medicine is a much-debated topic. Intuitively, checklists seem to have a place in emergency medicine, especially if the analogy to aviation is used. Checklists in aviation are a part of the very fabric of safe flight operations and used both as mental aids in preparing for flight but also to help pilots solve problems, such as an engine fire. Similarly, checklists in medicine seem to contribute to improve safety and reduce errors, eg as a mental aide to avoid errors of omission both pro-active and reactive.1 Many emergency care services report the use of checklists to help manage critical procedures but very few have studied the effect these checklists have on quality of care and patient outcome. The few studies that exist are promising and demonstrate increased provider vigilance and procedure adherence.2, 3 Checklists from other domains, like the safe surgery checklist, are well-established and have a proven positive effect on outcome and mortality.4, 5 Despite the positive evidence in favor of checklists in medicine, implementation can be troublesome and ruin a potentially positive effect on quality of care.6 Atul Gawande describes the long and troublesome path to implementing the safe surgery checklist among medical professionals despite obvious proof of effect in his book “The checklist manifesto”, a worthwhile read for all checklist enthusiasts and sceptics.7 The study by Klingberg et al in this issue illustrates the challenges with checklists in emergency medicine well.8 In their retrospective analysis of the data from the PHAST database they could not find clear evidence of the benefit of checklists in preparing for pre-hospital intubation. This is surprising in light of the positive evidence previously mentioned in favour of checklists and could very well be used as an argument against checklists. We think, however, that the study reveals some challenges that are both impacting the effect of the checklists negatively but also hamper implementation. The format of the checklists in the study by Klingberg et al was not controlled and could vary from written to mental and from long to short. This is not only a weakness in the design of the study but also plays a role in how the checklists impact outcome. Many checklists are poorly designed and probably do not support their intended mission. Too long checklists are a common issue and can be counterproductive especially when used for emergency procedures. This was tragically demonstrated in the Swiss Air 111 crash where checklists played a role in misleading the crew's actions and delaying proper response to an onboard fire that eventually caused the crash. Similarly, a rapidly deteriorating airway does not benefit from one minute of checklist rundown when seconds count. A crucial element in the success of a checklist is developing the right kind of checklist for the right purpose. The purpose of the checklist guides its format, it should be short, it should be written, and it should be precise, not too complex but easy to read and understand. A standard rapid sequence intubation—albeit an emergency—might be managed as normal with a checklist to ensure proper preparation and availability of necessary equipment. A checklist for an anticipated difficult airway can help prepare for possible outcomes. If the airway management fails, a checklist can ensure that proper next steps are taken. In this context a difficult airway algorithm is an excellent template for a failed airway checklist. Some systems have implemented distinct emergency action cards to address these issues that are in fact problem-solving checklists. Another issue that the study by Klingberg et al did not capture was whether professionals with different levels of experience and training need different types of checklists. The cohort of physicians in this study was fairly homogeneous and it would probably be impossible to study differences in this context. We do however know that checklists together with rigorous procedures and training play an important role in achieving high success rates in pre-hospital airway management in non-anaesthesiologists’ systems.9 As discussed by Klingberg and also by previous authors, anaesthesiologists managing pre-hospital airways may, however, be a different breed and might not require the same rigorous clinical management to achieve high success in pre-hospital advanced airway management.10 So, the question arises, do anaesthesiologists really need checklists and could this also explain the surprising low positive effect of checklists in this study? We postulate that checklists probably need to be tailored to the providers experience and competence. At the same time, however, believing that checklists can compensate for lack of experience and competence is a dangerous path to follow. Checklists should only serve as mental aides to ensure that the full potential of high-quality care is provided. They should help ensure that necessary equipment is at hand and contribute to reduce stress in critical care situation. Who can boldly say that they never forgot to bring the suction to the scene or always remember to optimize the position of the head before first attempt in an emergency intubation? Preparing for a difficult airway can be a stressful experience and making sure that all correct steps are taken can be lifesaving. To serve their purpose the checklist must be used. A checklist used at the discretion of the provider is rarely successful, especially if the checklist is also developed for problem solving. Checklists contribute to relieve stress. In stressful situations, you sink to the level of your training and to automized procedures—remembering to use a checklist that is never used is close to impossible. In the article by Klingberg and colleagues it was interesting to observe that the use of a checklist was omitted when there was a perceived urgency to manage the airway. The data analysed was not extensive enough to reveal why this was the case. However, it is tempting to speculate that it might be a result of checklists not being used to their full potential. If the same checklist is omitted for the same procedure when time is more critical it is either because they are forgotten in the heat of the moment, are regarded as a waste of time or are not needed because the provider knows what he or she is doing anyway. The true effect on patient outcome can only be revealed when this question is cleared. In conclusion, checklists must be developed with a clear aim and tailored to improve or ensure quality and safety of care. Ideally, checklists should reflect the performance of an individual system and as with all quality improvement their effect should be regularly evaluated.11 Checklists should be short and developed for the individual systems with the competence of the providers in mind. There is no such thing as a generic checklist or a one size fits all. Small systems with a low number of highly experienced providers may benefit from a completely different checklist concept than a large system with an extended number of airway providers of variable experience to ensure a benchmark standard of safety and quality. Finally, a successful checklist requires a culture where checklists are regarded as useful aides and not unnecessary timewasters. We believe in the impact checklists can have on safety in patient care, but as with all safety measures, half-hearted implementation can sometimes be just as dangerous as leaving things as they are. Checklists are much more than writing a series of to-dos on a paper. The authors have no other conflicts of interest to disclose.