Checklists for the Checklists

Atul Gawande’s book Checklist Manifesto recommends that health care providers employ checklists more widely to prevent us from overlooking essential details.  This is an excellent suggestion, but the misapplication of a checklist may not be all that beneficial, and could be potentially harmful.  That is, it is always tempting to extend a checklist’s oversight to areas where it should never be seen.  In the operating room, for example, we have been performing a “Time-Out” for several years now.  During the Time-Out, the entire operating room crew goes through a brief preoperative checklist to make sure we’re operating on the correct patient, the proper planned procedure is announced, and so forth.  One of the items on the checklist is whether or not the operative site has been marked.  Normally this makes sense, as it helps make us think about whether we’re fixing the left groin hernia or the right.  Or we’re amputating the right foot, not the left.  However, when I was confronted one day about whether or not I’d marked the patient’s anus, I just about lost it.  I was operating on a huge abscess of the anal region.  Not only would marking the area cause severe pain to the patient, but the ink wouldn’t actually work on the moist anal lining.

We don’t seem to ask ourselves if the checklist should be applied as is for each patient.  For example, managed care organizations often use the performance of an annual eye exam in diabetics as a means of judging the health maintenance effectiveness of the organization.  Unfortunately, these processes have led to quality points against physicians who failed to perform an annual eye exam in their blind diabetics.

Rather than question the appropriateness of the checklist for any given patient, we seem perfectly content to follow the list mindlessly.   Will there be a paradigm shift in medicine to create checklists to see if the checklist is suitable for the patient in question.