Clinical review: Checklists - translating evidence into practice

Critical Care

Volumn 13, Issue 6, 2009, Pages

  Winters, Bradford D ^a   Gurses, Ayse P ^a   Lehmann, Harold ^b   Sexton, J Bryan ^a,b   Rampersad, Carlyle J ^c   Pronovost, Peter J ^a,b  

^a JOHNS HOPKINS UNIVERSITY SCHOOL OF MEDICINE   (United States)

^b JOHNS HOPKINS UNIVERSITY   (United States)

^c Philadelphia International Airport   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

ANESTHESIA INDUCTION; CATHETERIZATION; CHECKLIST; CLINICAL PROTOCOL; HEALTH CARE QUALITY; HUMAN; INFORMATION PROCESSING; MEDICAL DOCUMENTATION; MEDICAL PRACTICE; PATIENT SAFETY; PRACTICE GUIDELINE; PRIORITY JOURNAL; PROFESSIONAL COMPETENCE; REVIEW; STANDARDIZATION; VENTILATOR ASSOCIATED PNEUMONIA; WORK SCHEDULE; ALGORITHM; COGNITION; EVIDENCE BASED MEDICINE; STANDARD;

ALGORITHMS; CHECKLIST; COGNITION; EVIDENCE-BASED MEDICINE; HUMANS; QUALITY ASSURANCE, HEALTH CARE;

EID: 77951629450     PISSN: 13648535     EISSN: 1466609X     Source Type: Journal    
DOI: 10.1186/cc7792     Document Type: Review

References (52)

