checklist vs. checklist

Lorri Zipperer Lorri at ZPM1.COM
Fri May 3 13:50:17 UTC 2013

----Original Message-----
From: Ross Koppel [mailto:rkoppel at] 
Sent: Friday, May 03, 2013 5:16 AM
To: Graber, Mark
Cc: Society to Improve Diagnosis in Medicine
Subject: Re: checklist vs. checklist

Mark,   As usual, wonderful insights and good info.  I also loved the 
finding about the double value of running thru the list with the 
patient.    I am not surprised many docs don't want to go thru some of 
the items out loud with the patient....for the obvious reason it detracts
from the idea of doc as all-knowing god, which of course docs know is absurd
but some patients want to believe.  (OK, and a few foolish MDs want to


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 5/3/2013 1:21 AM, Graber, Mark wrote:
> 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

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