Checklists - which prescribe the critical steps healthcare workers need to take to execute procedures correctly - have achieved some remarkable successes in improving patient safety.

Enthusiasm for checklists has rocketed since a study in Michigan hospitals showed that using a checklist could virtually eliminate common infections in intensive care units.

But, writing in The Lancet, two of the authors of that study, Peter Pronovost and Christine Goeschel of Johns Hopkins University in Baltimore, urge greater understanding of how checklists work. Widespread deployment of checklists without an appreciation of how or why they work is a potential threat to patient safety and to high quality care, they warn.

"Checklists can be a really good way of making healthcare safer. There's no doubt about that. They work by improving recall - prompting people to do all the necessary steps - and by making clear the minimum expectations. But they have to be used wisely," says Professor Pronovost, a MacArthur Foundation "genius" award winner who was rated one of the 100 most influential people in the world by Time magazine in 2008.

Writing with social scientists Charles Bosk of University of Pennsylvania and Mary Dixon-Woods of the University of Leicester in the UK, Pronovost explains that developing good checklists is hard, but securing effective implementation in healthcare organizations is much harder.

"The real threat to safety arises when a hospital thinks it has solved a problem by handing the workers a checklist and telling them to use it. The reality is that getting the checklist right is just the beginning. You have to get people motivated to cooperate. That's the really hard part, and it needs good understanding of how to implement checklists."

Professor Bosk points out that simply having checklists in a hospital does not stop errors occurring. He gives the example of a 17-year old girl who died in 2003 when she was given an organ transplant with a mismatched blood type. "That error happened even though there were checklists for checking blood type. The big challenge is how to get staff to use checklists consistently," he says. "They're not a magic pill - a checklist isn't something a hospital can swallow and expect care to get better, safer, or cheaper."

The mistake most commonly made when introducing checklists is to assume that a checklist - a technical solution - can solve a cultural problem. Many doctors resist using checklists because of how they are socialized, the authors say. "And it's a mistake to think that you can get workers to use checklists just by insisting on it. Instead, the Michigan study shows that you need to create incentives for people to cooperate." This includes using audit and feedback to create reputational and social incentives, and having advocates in organizations who act as champions. And organizations themselves need to provide the right kinds of support. But, says Professor Dixon-Woods, the science of checklist implementation is in its infancy, and needs much more attention. "We need a better grip on the social factors that affect uptake of patient safety measures," she said.

The authors of the article also comment that checklists work well for some types of problems in healthcare, but not others. "People often say that checklists in aviation help pilots complete take-off and landing safely, and that's true. It's less often pointed out that checklists are also used for baggage handling too, and there they don't work so well. It's the same in healthcare - checklists are not the answer to everything. We need a reality check for checklists."

Note: If no author is given, the source is cited instead.

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