Checklist design and implementation: critical considerations to improve patient safety for low-frequency, high-risk patient events

Abstract

Purpose: This pilot project describes the development and implementation of two specialised aviation-style checklist designs for a low-frequency high-risk patient population in a cardiac intensive care unit. The effect of the checklist design as well as the implementation strategies on patient outcomes and adherence to best practice guidelines were also explored. The long-term objective was to improve adherence to accepted processes of care by establishing the checklists as standard practice thereby improving patient safety and outcomes.

Methods: During this project, 10specialised crisis checklists using two specific aviation-style designs were developed. A quasiexperimental prospective pre-post repeated measure design including surveys along with repetitive simulations were used to evaluate self-confidence and self-efficacy over time as well as the perceived utility, ease of use, fit into workflow and benefits of the checklists use to patients. Performance, patient outcomes and manikin outcomes were also used to evaluate the effectiveness of the crisis checklists on provider behaviours and patient outcomes.

Results: Overall self-confidence and self-confidence related to skills and knowledge while not significant demonstrated clinically relevant improvements that were sustained over time. Perceptions of the checklists were positive with consistent utilisation sustained over time. More importantly, use of the checklists demonstrated a reduction in errors both in the simulated and clinical setting.

Conclusion: Recommendations from this study consist of key considerations for development and implementation of checklists including: utilisation of stakeholders in the development phase; implementation in real and simulated environments; and ongoing reinforcement and training to sustain use.

Keywords: crisis checklists; intensive care unit; low frequency high risk patient events; patient safety; repetitive simulation.

Figure 1

Read and Verify Impella Admission Checklist. This checklist provided superusers with guidance on the routine tasks that must be completed with all Impella patients on admission to the cardiac intensive care unit (CICU).

Figure 2

Read and Do Impella Catheter Position Verification Checklist. This checklist provided support to the super-users during critical patient situations and emergencies where the appropriate response may be dependent on the presence or absence of specific circumstances.