The Checklist Manifesto: ALiEM Book Club Synopsis

The Checklist Manifesto: ALiEM Book Club Synopsis

2017-01-20T12:31:07+00:00

Our dear readers have chimed in and we’ve received amazing commentary and feedback regarding this month’s book The Checklist Manifesto. Please read the summary of the discussion below. 

CHECKLISTS ARE EVERYWHERE IN EMERGENCY MEDICINE

Our readers have spotted checklists in a number of places including PALS/ACLS algorithms, Procedural Sedation protocols, and Clinical Decision Rules. Dr. Javier Benitez (@jvrbntz) stated that he uses a checklist for resuscitations at the start of shifts. Dr. Michelle Lin (@M_Lin) stated “We already use our own mental checklists in Med[icine]. It’s just not explicitly shared. Should have more overt shared checklists.” 

EXAMPLE OF A MENTAL CHECKLIST: Syncope and ECG

Several participants, Drs. Seth Trueger (@MDAware), Jordana Haber (@JoJoHaber), Tim Horeczko (@EMtogether), Teresa Chan (@TChanMD), weighed in regarding their own checklists regarding subtle findings on ECGs for patients presenting with syncope or palpitations (as led by Seth). A vigorous debate inevitably ensued regarding  ‘must haves’ on such a checklist.  Here is a complete list of items they all agreed to disagree upon:

  1. Long QTc
  2. Hypertrophic Cardiomyopathy (HCM)
  3. Brugada
  4. Short QTc + Delta Wave / Wolf-Parkinson-White (WPW)
  5. Short QTc / Lown-Ganong-Levine (LGL)
  6. Arrhythmogenic right ventricular dysplasia (ARVD)

DEBATES and DISCUSSIONS

The following were some key discussions that occurred during our online Twitter Book Club Discussions (#aliembook).

  • Standardization of Checklists

Not all checklists can be standardized as shown in the debate a few of the participants had when discussion subtle ECG findings that should be included on a checklist when evaluating a patient with syncope. There was variation on what should be included which reflects the variation that naturally occurs in different physician’s approach to evaluating a patient after syncope. 

  • How and who should create checklists?

Dr. Felix Ankel (@FelixAnkel) described tension between centralized and decentralized quality forces in the creation of checklists. This calls into question who is expert and able to create the checklists, and who can/should enforce the compliance with checklists.

  • Checklists as Cognitive Aids?

Some stated that checklists function as a cognitive forcing strategy.  Jeff Anderson (@JeffMedic) stated that “Forcing strategies don’t just slow you down they also help you focus. Even experts need to be prompted to focus.”

A published author on the topic of cognitive forcing strategies, Dr. Jonathan Sherbino (@Sherbino) tweeted that “a checklist is too simplistic/reductionistic to capture/assess expertise”.

CONCLUSIONS

Checklists are likely already fully integrated into our emergency departments. They are found in paper form (e.g. Procedural Sedation checklists), and in our head (Syncope ECG checklist). However, we should caution that they may be too simplistic and reductionist in advanced situations when expertise is required.    

Perhaps expertise means knowing when to use checklists and when to stray from them?

LINKS

An adjudicated ,‘storified’ book club discussion can be found at this link:  http://sfy.co/iPtJ

Useful links found by our readers and participants:

  1. Checklist Implementation Problems (2013 JACS publication) from Teresa Chan (@TChanMD) via @Skepticscalpel
  2. Issues with Checklist Implementation (2013 BMJ Open publication): from Teresa Chan (@TChanMD) via Mary Dixon Woods (@MaryDixonWoods)
  3. RSI checklist from Univ Hospital of South Manchester: from Dr. Amy Walsh (@docamyewalsh) via Dr. Simon Carley (@EMManchester)
  4. Resuscitation Checklist: from Javier Benitez (@jvrbntz)
  5. Polarity Management book – describe’s tension in creating checklists revolves around the management of centralized versus decentralized quality forces – suggested by Felix (@felixankel) to Dr. Amy Walsh (@docamyewalsh)
  6. From an Australian ED doc via our Comments Section
  7. Procedural Sedation Checklist from EMUpdates by Reuben Strayer (@emupdates)- from Dr. Brent Thoma (@BoringEM)  

Have more to say on this topic?  Have other links to share? Drop us a line in the comments section!

Also, join us next month (September) for the ALiEM book club on the infamous masterpiece ‘House of God’ by Dr. Samuel Shem.

Peer reviewed by Nikita Joshi, MD and Michelle Lin, MD


Teresa Chan, MD
ALiEM Associate Editor
Emergency Physician, Hamilton
Assistant Professor, McMaster University
Ontario, Canada + Teresa Chan
  • Phillip Andrus

    Teresa the PSA checklist from emupdates is by Reuben Strayer @emupdates

    • TChanMD

      Thank-you my friend. Dr. Brent Thoma suggested the link though. I will clarify that.

  • Adam Hill

    Teresa, I agree checklists are important and I agree with almost all the points made above. But I’m not so sure checklists are fully integrated into EM. That they are not was the whole point of Guwande’s book.

    It’s true some checklists are integrated and apparent (before procedural sedation, PERC rule, etc), but the ones in our heads are highly variable and inconsistently deployed… they need to be used far more overtly I think. Pilots use checklists extensively, every day, for both the critical and the mundane. In my mind we have a long way to go to close the gap between medicine and aviation.

    Some examples of errors I’ve seen that might have been avoided with the use of a checklist:

    – My department chair presented a case at M&M of a headache diagnosis he missed… it was acute glaucoma.

    – A colleague repeatedly shocked a wide complex tachycardia, which he mistook for VT, when the rhythm was actually sinus tach in the setting of cocaine toxicity.

    – A patient was all draped up for a central line, the MD gowned with needle in hand, only then realizing the initial Chlorhexadine skin prep had been omitted.

    – An ETT was placed in the esophagus simply because the stylet was left out.

    And I suspect if you handed 100 EP’s an EKG from a syncope case and asked us to pick up a critical abnormality, more of us would find it when prompted to look for specific findings with a written checklist than when working with ones in our own heads.

    The big question in my mind is exactly HOW to make the checklist leap? I’ve created many checklists https://www.dropbox.com/sh/kar2w067s5xtv4g/ph6TCgT9Ix, but they are in various formats and I have certainly not deployed them fully. How much of this is my own limitations and how much of this reflects progress to be made in the house of medicine at large isn’t clear to me.

    Kudos for an overall nice discussion above!

    Adam Hill, MD

    Denver, CO

    • njoshi8

      Thats fantastic that you have started to create checklist and store them in your dropbox. I am sure with the use of social media that we can spread them around, and perhaps even “validate” them with all the FOAM users trying them out. Great start!