The limits of checklists: Handoff and narrative thinking

BMJ Quality and Safety

Volumn 23, Issue 7, 2014, Pages 528-533

  Hilligoss, Brian ^a   Moffatt Bruce, Susan D ^b  

^a OHIO STATE UNIVERSITY   (United States)

^b THE OHIO STATE UNIVERSITY WEXNER MEDICAL CENTER   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

AMBIGUITY; CHECKLIST; CLINICAL PRACTICE; HUMAN; INTERPERSONAL COMMUNICATION; KNOWLEDGE; NARRATIVE; PATIENT SAFETY; REVIEW; THINKING; UNCERTAINTY; CLINICAL HANDOVER; COGNITION; HUMAN RELATION; PROCEDURES; PUBLIC RELATIONS; VERBAL COMMUNICATION;

CHECKLIST; COGNITION; HUMANS; INTERPROFESSIONAL RELATIONS; NARRATION; PATIENT HANDOFF; PATIENT SAFETY; PROFESSIONAL-PATIENT RELATIONS;

EID: 84902466315     PISSN: 20445415     EISSN: None     Source Type: Journal    
DOI: 10.1136/bmjqs-2013-002705     Document Type: Review

References (38)

1. Joint Commission. The Joint Commission's sentinel event policy: ten years of improving the quality and safety of health care. Jt Comm Perspect 2005;25:1-5.
2. Hilligoss B, Cohen MD. Hospital handoffs as multifunctional situated routines: implications for researchers and administrators. Adv Health Care Manag 2011;11:91-132.
3. Pronovost PJ, Needham D, Berenholtz S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med 2006;355:2725-32. (Pubitemid 46021509)
4. Haynes AB, Weiser TG, Berry WR, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 2009;360:491-9.
5. Riesenberg LA, Leitzsch J, Little BW. Systematic review of handoff mnemonics literature. Am J Med Qual 2009;24:196-204.
6. Bosk CL, Dixon-Woods M, Goeschel CA, et al. Reality check for checklists. Lancet 2009;374:444-5.
7. Davidoff F. Checklists and guidelines: imaging techniques for visualizing what to do. JAMA 2010;304:206-7.
8. Moffatt-Bruce SD, Ellison EC. Celebrating human resilience to provide safe care. Ann Surg 2012;256:211-12.
9. Bion J, Richardson A, Hibbert P, et al. "Matching Michigan": A 2-year stepped interventional programme to minimise central venous catheter-blood stream infections in intensive care units in England. BMJ Qual Saf 2013;22:110-23.
10. Dixon-Woods M, Leslie M, Bion J, et al. What counts? An ethnographic study of infection data reported to a patient safety program. Milbank Q 2012;90:548-91.
11. Dixon-Woods M, Bosk CL, Aveling EL, et al. Explaining Michigan: developing an ex post theory of a quality improvement program. Milbank Q 2011;89:167-205.
12. Rydenfält C, Ek Å, Larsson PA. Safety checklist compliance and a false sense of safety: new directions for research. BMJ Qual Saf 2014;23:183-6.
13. Glouberman S, Zimmerman B. Complicated and complex systems: what would successful reform of Medicare look like? Commission on the Future of Health Care in Canada: Discussion Paper No. 8. 2002;8:21-53.
14. Bruner JS. Actual minds, possible worlds. Cambridge: Harvard University Press, 1986.
15. Zukier H. The paradigmatic and narrative modes in goal-guided inference. In: Sorrentino RM, Higgins ET, eds. Handbook of motivation and cognition: Foundations of social behavior. Chichester: John Wiley & Sons, 1986, 465-502.
16. Weick KE. Sensemaking in organizations. Thousand Oaks, CA: Sage Publications, 1995.
17. Mandler JM, Johnson NS. Remembrance of things parsed: Story structure and recall. Cognit Psychol 1977;9:111-51.
18. Fisher WR. Narration as a human communication paradigm: the case of public moral argument. Communication Monographs 1984;51:1-22.
19. Eisenberg EM, Murphy AG, Sutcliffe K, et al. Communication in emergency medicine: Implications for patient safety. Commun Monogr 2005;72:390-413. (Pubitemid 41711551)
20. Charon R. Narrative medicine: honoring the stories of illness. New York: Oxford University Press, 2006.
21. Montgomery Hunter K. Doctors' stories: the narrative structure of medical knowledge. Princeton, NJ: Princeton University Press, 1991.
22. Steiner JF. The use of stories in clinical research and health policy. JAMA 2005;294:2901-4. (Pubitemid 41785872)
23. Gilbert S. Wrongful death: a memoir. New York: Norton, 1995.
24. Berlinger N. Broken stories: patients, families, and clinicians after medical error. Lit Med 2003;22:230-40.
25. Patterson ES, Hofer T, Brungs S, et al. Structured interdisciplinary communication strategies in four ICUs: an observational study. Proceedings of the human factors and ergonomics society 50th annual meeting; San Francisco, CA. London: Sage, 2006,929-33.
26. Dunn EJ, Mills PD, Neily J, et al. Medical team training: applying crew resource management in the Veterans Health Administration. Jt Comm J Qual Patient Saf 2007;33:317-25.
27. Patterson ES, Wears RL. Patient handoffs: standardized and reliable measurement tools remain elusive. Jt Comm J Qual Patient Saf 2010;36:52-61.
28. Cohen MD, Hilligoss B, Amaral ACK. A handoff is not a telegram: an understanding of the patient is co-constructed. Crit Care 2012;16:303-8.
29. Ricoeur P. Time and narrative: Volume 2. Chicago: University of Chicago Press, 1985.
30. Forster EM. Aspects of the novel. Orlando: Harcourt, 1955.
31. Sutcliffe K, Lewton E, Rosenthal MM. Communication failures: an insidious contributor to medical mishaps. Acad Med 2004;79:186-94. (Pubitemid 38461509)
32. Krauss RM, Fussell SR. Perspective-taking in communication: representations of others' knowledge in reference. Social Cognition 1991;9:2-24.
33. Chang VY, Arora VM, Lev-Ari S, et al. Interns overestimate the effectiveness of their hand-off communication. Pediatrics 2010;125:491-6.
34. Frankel RM, Flanagan M, Ebright P, et al. Context, culture and (non-verbal) communication affect handover quality. BMJ Qual Saf 2012;21(Suppl 1):i121-8.
35. Greenstein EA, Arora VM, Staisiunas PG, et al. Characterising physician listening behaviour during hospitalist handoffs using the HEAR checklist. BMJ Qual Saf 2013;22:203-9.
36. Hu Y, Arriaga AF, Roth EM, et al. Protecting patients from an unsafe system: the etiology and recovery of intraoperative deviations in care. Ann Surg 2012;256:203-10.
37. Woods DD, Hollnagel E. Prologue: resilience engineering concepts. In: Hollnagel E, Woods DD, Leveson N, eds. Resilience engineering: concepts and precepts. Hampshire, UK: Ashgate, 2006, 1-16.
38. Pettker CM, Thung SF, Raab CA, et al. A comprehensive obstetrics patient safety program improves safety climate and culture. Obstet Gynecol 2011;204:216.e1-6.