Checklist Usage Checklist Usage in High-Risk in High-Risk SituationsSituations

By Rick DixonBy Rick Dixon

Industrial & Systems Industrial & Systems EngineeringEngineering

Overview Hudson River Plane CrashHudson River Plane Crash

Strengths of Using Checklists in ICUsStrengths of Using Checklists in ICUs

Resistance to Checklists Usage in Aviation Resistance to Checklists Usage in Aviation and ICUsand ICUs

Human Factors IssuesHuman Factors Issues

Recommendations and ConclusionRecommendations and Conclusion

Hudson River Plane Crash

150 passengers 150 passengers and 5 crew and 5 crew members members

Birds struck Birds struck planeplane Canada GeeseCanada Geese

Source: http://commons.wikimedia.org

Hudson River Plane Crash

Plane landed in Hudson Plane landed in Hudson River within a mile of River within a mile of Times Square in NYTimes Square in NY

Survival rate was 100%Survival rate was 100%

Emergency landing Emergency landing procedure checklist procedure checklist used used

Source: http://timeinc8-sd11.websys.aol.com/time/photogallery.html

Human Factors and Human Factors and DesignDesign

Using complex equipment such as Using complex equipment such as airplanes calls for having good design.airplanes calls for having good design.

Some general design considerations:Some general design considerations: Use simplest display concepts possibleUse simplest display concepts possible Minimize the memory loadMinimize the memory load Provide good error messages and feedbackProvide good error messages and feedback Speak the user’s languageSpeak the user’s language Be consistentBe consistent

MemoryMemory

Short-term memory Short-term memory Acts like RAM on a computerActs like RAM on a computer We generally remember seven bits of We generally remember seven bits of

information.information.

Emergency Landing Emergency Landing Checklist ExampleChecklist Example

Concerns in ICUs

Currently 2 million Currently 2 million patients are held in patients are held in ICUs in United States.ICUs in United States.

About 28,000 patients About 28,000 patients die from catheter-die from catheter-related bloodstream related bloodstream infections (line infections (line infections) each year.infections) each year.

Many patients also die Many patients also die from ventilator-from ventilator-associated pneumonia associated pneumonia (VAP)(VAP)

Source: http://solutions.3m.com

Strengths of Using Checklists in ICUs

Assurance that Critical Steps are Assurance that Critical Steps are taken in medical procedurestaken in medical procedures

Reduction of Line InfectionsReduction of Line Infections

Reduction of Ventilator-Associated Reduction of Ventilator-Associated Pneumonia (VAP) CasesPneumonia (VAP) Cases

Assurance that Critical Assurance that Critical Steps are TakenSteps are Taken

Acts as a memory guideActs as a memory guide Put more knowledge in the world instead of in Put more knowledge in the world instead of in

the head.the head.

Enhances Coordination in Stressful Enhances Coordination in Stressful SituationsSituations Good to use when your in a hurry Good to use when your in a hurry Good for activities that involve lots of repetitionGood for activities that involve lots of repetition

Redundancy FactorRedundancy Factor

Line InfectionLine Infection Through the use of catheter Through the use of catheter

tubes (lines), many patients are tubes (lines), many patients are able to drink fluids and receive able to drink fluids and receive necessary medications.necessary medications.

Infections can be obtained by:Infections can be obtained by: Leaving Catheter in for too Leaving Catheter in for too

longlong Not Properly Cleaning Not Properly Cleaning

Catheter SiteCatheter Site Even germs from your own Even germs from your own

skin skin

Symptoms include:Symptoms include: Fever/ChillsFever/Chills Shortness of BreathShortness of Breath Pain/Redness near catheterPain/Redness near catheter

Key Fact about Line Key Fact about Line InfectionsInfections

ICUs place 5 million lines/yearICUs place 5 million lines/year

After 10 days After 10 days 4% infection rate or 4% infection rate or 80,000 line infections80,000 line infections