1. Gawande A. The checklist: if something so simple can transform intensive care, what else can it do?. New Yorker. 10 December 2007; Annals of Medicine section 1-8.
2. Hales B, Terblanche M, Fowler R, Sibbald W. Development of medical checklists for improved quality of patient care. Int J Qual Health Care 2008, 20:22-30. 10.1093/intqhc/mzm062, 18073269.
3. Pronovost PJ, Thompson DA, Holzmueller CG, Lubomski LH, Dorman T, Dickman F, Fahey M, Steinwachs DM, Engineer L, Sexton JB, Wu AW, Morlock LL. Toward learning from patient safety reporting systems. J Crit Care 2006, 21:305-315. 10.1016/j.jcrc.2006.07.001, 17175416.
4. Lingard L, Espin S, Whyte S, Regehr G, Baker GR, Reznick R, Bohnen J, Orser B, Doran D, Grober E. Communication failures in the operating room: an observational classification of recurrent types and effects. Qual Saf Health Care 2004, 13:330-334. 1743897, 15465935, 10.1136/qshc.2003.008425.
5. Sutcliffe KM, Lewton E, Rosenthal MM. Communication failures: an insidious contributor to medical mishaps. Acad Med 2004, 79:186-194. 10.1097/00001888-200402000-00019, 14744724.
6. Gawande AA, Zinner MJ, Studdert DM, Brennan TA. Analysis of errors reported by surgeons at three teaching hospitals. Surgery 2003, 133:614-621. 10.1067/msy.2003.169, 12796727.
7. Degani A, Wiener EL. Cockpit checklists: Concepts, design, and use. Hum Factors 1993, 35:345-359.
8. Peleg M, Boxwala AA, Ogunyemi O, Zeng Q, Tu S, Lacson R, Bernstam E, Ash N, Mork P, Ohno-Machado L, Shortliffe EH, Greenes RA. GLIF3: the evolution of a guideline representation format. Proc AMIA Symp 2000, 645-649. 2243832, 11079963.
9. Kendell J, Barthram C. Revised checklist for anaesthetic machines. Anaesthesia 1998, 53:887-890. 10.1046/j.1365-2044.1998.00462.x, 9849283.
10. Berenholtz SM, Pronovost PJ, Lipsett PA, Hobson D, Earsing K, Farley JE, Milanovich S, Garrett-Mayer E, Winters BD, Rubin HR, Dorman T, Perl TM. Eliminating catheter-related bloodstream infections in the intensive care unit. Crit Care Med 2004, 32:2014-2020. 10.1097/01.CCM.0000142399.70913.2F, 15483409.
11. Pronovost P, Needham D, Berenholtz S, Sinopoli D, Chu H, Cosgrove S, Sexton B, Hyzy R, Welsh R, Roth G, Bander J, Kepros J, Goeschel C. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med 2006, 355:2725-2732. 10.1056/NEJMoa061115, 17192537.
12. Makary MA, Holzmueller CG, Thompson DA, Rowen L, Heitmiller ES, Maley WR, Black JH, Stegner K, Freischlag JA, Ulatowski JA, Pronovost PJ. Operating room briefings: working on the same page. Jt Comm J Qual Patient Saf 2006, 32:351-355. 16776390.
13. American Society of Anesthesiologists homepage. , http://www.asahq.org
14. Burian B. Aeronautical emergency and abnormal checklists: expectations and realities. Proceedings of the Human Factors and Ergonomics Society 50th Annual Meeting: 16-20 October 2006; San Francisco 2006, 101-105. Santa Monica, CA: Human Factors and Ergonomics Society.
15. Swain AD, Guttman HE. Handbook of Human Reliability Analysis with Emphasis on Nuclear Power Plant Applications (NUREG/CR-1278) 1983, Washington, DC: Nuclear Regulatory Commission.
16. Hayashi I, Wakisaka M, Ookata N, Fujiwara M, Odashiro M. Actual conditions of the check system for the anesthesia machine before anesthesia. Do you really check?. Masui 2007, 56:1182-1185.
17. Colon-Emeric CS, Lekan D, Utley-Smith Q, Ammarell N, Bailey D, Corazzini K, Piven ML, Anderson RA. Barriers to and facilitators of clinical practice guideline use in nursing homes. J Am Geriatr Soc 2007, 55:1404-1409. 2276683, 17767682, 10.1111/j.1532-5415.2007.01297.x.
18. Hewson KM, Burrell AR. A pilot study to test the use of a checklist in a tertiary intensive care unit as a method of ensuring quality processes of care. Anaesth Intensive Care 2006, 34:322-328.
19. Huang HC, Lin WC, Lin JD. Development of a fall-risk checklist using the Delphi technique. J Clin Nurs 2008, 17:2275-2283. 10.1111/j.1365-2702.2008.02337.x, 18705704.
20. Makary MA, Mukherjee A, Sexton JB, Syin D, Goodrich E, Hartmann E, Rowan L, Behrens DC, Marohn M, Pronovost PJ. Operating room briefings and wrong site surgery. J Am Coll Surg 2007, 204:236-243. 10.1016/j.jamcollsurg.2006.10.018, 17254927.
21. Verdaasdonk EG, Stassen LP, Hoffmann WF, Elst M, Dankelman J. Can a structured checklist prevent problems with laparoscopic equipment?. Surg Endosc 2008, 22:2238-2243. 10.1007/s00464-008-0029-3, 18597142.
22. Pronovost P, Berenholtz S, Dorman T, Lipsett PA, Simmonds T, Haraden C. Improving communication in the ICU using daily goals. J Crit Care 2003, 18:71-75. 10.1053/jcrc.2003.50008, 12800116.
23. Lingard L, Regehr G, Orser B, Reznick R, Baker GR, Doran D, Espin S, Bohnen J, Whyte S. Evaluation of a preoperative checklist and team briefing among surgeons, nurses, and anesthesiologists to reduce failures in communication. Arch Surg 2008, 143:12-17. discussion 18, 10.1001/archsurg.2007.21, 18209148.
24. Torr J, Iacono T, Graham MJ, Galea J. Checklists for general practitioner diagnosis of depression in adults with intellectual disability. J Intellect Disabil Res 2008, 52:930-941. 10.1111/j.1365-2788.2008.01103.x, 18647215.
25. Iacono T, West D, Bloomberg K, Johnson H. Reliability and validity of the revised Triple C: Checklist of Communicative Competencies for adults with severe and multiple disabilities. J Intellect Disabil Res 2009, 53:44-53. 10.1111/j.1365-2788.2008.01121.x, 18759959.
