checklist vs. checklist

Ross Koppel rkoppel at SAS.UPENN.EDU
Fri May 3 01:54:54 UTC 2013


Checklist for what?

A checklist for a procedure is one thing.  A check list to improve Dx is 
another.   For the procedure, you want tools, steps, etc. Checklists are 
great.  (OK, also see Peter P's very nuanced article in Millbank 
Memorial Quarterly...maybe not so cut and dry)

For Dx, on the other hand, I can imagine a checklist that's a bolus of 
difficult questions that may not improve outcomes, but rather just anger 
the clinician.  Consider the following almost absurd but not irrelevant 
questions:
      Do you remember other known causes of this problem?
     Have you prematurely closed inquiry?
     Did you take enough time?
     Have you examined the pt's history carefully enough?
     Do you remember your pharmacology well enough?
     Did you meet with the radiologist(s) for fully explore the 
ambiguities?
     When you go into another room, do you increasingly wonder why you 
are there?
     Are you willing to admit your ignorance?
     Should you talk to someone else?
     Did you do the all of the appropriate tests but none extra?


I would suggest that some of the Dx-related questions are very different 
than asking about the availability of gloves.  More important, some are 
unlikely to get answers beyond annoyance.

Ross Koppel, Ph.D. FACMI
Sociology Dept and Sch. of Medicine
University of Pennsylvania, Phila, PA 19104-6299
215 576 8221 C: 215 518 0134

On 5/2/2013 8:37 PM, Robert L Wears, MD, MS, PhD wrote:
> Certainly it can often be used as an excuse, but the effects of 
> time/production pressure are
> often more subtle and distributed.  People habituate to various 
> constraints -- if they are
> often time pressured, and must sacrifice thoroughness for efficiency, 
> those behavioural
> patterns tend to carry over into other instances where time pressure 
> may be absent.
>
> I'd suggest reading Erik Hollnagel's book on the 
> efficiency-thoroughness tradeoff.  One idea
> he brings up is that people tend to be biased to favour efficiency 
> over thoroughness, and
> that this is so deeply ingrained one would suspect an evolutionary 
> basis for it.  Saving a bit
> of time is not often important, but in an open system, a world with 
> uncertainty, risk, and
> unexpected events in it, a bit of extra time sometimes turns out to be 
> critical in dealing w/
> the unexpected.
>
> The full reference is:
>
> Hollnagel, E. (2009). /The ETTO Principle:  Efficiency-Thoroughness 
> Tradeoff (Why Things That Go Right Sometimes Go Wrong)/. Farnham, UK: 
> Ashgate.
>
> bob
>
> On 2 May 2013 at 3:19, Jason Maude wrote:
>
> > I initially saw my GP (very experienced and senior partner in the
> > practice) who was certainly not rushed as he even asked me about some
> > other things I had seen him with before. The x-ray was carried out at
> > the small local hospital that was attached to the practice. There was
> > no queue to get the x-ray done so I don't believe that the radiologist
> > was rushed. It was then looked at again by a couple of nurse
> > practitioners, all in the calm of a sleepy English country town
> > hospital!
> >
> > This is why I started to conclude that lack of time could often be an
> > excuse rather than a legitimate explanation. I also blamed myself for
> > too easily accepting what seemed a plausible diagnosis. I should have
> > asked "what else could it be" and acted as the trigger for more
> > thinking. The whole episode showed me what an easy trap it is to fall
> > into.
> >
> > So do we either accept this as the norm and say that nothing can be
> > done (not enough time etc)- in other words there will be an inbuilt
> > industry dx error of 10-20% - or is there a way we can force change.
> > My view, reinforced by this episode, remains that the differential (or
> > say 3 diagnoses) must be recorded in the medical notes at the time of
> > the consultation.
> >
>
> Robert L Wears, MD, MS, PhD
> University of Florida    Imperial College London
> wears at ufl.edu      r.wears at imperial.ac.uk
> 1-904-244-4405 (ass't)            +44 (0)791 015 2219
> What hits the fan will not be evenly distributed.
>
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