Douglas Noble on checklists

douglas nobleI remember as a medical student when the Rockall score for GI bleeding came into common practice.  As with all checklists and tick box style scoring systems, well thumbed photocopies of ever decreasing quality slowly surfaced in emergency departments and acute medical units.  The first time I ‘scored’ a patient I was surprised that their risk of complications was far higher than I had thought from clinical assessment.  It seemed a great idea: standardise assessment, gauge risk, and manage accordingly. 

More recently the checklist approach has become increasingly advocated in many areas of medicine.  Apparently aviation changed much of its unsafe practice through the simple introduction of checklists, standard operating procedures and the like.  No doubt it has disadvantages, reducing clinical autonomy, or increasing the number of times nurses call doctors to the ward because a patient has ‘scored’ (not a football match breaking out on the ward, but a triage score of basic measures such as heart rate and blood pressure that indicate the need for escalation of care). 

Specific checklists claim to have made a dramatic impact on patient safety.  The WHO Surgical Safety Checklist contains a series of basic checks prior to surgery, including: antibiotics given on time, estimated blood loss and checking the correct site of surgery.  Despite the latter seeming patently obvious, the National Patient Safety Agency recently reported 15 burr holes being drilled on the wrong side of the head – the mind literally boggles. 

Is there not an inherent sensibleness about such an approach?  How often in the operating theatre have you heard the inevitable question from surgeon to anaesthetist: ‘have you given the antibiotics yet?’ or the predictable panic when it’s realised that there’s not enough matched blood available. 

As with all change in practice it’s usually difficult and invariably messy.  At some point I suspect someone will think of linking use of checklists to payments for quality of care.  Payment could improve uptake and I suspect would see a reversal of some of the current apathy.  Maybe even a step further is needed.  What about tying such quality improvement interventions to clinical excellence awards?  Now that would definitely send temperatures soaring!

Douglas Noble has worked in surgery, emergency medicine, public health and for WHO Patient Safety. From 2006 to 2008 he was clinical adviser to chief medical officer for England, Sir Liam Donaldson.