Fatality Rate Fatality Rate 5 – 28% 5 – 28%

Survivors spend on average an extra week Survivors spend on average an extra week in ICUin ICU

Keystone InitiativeKeystone Initiative

Study performed by Study performed by Physician Peter Provonost Physician Peter Provonost and his colleaguesand his colleagues

Conducted in 103 Conducted in 103 Michigan ICUs from 2001-Michigan ICUs from 2001-20032003

Reduced the number of Reduced the number of line infections by using line infections by using checklist in ICUschecklist in ICUs

Saved over $75 million in Saved over $75 million in cost of care for hospitalscost of care for hospitals

Over 1500 lives were Over 1500 lives were saved saved

Line Infection ChecklistLine Infection Checklist

Source: http://www.ntinewsonline.org/2007/Th/Th2007_CE.htm

Ventilator-Associated Ventilator-Associated Pneumonia (VAP)Pneumonia (VAP)

Variation of common Variation of common pneumoniapneumonia

Infection of the lung Infection of the lung

Affects patients who Affects patients who are assisted by are assisted by mechanical mechanical ventilators (breathing ventilators (breathing machines)machines)

High death rateHigh death rateSource: http://www.topnews.in/health/regions/washington?page=4

Reduction of Ventilator-Reduction of Ventilator-Associated Pneumonia VAPAssociated Pneumonia VAP

During Provonost’s study, there were 21 fewer During Provonost’s study, there were 21 fewer cases of death from VAP than in the previous cases of death from VAP than in the previous year by using checklists.year by using checklists.

During Debose’s study, the number of patients During Debose’s study, the number of patients staying on ventilators > 72 hours fell from 74% staying on ventilators > 72 hours fell from 74% to 62%. to 62%.

Resistance to Checklists Resistance to Checklists Usage in Aviation and ICUsUsage in Aviation and ICUs

More PaperworkMore Paperwork

Length of Length of ChecklistChecklist

Source: http://www.csallergy.com/Forms.html

Length of ChecklistLength of Checklist Long checklist may Long checklist may

take away time take away time from patient carefrom patient care

Checklist may be Checklist may be confusingconfusing

Source: http://ntl.bts.gov/DOCS/etis.html

Other ProblemsOther Problems

Misuse of ChecklistMisuse of Checklist Overlooking/Skipping StepsOverlooking/Skipping Steps

Being temporarily distractedBeing temporarily distracted Thinking that a procedure on checklist has Thinking that a procedure on checklist has

already been completed when it had not.already been completed when it had not.

Waste of time for PhysiciansWaste of time for Physicians

Human Factors IssuesHuman Factors Issues

Top-Down Processing (TDP)Top-Down Processing (TDP) What you expect to seeWhat you expect to see

Mental Model Mental Model Becomes more rigid over timeBecomes more rigid over time May adjust perception and May adjust perception and

mislead brain into “seeing mislead brain into “seeing what one is used to seeing”what one is used to seeing”

TDP can override and TDP can override and contradict the physical contradict the physical evidenceevidence

Checklists could resolve this Checklists could resolve this issueissue

Source: Wickens, Lee, Liu

RecommendationsRecommendations

Use a paper checklist that is short in lengthUse a paper checklist that is short in length

Checklists should be clear, concise, and Checklists should be clear, concise, and straight to the pointstraight to the point

Have a checklist for each processHave a checklist for each process

Intervention necessary if procedures on Intervention necessary if procedures on checklists are not being performed correctly.checklists are not being performed correctly.

ConclusionConclusion

Checklists can help:Checklists can help: Assure critical steps are taken in high Assure critical steps are taken in high

risk situationsrisk situations Save lives and money in aviation and Save lives and money in aviation and

medical fields.medical fields.

SimpleSimple and and inexpensiveinexpensive tool to tool to implement in our falling economy.implement in our falling economy.

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