On Wednesday, October 30, 1935, an evaluation flight of the Boeing Model 299 was undertaken at Wright Field, northeast of Dayton, OH, USA. The Model 299 was the most technologically sophisticated aircraft of its time and was nicknamed the Flying Fortress because of the extent of its armaments. Major Ployer P. Hill was the pilot, and it was his first flight in the new aircraft. The aircraft appeared to ascend normally, but suddenly stalled, turned on one wing, and crashed, killing two of the aircraft’s five crew, including Major Hill. The investigation into the crash discovered that Major Hill had omitted a crucial step during the preflight preparation; he forgot to release a catch, which on the ground locked the aircraft’s control flaps. Once in the air, this mistake rendered the aircraft uncontrollable. The crash investigators knew that there was probably no one better qualified to fly the new aircraft than Major Hill—his co-pilot was also highly qualified—yet despite this, the fatal error was still made. The investigators concluded that given the experience of the pilots, further training would not be an effective response to prevent such an event from happening again; a response that is very different from that which often occurs in health care when a mistake is made. Some commentators initially believed that this meant the new aircraft was simply too complicated to fly reliably. A new approach was needed, and it took the form of a simple list of crucial tasks that must be completed before the aircraft could leave the ground. The first aviation checklist had been devised. With the checklist in use, despite the aircraft’s sophistication, the Model 299 (and later versions of it) performed safely for many years. (Webster, 2017, p.178-179).
Lesson Learned from the Airline Industry
The successful use of checklists was eventually integrated into healthcare. An early, well-known example of this is the Surgical Safety checklist developed by the World Health Organization (WHO). Similar to aviation, the operating room setting involves high technology within a complex environment, with the surgeon as captain and a multidisciplinary crew, in which key steps are required to ensure safety. Use of the checklist promotes team communication and standardization by review of essential items before and after the procedure. The positive relationship between checklists and reducing harm has also been demonstrated in healthcare, with studies showing significant reductions in postoperative complications with the use of the WHO Surgical Safety Checklist (Webster, 2017).
Checklists as Cognitive Aids to Reduce Errors
When developed and implemented properly, checklists serve as a way to ensure the same steps are followed or completed each and every time. They are tools to help reduce reliance on memory, which can fail especially during times when people are distracted, stressed, or multi-tasking. Checklists also serve as a way to promote teamwork and communication because, when used in a team format, they help ensure that everyone is on the same page with pertinent care information.
What does Successful Design of a Checklist Look Like?
To begin, effective checklists are designed in a user-friendly manner. This includes the following characteristics:
- Brief, ideally one page
- Easy to read (font, color, etc.)
- Inclusion of critical steps
- Designation of team role responsibilities (ex. circulating nurse reviews a time out a checklist with the team)
- Ability to be read aloud (Bernstein, 2017)
Designing the checklist effectively involves multidisciplinary staff input, including those who will be using the checklist. These team members can also serve as champions in the day-to-day. Consideration for the best time to review the checklist should be determined.
Careful planning of checklist implementation is of great importance. For example, simulation is an action-oriented way to allow participants to practice the process. Ideas for improvement may be generated including staff ideas on real-time tools that can help ensure compliance such as laminated templates or checklists built into the electronic medical record. The rationale and evidence supporting checklist use can be reinforced, which helps to promote buy-in for the process. Last, key details can be reviewed such as:
- all staff members being in the moment and paying attention
- the leader referencing the checklist while going through each item, versus going off memory and then checking off the boxes
The next part of implementation can involve piloting the checklist to evaluate how it works and determine if any modifications need to be made. Once trialed it can be scaled for widespread use. Finally, compliance with the process can be measured to evaluate successful implementation. One way to measure compliance is by auditing. These can be done during the initial implementation and periodically afterward to measure sustainability.
In summary, checklists are an evidence-based approach to improving patient safety. With careful design, planning, and implementation, successful integration into practice can be achieved.
Bernstein, Peter S., et al. “The Development and Implementation of Checklists in Obstetrics.” Society for Maternal-Fetal Medicine Special Report, 2017, pp.B2-B6
Webster, C.s. “Checklists, Cognitive Aids, and the Future of Patient Safety.” British Journal of Anaesthesia, vol. 119, no. 2, 2017, pp. 178–181., doi:10.1093/BJA/aex193.
Boeing B-17 Flying Fortress. (2021, November 24). Retrieved from https://en.wikipedia.org/wiki/Boeing_B-17_Flying_Fortress
Image from the U.S. Air Force –
Side view of the Boeing XB-17 (Model 299) after the fire was extinguished
Copyright by Jeanette Zocco MSN, RNC-OB, C-EFM, C-ONQS