Checklist mentality


The case for checklists has been made so well – see this fantastic article by Atul Gawande – yet those responsible for embedding them struggle. They are an effort, an obstacle, an apparently petty imposition. I know it’s the right patient! I know they’re not on Warfarin! I know what equipment we need to do the procedure. It’s all so obvious. Yet, now and again, something goes wrong. Never events happen. (See the recent Health Safety Investigation Branch findings.) The wrong patient is operated on, the wrong tooth is removed, or an allergy is missed and a drug that is dangerous to them is injected. Checklists reduce these events, so what’s the problem?

My experience with checklists has been interesting. I am a proponent, a kind of champion, yet often I huff and puff as, on the brink of putting an endoscope down, the wretched piece of paper is waved at me. Grrrr!

The process of completing the particular checklist that we have developed takes a minute at most. It requires standing still (a problem when you’re in a hurry), focusing the team’s attention on the responses (for what is the point of the patient telling me they are allergic to something if no one else in the room is aware?) and communicating with the patient (a problem for some, especially when in a hurry).

Perhaps it’s this need to pause and be still that frustrates doctors and surgeons. We, they, like to keep moving, to flow through the tasks, to get to the nitty gritty (the technique, the findings, the pathology, the treatment) as soon as possible. It is this habit that is so difficult to break. It is a mind-set. And it reveals something about our approach our surgical lists. They are our lists. They have our names on them. Their character – relaxed, rushed, efficient, friendly, spikey, miserable – stems from our own behaviour and the clinical leads in the room. The checklist is an obstacle to our progress through the day and to a successful outcome. With this mind-set, the fact that it is the patient’s procedure can be forgotten; forgotten also the fact that around the surgeon buzzes a team of highly assistants without whom the procedure could not take place. The checklist is the best, probably only way to ensure that for a moment, everyone is focussed on that patient, and the last opportunity to identify possible harm is heeded.

Gradually, slowly, the checklist should become natural, and depending on your psychology, you feel that something is missing without it. We didn’t to clean our hands before and every patient contact; now, if I haven’t, I feel kind of tainted, as though there is something on my skin that hasn’t been taken off. They are clean of course, but the habit has become so ingrained my mind insists on the slap of antiseptic foam before moving on. In the same way, the checklist should become a door through which your mind insists on moving before embarking on the procedure.

I’m not sure I’m at that stage yet. If there are distractions, or if I am running very late, the checklist can be overlooked, until a colleague holds it up and pulls me back. I know that if harm does occur in relation to a surgical procedure, the absence of a checklist looks bad. Completed correctly, it serves to protect you, as the surgeon. It demonstrates that care was taken, and thought given to the patient as an individual, not as a ‘procedure’.

Most doctors and nurses are already converted. But the checklist mentality remains a change, and a challenge. As Gawande says, comparing the flair and fluidity with which surgeons like to move through their lists with the early astronauts from The Right Stuff,

‘…the prospect [of checklists] pushes against the traditional culture of medicine, with its central belief that in situations of high risk and complexity what you want is a kind of expert audacity—the right stuff, again. Checklists and standard operating procedures feel like exactly the opposite, and that’s what rankles many people.’

Expert audacity vs regimentation, again in Gawande’s words. This points to the same psychology I explored above. The audacity, the flair, the speed, all relate to the surgeon.

But it’s the patient’s procedure.


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