Can mandatory checklists actually improve patient safety?

In the world of healthcare, the medical checklist has become a superstar. In essence, it seems like a simple, easy-to-use method that has been used by hospitals for functions such as preventing medical errors or attacking healthcare-acquired infections. But should they be mandated?

That's the question I came across this week when I noticed legislation was pending in Nevada. On Thursday, a state Senate committee passed what is called the "Patient Protection Checklist Bill" (Assembly Bill 280). The bill would require patient safety committees of medical facilities "to adopt certain patient safety checklists to improve the health outcomes of patients." The patient safety committees then would be required to review those checklists annually--and revise as necessary.

Nevada Assembly Speaker John Oceguera (D-Las Vegas), who is a bill sponsor, said 48,000 Americans die each year in U.S. hospitals from preventable infections--and that using checklists should cut down on medical errors.

I can't argue there. In fact, a major study published in this week's Archives of Internal Medicine, found that hospital ICUs could eliminate central line-associated bloodstream infections for up to two years or more in Michigan using tools such as checklists to promote practices based on guidelines from the Centers for Disease Control and Prevention.

But what I would argue is that mandating the use of checklists doesn't mean it will automatically work. I base part of this on the conversation I had about a year ago with Peter Pronovost, MD, who brought to the attention of the medical establishment the potential of the checklist more than a decade ago. Pronovost, a professor and medical director for Johns Hopkins' Center for Innovation in Quality Patient Care in Baltimore, is one of the coauthors of the Michigan study.

Pronovost, who relates his experiences with checklists and patient safety in his book, Safe Patients, Smart Hospitals, notes how ironically the medical staff he was working with at Hopkins initially refused to use a simple checklist to help reduce catheter-related bloodstream infections.

Pronovost says that while having a checklist is an important step in patient safety, what has to be addressed is the culture where it is introduced. Are members of the hospital staff, such as nurses, able to speak up if something is wrong? Do physicians or surgeons dominate the way medicine is practiced--without input from other hospital staff? And can hospital staff learn together what is working or not working with a checklist?

Media reports note that opponents of the Nevada measure contend that checklists could increase costs and that physicians already have too much paperwork to deal with.

That's a difficult claim because isn't making healthcare safer a way to lower costs? I think the argument, though, needs to focus on buy-in--to make sure that everyone on the healthcare team is aligned toward achieving the same goal. Mandating that a checklist exists doesn't mean a goal will be accomplished: It's the people behind it--and the culture they work in--that is going to make the checklist ultimately work. - Janice