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Better Care Through HCIT 101: Part Five - My Garage, Your Checklists & Patient Safety

June 5, 2009
by Joe Bormel
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Checklists – They’re Not All In Your Mind

"Human beings, who are almost unique in having the ability to learn from the experience of others, are also remarkable for their apparent disinclination to do so, [like using checklists]."

- Douglas Adams

The first few generations of electronic medical records were geared to replace parts of the paper charts that preceded them. Sections often replicated the tabs of paper charts with electronic equivalents. In recent years, parts of EMRs have transcended the original paper chart roots, to include direct support for task lists. Tasks like signing verbal orders, dictated transcription, or addressing orders with “automatic stop” criteria. As was pointed out by

Jim Walker recently, the bigger game transcends EMRs and tasks, and moves to reliable, collaborative processes.


In the last decade, we entered the realm of using EMRs to address patient safety. One of the promising areas is automating checklists. If you aren’t familiar with Peter Pronovost’s checklist work, there’s a great

New Yorker article by Atul Gawande from December of 2007 . Here’s a quote about the impact in ICU care:

The rate of death was 1.5% before the checklist was introduced and declined to 0.8% afterward (P=0.003). Inpatient complications occurred in 11.0% of patients at baseline and in 7.0% after introduction of the checklist (P<0.001).

That brings us to My Garage. For several years, I’ve started a formal talk by asking the audience what they do each morning, between the time they lock their home behind them, put their car into gear, and start their drive to work. I encourage two people to walk through their routine for the larger audience.

Their responses have typical components, as well as atypical. That’s nice because it keeps it fresh for me! It often goes like this: I open the car door, put in my briefcase and lunch. I turn on the radio and make sure I have my cell phone. Then I open the garage door, drive to the street, press the remote control to close the garage door, and I’m on my way.

The lists vary from person to person of course, and someone in the audience always enthusiastically wants to add something that wasn’t mentioned. They’re into it! But, in the years I’ve done this exercise, dozens upon dozens of times, no one has ever said that they check their fuel gauge. I like to point out that, if you have a driving and refueling routine and don’t share your car with others, you may not need to check. If you have a low fuel alert/alarm, it may be less critical. I’ve yet to meet anyone who uses a written checklist before their daily “take-off.” I certainly don’t. I sometimes use a mental checklist, and I definitely have routines that make skipping the checklist stuff work out okay … almost all the time.

Gawande pointed out that in aviation, when planes reached a certain level of complexity, written checklists became clearly required. The “My Garage” exercise simply points out, among other things, that we don’t like to use checklists.

The central importance of written (or electronic) checklists for personal, executive function has been extremely well elaborated by David Allen, in his popular book and methodology known as

GTD or

Getting Things Done. Incidentally, his book and seminars are chock full of tips related to checklists, from strategic to tactical, from brainstorming and mind mapping to simply using checklists to

dramatically lower toxic anxiety that arises from expecting your brain to remember everything you need.

My understanding of checklists became complete when I put together two thoughts:


we all need to be able to create, as well as eliminate checklists with comfort on an individual basis; and


using checklists can represent the highest level of disciplined management, as well as the lowest (for example, when the items of a check list can and should be built into a workflow such that the checklist is used as an invisible byproduct of doing the job; also known as the concept of forcing functions).

Conclusion and Lessons?

Checklists are central and crucial to healthcare delivery. They’re also explicitly or implicitly embedded in almost every EMR screen. Whether they’re signature queues, inboxes, flowsheets, medication administration and reconciliation screens, etc. Those screens are either explicitly checklists, or being used by providers as triggers for mental checklists associated with delivering care.

Well utilized EMRs are customized and evolved to support care processes. As a result, the creation, evolution and elimination of checklists is an important discipline to develop and plan for.





Wonderful post! Personally I don't see how busy people can function efficiently without some kind of checklist system built into their work/playflow. There's nothing more satisfying (well that may be a slight exaggeration) than marking through items on a list, knowing that you're getting closer to your goal, whatever that may be. And I'm positive I'm not the only one to add already-completed items to the list, just to have the satisfaction of crossing them off! But I'm a nerd that way.


Thanks Gwen.
The emotional value of getting one's inbox to zero or checklist reduced/completed is huge. Allen uses the term "stress-free productivity." It's a nice vision.

Thanks for this post Joe. I'm a huge fan of checklists. I have one set as a recurring Outlook appointment in the AM that has about 15 things on it, replete with links to the sites I need to visit while hunting for information.

Is there, however, a downside to checklists. You've heard of a "checklist mentality," which implies someone who cares little for the quality with which they complete a task, only that it can be crossed off their list.

IA, thanks for your kind words and comment.

Elsewhere, you've shared that MicroSoft Outlook, even with its GTD plug-in, is not currently adequate to manage your lists.

I think most people using paper instead of electronic automation are quietly combining the "processesing" step of lists with the entry step. During the process of re-writing their lists, they are reviewing them in ways that are less reliable with electronic lists.

Definitely an interesting area. Again, thanks for your comment.

Mobile devices, and more specifically Smart Phones create interesting opportunities with respect to Checklists.

Here, for example is a $2 (two dollar) iPhone app from QxMD Medical Software:  (thanks Shahid, the healthcareguy !)

