Updated Sept.18th 2016
A recent literature review, (pdf link), of the evidence regarding whether surgical checklists affect outcomes comes to no firm conclusion ... the evidence is mixed. A previous Canadian study published in the NEJM, showed little or no impact to surgical checklists and in his accompanying editorial Lucian Leape, noted patient safety expert, stated that checklists that are not used or implemented poorly always fail to have an impact.
So why do high reliability organizations, pilots , safety experts and the World Health Organization continue to tout the need for checklist adoption? Atul Gawande has written an entire text "The Checklist Manifesto" on the topic, emphasizing checklist utility.
The downfall of the checklist is not inherent to the list or the process itself but the more important question of how we create sustained changes in human behavior. The literature is nascent regarding successful use of implementation science. The business world talks about change management. Behavioral psychologist, economists and neurocognitive researchers struggle to achieve sustained changes in human behavior.
Kahneman has shown our flawed decision making regarding behavioral economics in "Thinking Fast and Slow", but the poor rationale appears in all spheres of life. The natural consequence of flawed decision making is flawed behaviors that follow. Research continues on specific techniques to achieve the goal of influencing behaviors. Some focus on creating intrinsic motivation to cause change. Others rely on education or typical carrots and sticks approaches. More are moving to neurocognitively aware methods using
- heuristic techniques,
- progressive participatory dialectic techniques,
- closed loop data collection with real-time feedback
- video and simulation training.
( See work of Itiel Dror)
Dan Ariely author of "Predictably Irrational" has clearly stated that typical didactic education doesn't work. He is absolutely right! The time for sending out a checklist, writing a new policy or listening to a PowerPoint lecture is over. Please do create and promulgate your checklist but then take the opportunity to learn the science of changing human behavior and start on a path to safer behaviors and sustained improvements. Using the techniques described above is a good start to creating sustained changes in our behavior.
Nicolas Argy, M.D., J.D.
Copyright © 2016 Dr. Nicolas Argy
Health/Business Consultant/Educator, Patient Safety, Quality, Risk Management, Public Health Advocate, Witness Prep