Pilots Use Checklists, Why Don’t Anesthesiologists? The Future Lies in Resilience

As a medical specialty, anesthesiology has had a remarkable track record in patient safety. Over the past several decades, anesthesiologists have been leaders in finding ways to reduce risk and avoid errors. Inevitably, the connection between aviation safety and anesthesia safety has been made. In particular, checklists are widely touted as a successful application of aviation safety procedures to prevent avoidable medical errors. Why have pilots embraced the concept of checklists, whereas anesthesiologists have not? First, modern pilots grew up using them, have been trained to use them, and are comfortable with the concept. Their checklists have been tested, adapted, modified, and optimized. Second, pilots take checklists seriously. A pilot knows that a mistake in the cockpit may result in his or her own death and that, even if no bad outcomes occur, shortcuts may result in severe consequences, including loss of license. Third, the hierarchical nature of medicine is such that there often has not been a culture of teamwork. Aviation checklists not only remind the pilot of the steps that must be taken, but also encourage discussion of the shared mental model, something not always welcome in the operating room (OR). Although not yet embraced by the anesthesia community, the concept of checklists has resonated with hospital leaders, and, thus, it is not surprising that the introduction of checklists has blossomed over the past decade. This issue of the journal presents an article by Neuhaus et al.1 that once again examines the use of a checklist in the OR. Although clinicians reflecting on this article1 might ask “Why another checklist?” we believe that this is an important and timely contribution and that Neuhaus et al. provide a valuable and unique response to this question. The authors note how medicine has “adopted, rather than adapted tools, practices, and measures” (such as checklists) borrowed from aviation. The incremental modification and discussion promoted by Neuhaus et al.1 are anchored by insights from commercial pilots adding depth and realism to their novel checklist adaptations. Although we applaud these modifications to the checklist process, we cannot help but note that the scientific track record of medical checklists in many developed urban settings is conflicted or unproven.2 Thus, one may wonder whether the checklist concept is flawed, misapplied, or poorly implemented.3 Although the theory of checklists is sound, we believe that inadequate understanding, misapplication, poor construction, and rushed implementation lead to inconsistent use of checklists along with suboptimal results. In an effort to improve the functionality of checklists, clinicians need to recognize and navigate significant inherent limitations in the process. These confines include: Intrinsic human resistance to change. Complexity of good medical checklists. The need for anesthesiology to optimize cognitive aids such as checklists while simultaneously evolving to the philosophy of Safety II (resilience). HUMAN RESISTANCE TO CHANGE Neuhaus et al.1 note that formal checklists “are often performed halfheartedly or skipped altogether.” Unfortunately, we must agree. Why does this occur? First, physicians’ willingness to adopt new (and potentially beneficial) interventions such as checklists is far less than their willingness to abandon old (even potentially harmful) habits.4 Second, to repeat the old cliché, people intrinsically resist change. Common reasons for this are as follows: Fear of the unknown: Resistance occurs when a change, perceived as negative or adverse, is thrust onto people without giving them adequate education and without their full understanding of how their work will be impacted.5 Poor timing and overload: Heaping too much change on unprepared staff over a short period of time causes confusion and generates resistance.5 What looks like laziness is often exhaustion. Mistrust: If the leader/decision maker is new or has not yet earned the trust of the workforce, the uncertainty will likely transform into resistance.5 Individual and organizational change: People vary in their coping skills and adaptability. Moreover, resistance to change may be related to the organization and the individual. Existing organizational culture may play a role in either embracing or resisting change.5 Medical leaders promoting change to OR workflow and process also need to recognize the psychology of change. This idea has been richly articulated in the book, Switch: How to Changes Things When Change Is Hard,6 where Heath and Heath illustrate that every major change is a struggle between the emotional side (the authors use the analogy of an “Elephant”) and the rational or intellectual side (the human “Rider” directing the Elephant).6 Applying this analogy to checklists provides additional insights to those already elucidated by Neuhaus et al. That is, although our rational brain (the Rider) recognizes the theoretical value in additional safety checks inherent in the preoperative brief checklist, our emotional side (the Elephant) is not so sure; indeed, the Elephant may be rather annoyed by the additional time and bureaucracy embedded in the checklist process and feels no immediate gratification for the effort. Obviously, given that the Elephant vastly outweighs the Rider, an unconvinced Elephant will surely proceed down its usual, comfortable, well-worn path conveniently “forgetting” the checklist. CHECKLISTS ARE COMPLEX! At their core, checklists are a form of cognitive aid. We know that adverse events in hospitalized patients are common and system flaws are a major contributor to these errors. Moreover, failure analysis concludes that up to 50% of these errors are probably avoidable, and checklists and similar standardization protocols may be a key component to diminishing such failures. Thus, checklists are widely touted to address some of these system issues and thereby prevent avoidable errors. Gawande,7 an expert on the utility of checklists, has opined: “We (humans) are built for novelty and excitement, not for careful attention to detail.” But in actual clinical studies, the introduction of a medical checklist has been varied. Sometimes they have been found to be beneficial,8–10 sometimes lacking in benefit,2,11 or potentially they can even have a negative impact on team function.12 One of the best-known checklists is the standardized surgical checklist from the World Health Organization.8 This algorithm has worldwide acceptance and acclaim, which is why the medical community was startled recently to learn that its (or a local customized form of it) mandatory implementation in all 133 surgical hospitals in Ontario, Canada, was not associated with significant reductions in either operative mortality or complications.2 It appears to confirm earlier findings that a checklist does not change outcomes in hospitals that are already compliant with policies and have low rates of complications. So, is the checklist concept misapplied or poorly implemented? We believe that both these factors may be involved in current medical applications of the checklist13 and that incremental changes, such as the efforts described by Neuhaus et al.,1 are needed to improve our results. In our view, the “simplicity” of the