26. Clay AS, Que L, Petrusa ER, Sebastian M, Govert J. Debriefing in the intensive care unit: a feedback tool to facilitate bedside teaching. Crit Care Med 2007, 35:738-754. 10.1097/01.CCM.0000257329.22025.18, 17255866.
27. Levy MM, Pronovost PJ, Dellinger RP, Townsend S, Resar RK, Clemmer TP, Ramsay G. Sepsis change bundles: Converting guidelines into meaningful change in behavior and clinical outcome. Crit Care Med 2004, 32:S595-S597. 10.1097/01.CCM.0000147016.53607.C4, 15542969.
28. Miller GA. The magical number seven plus or minus two: some limits on our capacity for processing information. Psychol Rev 1956, 63:81-97. 10.1037/h0043158, 13310704.
29. Lorist MM, Boksem MA, Ridderinkhof KR. Impaired cognitive control and reduced cingulate activity during mental fatigue. Brain Res Cogn Brain Res 2005, 24:199-205. 10.1016/j.cogbrainres.2005.01.018, 15993758.
30. Halford GS, Baker R, McCreeden JE, Bain JD. How many variables can humans process?. Psychol Sci 2005, 16:70-76. 10.1111/j.0956-7976.2005.00782.x, 15660854.
31. Hutchins E. Cognition in the Wild 1996, Cambridge, MA: MIT Press.
32. Norman DA. Design principles for cognitive artifacts. Res Eng Des 1992, 4:43-50.
33. Xiao Y. Artifacts and collaborative work in healthcare: methodological, theoretical, and technological implications of the tangible. J Biomed Inform 2005, 38:26-33. 10.1016/j.jbi.2004.11.004, 15694883.
34. Rodriguez-Paz JM, Mark LJ, Herzer KR, Michelson JD, Grogan KL, Herman J, Hunt D, Wardlow L, Armour EP, Pronovost PJ. A novel process for introducing a new intraoperative program: a multidisciplinary paradigm for mitigating hazards and improving patient safety. Anesth Analg 2009, 108:202-210. 10.1213/ane.0b013e31818ca423, 19095851.
35. Surowiecki J. The Wisdom of Crowds: Why the Many Are Smarter than the Few and How Collective Wisdom Shapes Business, Economics, Societies and Nations 2004, New York, NY: Random House, 1.
36. Gurses AP, Seidl KL, Vaidya V, Bochicchio G, Harris AD, Hebden J, Xiao Y. Systems ambiguity and guideline compliance: a qualitative study of how intensive care units follow evidence-based guidelines to reduce healthcare-associated infections. Qual Saf Health Care 2008, 17:351-359. 10.1136/qshc.2006.021709, 18842974.
37. Oberauer K, Kliegl R. Simultaneous cognitive operations in working memory after dual-task practice. J Exp Psychol Hum Percept Perform 2004, 30:689-707. 10.1037/0096-1523.30.4.689, 15301618.
38. Nielsen J. Usability Engineering 1993, San Diego, CA: Academic Press.
39. Strauss A, Corbin J. Basics of Qualitative Research: Techniques and Procedures for Developing Grounded Theory 1998, Newbury Park, CA: Sage Publications, 2.
40. Wicker P, Smith B. Checking the anaesthetic machine. J Perioper Pract 2006, 16:585-590.
41. Brockwell R. The anesthesia machine: what's new besides the name?. ASA Newsletter 2006, 70., http://www.asahq.org/Newsletters/2006/05-06/whatsNew05_06.html
42. O'Grady NP, Alexander M, Dellinger EP, Gerberding JL, Heard SO, Maki DG, Masur H, McCormick RD, Mermel LA, Pearson ML, Raad II, Randolph A, Weinstein RA. Guidelines for the prevention of intravascular catheter-related infections. Centers for Disease Control and Prevention. MMWR Recomm Rep 2002, 51:1-29.
43. Pronovost PJ, Berenholtz SM, Goeschel C, Thom I, Watson SR, Holzmueller CG, Lyons JS, Lubomski LH, Thompson DA, Needham D, Hyzy R, Welsh R, Roth G, Bander J, Morlock L, Sexton JB. Improving patient safety in intensive care units in Michigan. J Crit Care 2008, 23:207-221. 10.1016/j.jcrc.2007.09.002, 18538214.
44. El-Khatib MF, Bou-Khalil P. Clinical review: liberation from mechanical ventilation. Crit Care 2008, 12:221. 2575571, 18710593, 10.1186/cc6959.
45. Pronovost PJ, Berenholtz SM, Goeschel CA, Needham DM, Sexton JB, Thompson DA, Lubomski LH, Marsteller JA, Makary MA. Creating high reliability in healthcare organizations. Health Serv Res 2006, 41:1599-1617. 1955341, 16898981, 10.1111/j.1475-6773.2006.00567.x.
46. Koppel R, Metlay JP, Cohen A, Abaluck B, Localio AR, Kimmel SE, Strom BL. The impact of computerized physician medication order entry in hospitalized patients--a systematic review. JAMA 2005, 293:1197-1203. 10.1001/jama.293.10.1197, 15755942.
47. Eslami S, de Keizer NF, Abu-Hanna A. The impact of computerized physician medication order entry in hospitalized patients--a systematic review. Int J Med Inform 2008, 77:365-376. 10.1016/j.ijmedinf.2007.10.001, 18023611.
48. Windle J, Van-Milligan G, Duffy S, McClay J, Campbell J. Rapid deployment of physician order entry using web-based, disease-specific order sets. AMIA Annual Symposium Proceedings 2003, 1079. Omaha, NE: University of Nebraska Medical Center, 1479916, 14728582.
49. Wrona S, Chisolm DJ, Powers M, Miler V. Improving processes of care in patient-controlled analgesia: the impact of computerized order sets and acute pain service patient management. Paediatr Anaesth 2007, 17:1083-1089.
50. Donaldson NE, Rutledge DN, Ashley J. Outcomes of adoption: measuring evidence uptake by individuals and organizations. Worldviews Evid Based Nurs 2004, 1(Suppl 1):S41-51. 10.1111/j.1524-475X.2004.04048.x, 17129334.
51. Titler MG. Methods in translation science. Worldviews Evid Based Nurs 2004, 1:38-48. 10.1111/j.1741-6787.2004.04008.x, 17147757.
52. Atlantic Sun Airways CAT B pilot procedures and checklists series. , http://www.atlanticsunairways.com/training/checklist_b727f.pdf