There are easily a dozen non-healthcare apps for the iPhone whose sole purpose is to make Checklist use easy and more productive.  Most of these sync to services like Outlook, MobileMe, etc, as well as custom servers and web access tools.  Many support aspects of the GTD method.

This is part of the face of things to come in CDI - clinical documentation improvement initiatives.

Anthony, you asked:

Is there, however, a downside to checklists? You've heard of a "checklist mentality, which implies someone who cares little for the quality with which they complete a task, only that it can be crossed off their list.


In the genre that you're describing, I recently heard this story:  [Director of Clinical Informatics speaking here:]

We rolled out on-line clinical documentation for nursing, complete with a task list including cross-patients the scheduled assessments, medication administration, and other tasks.  Occasionally, a nurse would finish their shift, complete their 'checklist' (aka task list) and go home.  They didn't stop and think like a nurse - what does my patient need, what conversations have I had with each of my patients this shift, with the coordinators, doctors, families, etc.   We had to remind these nurses that HCIT does not replace your professional judgment or responsibilities; it only services to facilitate some aspects of some tasks.

It's often not even a question of caring about quality.  Part of the more common cause, Anthony, of that behavior is simply being overwhelmed by the volume and complexity of tasks that modern life presents each of us with.  And, of course, interruptions cause us to immediately forget things as well.  Without this volume, task complexity and interruptions, we might not need checklists.  Been on a hospital floor or in a physician's office?

And that, is an important subtext of this Checklists blog post.  Checklists have become essential because of the volume and complexity of our lives.  The "volume of stuff" is more than our brains are designed to do without writing things down.  Electronically or on paper.  Whatever works.  And then, of course, reviewing what we've wrote down in a timely fashion.  It's not easy and the discipline required should not be taken as a given.

Thanks for your comment.

Thanks for your observations from the Air Force. Doctors in training also memorize ACLS (advanced cardiac life support) protocols for how to respond to various life threatening scenarios. I remember, in 1988, using a DOS-based ACLS simulator, to practice responding to cardiac arrests with electrical defibrillator paddles and drugs.

That was the pinnacle. We had less formally sanctioned checklists, that often took the form of Mnemonic devices ( to remember them. For example, if a patient came into my ER unresponsive but breathing with a pulse, the mneumonic device was Thi-O-Glu-Can. That meant, give thiamine, oxygen, glucose and narcan.

I would put those things in the category of runway level checklists.

At the forty thousand foot level, the mnemonic checklist might be, Vitamin DNC. That "checklist" was a way to remember the high level categories that can cause symptoms, such as "coming into my ER unresponsive but breathing with a pulse," for example from a stroke, meningitis, head trauma, etc.  Same patient presentation, different checklist for a different level of problem solving.

Vitamin DNC:
Vascular, anatomic
   Cerebral Aneurysm
   Cerebral thrombosis or hemorrhage
   Sickle Cell Disease
   Postpartum necrosis (Sheehan's Syndrome)
   Pregnancy (transient)
   Encephalitis, Meningitis, Gullain-Barre' syndrome
Trauma: (physical/environmental/toxic/surgical)
   Head trauma, skull fracture, and orbital trauma
Autoimmune, e.g. Graves
Inflamation, Iatrogenic(steroid txmt),hypersensitivity
   Sarcoid, Wegener's granulomatosis, TB, Syphilis
   Eosinophilic granuloma
   Hand-Schuller-Christian Disease
Neoplasm, e.g. primary, metastatic, paraneop/syndrome
   Primary: (suprasellar cyst, craniopharyngioma, pinealoma)
   Secondary: metastatic breast Cancer, Leukemia

Degeneration: -
Neuro/Psychiatric: -
Congental: hereditary -

I went through the trouble of elaborating that example to point out that checklists are an extremely powerful tool, and, their effective use is not necessarily a simple matter.  They're applicable at different levels in different ways.

For example, in David Allen's seminars, he has group brainstorming sessions to create checklists at the beginning of a project, to ensure that management is tracking on a broad set of issues. For more on frameworks as checklists in HCIT, see this post.

I'll move on the Anthony's point next.


Great post!

I'm using OmniFocus, which keeps all of my personal checklists (using GTD structure) sync'd between my iPhone, my desktop and notebook computers. I've been using it for about 8 months.

You didn't go into detail, but tools like this,
 - that let you manage your checklists in 2 minutes or less,
 - from anywhere you are and
 - on any device,
can be critical to the success of reliably using checklists.

Again, thanks for raising the topic. I agree - executives in healthcare informatics really need to gain experience with using checklists!


Follow up to the checklist post.

In the Air Force, we had all kinds of checklists (pre-flight, post-flight, emergencies, etc.). We also had emergency procedures that we call "bold face". Those were the absolutely critical, absolutely had to be correct procedures. For those, we were given written tests periodically and had to write the procedures down, EXACTLY correctly or we were grounded until we studies and retested. Those procedures were also tested in the simulator check rides (evaluations). If you missed one there, you failed the evaluation. Period, no discussion. Again, more training followed by a reevaluation.

Some things are so important, that you need to have the checklist memorized and your memory evaluated periodically. No art, no creativity, just do it because it will work and doing anything else will put the aircraft in jeopardy.

There weren't many bold face procedures, but they were all critical and time sensitive. I was very glad to have had them the few times that I had to use them in the aircraft.