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Here we share some thoughts, insights and ideas related to Human Factors Training

Checklists – the luck barrier

Have you ever ticked a box on a checklist, without carrying out the check?

Worryingly, this is part of the culture in some of the hospitals we visit, where we often hear about people ticking boxes on checklists, despite the item patently not being checked.

We know the item wasn't checked, because there's been a subsequent fault, like a retained swab despite the checklist claiming all of the instruments were counted at the end of the procedure.

The boxes are all ticked, yet there's been an error. So, how the heck can that happen?

To counter this issue, I will show medical professionals examples of the checklists we use in aviation, the majority of which have no tick boxes. 

As pilots, we don't tick boxes. Instead, we make it a matter of personal and professional discipline that you do the check.

If you are interrupted during the check, you start it again. In other words, it's not about ticking the box.

Aviation also has standardised responses that are pertinent to the item. Such as...

"Flaps?" response - "checked and set 20, green light on"

"Landing Gear?" response – "down and three green lights"

Note none of the responses are "yup" or "OK".

So maybe "antibiotics?" response - "administered (and state which one)"

"Surgical site marking?" response – "seen and cross-checked with consent and operating list"

There's an important question here for managers; how do you audit the correction completion of a checklist? 

Do you just go and count the ticks and boxes? Are they aware they're being audited? Do your people get in trouble if a box isn't ticked?

I think this is about understanding the purpose of checklists; what they are for and for what they are not.

Are they a 'read and do checklist, for example, check the patient's name and date of birth, and then actually do it? Or are they a 'challenge, response' checklist? "Yep, I've already checked the patient's name and consent, or date of birth."

It's about understanding the purpose of the checklist, how to use them correctly, and how not to use them.

There's a scene in the movie Sully, where the co-pilot works through an emergency checklist, following a catastrophic bird strike on both engines. The co-pilot works through this checklist with Captain Sullenberger, despite familiarity with the various steps to take.

Despite what would have been memory items, they take out the checklist, and they work through it together. When you're in a hurry, with a life-threatening incident taking place, you use a list to ensure your memory hasn't let you down.

Earlier this year, I watched a senior nurse in theatre proudly complete the timeout check from memory. We had already spoken about the check and how it wasn't about the ability to recall the items from memory. Despite that conversation, he immediately slipped back into his usual way of doing it.

What was particularly interesting was, of course, he forgot something on the checklist. A consultant surgeon picked him on the missing checklist item.

This experience made the point beautifully that our memories are fallible. The use of checklists is not about how clever you are.

Being professional is about doing something the right way, every time, such that it's the way you do it when you need it the most. That one time when your luck runs out.

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