checklist is one of its greatest strengths and weaknesses. All too often medical experts and administrators leap to the introduction of a “simple” new form with a series of “tick boxes” (i.e., a checklist) as a quick, inexpensive, and verifiable solution to a recent adverse patient event. The temptation then is to propagate this methodology to every new complication, adverse event, machine defect, drug administration error, or communication lapse that can “easily” be addressed by another checklist.13 Thus, although the checklist concept has real utility and benefit in many instances, it requires thoughtful and selective application in the right situation and for the right reasons. It must also be done well and at the right time.13 Of concern, checklists can actually be distracting and have the potential to interfere with other key responsibilities at critical times. In addition, too many checklists produce fatigue.13 Providers then may complete these forms without actually performing the actions. The concept loses relevance, and team members become disenfranchised by the extra tasks. And even more alarming, checklists may paradoxically reduce vigilance. Excessive reliance on a mandated external checklist can incorrectly lessen the perceived personal level of engagement and responsibility for an issue. Essentially, some providers conclude the “system” will protect the patient now, so they do not have to pay attention. But the ability of any individual to remember every critical step necessary for induction and delivery of anesthesia in every conceivable situation is now exceeded by the complexity of the OR, our drugs and equipment, and our patients. Thus, the importance of checklists is clear, especially during emergency situations. Indeed, when evaluating a checklist for urgent surgery, Weiser et al.14 found that both complications and mortality were reduced after use of a checklist. Nonetheless, checklists are not a simple cure-all for all medical errors, and checklists are not a substitute for judgment. Enhanced, clear, and tested checklists, however, go a long way. An optimally designed checklist must have a clear purpose, must be easy to access, include important items that are easy to forget, while excluding automatic behaviors that are being done without reminder, and be periodically tested and updated.15 If a checklist is to be used in clinical environments, it should be first tested and taught in a simulated environment, including all members of the medical/surgical team. A checklist that is used improperly or that is allowed to interfere with doctor–nurse or doctor–patient workflow may be more detrimental than no checklist at all. McLaughlin provides further information with specific advice that is essential for developing good checklists.a The following are suggested: Involvement of experts Task analysis Request specific outcomes Identification of conflicting physical demands (e.g., if the task requires both hands, the checklist cannot require the use of hands if it is to be done alone) Consideration of all possible task scenarios Be realistic about the task, e.g., know how people actually perform the task, not how the task is prescribed to be performed Include pauses Adhere to basic usability guidelines Indicate task possession, e.g., allocate tasks to individuals Test the checklist SAFETY II (RESILIENCE) Checklists and similar standardization efforts (timeouts, briefs, written handoffs, site markings, etc.) are core tenets to avoid medical errors. However, we submit that checklists are a necessary but insufficient condition to optimize patient safety. Indeed, given the ongoing challenges noted above, one might wonder if our traditional, current way of handling “risk” and “avoiding error” is the best, or only fit for our future. This current approach to patient safety, often termed “Safety I,” is largely predicated on a “report and respond” or “find and fix” methodology. In essence, its focus is on “what went wrong?” Indeed, Safety I generally identifies when things went wrong after an event, institutes an analysis (such as root cause analyses), and then applies a fix to standardize a process, perhaps with a new checklist. The error is then considered addressed; the fix is assumed to be the cure. But health care is much more complex than this linear model can manage.16 We concur with others that standardization of process, while invaluable, inevitably hits certain limits in the dynamic milieu of complex health care systems.16–18 Resilience has been defined as the intrinsic ability of a system to adjust to its functioning before, during, or after changes and disturbances so that it can sustain required operations, even after a major mishap or in the presence of continuous stress.b Thus, we believe that the anesthesia community should consider refining our approach to what is called Safety II, which is an adaptive focus to identify, enable, and recognize how things go right. High-performing industries such as civil aviation and nuclear engineering use resilience to deal with their challenges of ever increasing complex operations. We believe that anesthesiology and perioperative medicine are equally complex and should consider evolution of current safety management paradigms. The differences between Safety I and Safety II are philosophical and pragmatic.16–18 At its core, Safety II recognizes that health care delivery is a complex and continually adaptive system, where every component interacts and impacts the actions of every other component of the system (Table 1). The complexity of health care is illustrated by the recognition that, despite initiating identical operations by identical staff in virtually identical patients, the same clinical result (“output”) cannot be guaranteed. The key is to appreciate that our perioperative systems must be hugely resilient, but, nonetheless, everyday performance succeeds much more often than it fails. Clinicians constantly adjust what they do to match the conditions with the aid of checklists, yes, but also based on their education, training, experience, intuition, and organizational culture. We experience this daily in the OR where resilience is characterized by alert human recognition, anticipation, reaction, and continual learning. Facilitating complex work with sufficient and expert staff, while actively trying to increase the capacity of clinicians to deliver more care more effectively, is a key to this new paradigm.Table 1.: Comparison of Safety I and Safety IISo what can we conclude? First, we congratulate Neuhaus et al. for their continued efforts at incremental change to adapting current checklists to more realistic and optimal workflow in the OR. Such standardization efforts are invaluable. But we must also realize that long-term improvements in patient safety are not simple, swift, inexpensive, or simply the product of building a better checklist. We must become resilient! DISCLOSURES Name: Richard C. Prielipp, MD, MBA, FCCM. Contribution: This author helped design and write the manuscript. Attestation: Richard C. Prielipp approved the final manuscript. Name: David J. Birnbach, MD, MPH. Contribution: This author helped write the manuscript. Attestation: David J. Birnbach approved the final manuscript. This manuscript was handled by: Sorin J. Brull, MD.

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