checklist vs. checklist

Lorri Zipperer Lorri at ZPM1.COM
Fri May 3 13:41:27 UTC 2013

-----Original Message-----
From: Graber, Mark [mailto:Mark.Graber at] 
Sent: Thursday, May 02, 2013 11:21 PM
To: Society to Improve Diagnosis in Medicine; Ross Koppel
Subject: Re: checklist vs. checklist

Hardeep Singh and I (and colleagues) pilot tested some checklists for
diagnosis in the ER as part of AHRQ project last year.  Before we started,
my bias was along the lines that Ross outlined - we all know the steps, and
it would probably be more annoying than helpful to run through them.  What
changed our minds was talking to the checklist guys at Boeing and NASA -
they both said that if you really want to get to the next level of
reliability, checklists (even with some obvious elements) might help you get
there, and you at least have to try them.

We compared a short general checklist ( including things like: "Consider
using the universal antidote: What else could this be?"), to symptom
specific checklists that John Ely developed ( ).   For anyone interested, you can
watch how John quickly runs through one of these with a patient here:
Watching the video, its obvious that running through the checklist with the
patient has double value - not only does it jog YOUR memory, it has the same
effect on the patient.

We didn't have enough funding to count errors, so the results were simply
the impressions of the users in 2 ER's.  Sure enough, the grizzled older
guys were annoyed, as Ross predicted.  They did point out, though, value in
being alerted to patients at highest risk for dx error (patients arriving
with a diagnosis; patients seen in the ER a few days ago, etc).  The younger
guys seemed to value the general checklist, particularly as a teaching tool
for trainees.  Maybe 1 in 5 said that they would have missed the diagnosis
if they hadn't run through the specific checklists.  John has reported the
same phenomenon amongst his family medicine colleagues who've tried the
checklist - Some have had an epiphany are now believers.  Interestingly,
none of the docs in our study used the checklist in front of the patient as
John did in the video.

Mark L Graber MD FACP
Sr Fellow, RTI International
Professor Emeritus, SUNY Stony Brook School of Medicine

From: Ross Koppel <rkoppel at SAS.UPENN.EDU>
Reply-To: Society to Improve Diagnosis in Medicine
Date: Thu, 2 May 2013 21:54:54 -0400
Subject: checklist vs. checklist

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
      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
     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
patterns tend to carry over into other instances where time pressure may be

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.


Robert L Wears, MD, MS, PhD
University of Florida    Imperial College London
wears at            r.wears at
1-904-244-4405 (ass't)            +44 (0)791 015 2219
What hits the fan will not be evenly distributed.

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