Lately, I have been pretty obsessed with checklists. The main motivating factor to this has been reading Atul Gawande’s book “The Checklist Manifesto”². I also admit, though, that I probably have a propensity for liking checklists given my inclination to make “To-Do” lists and write post-it notes to myself and enjoy the satisfaction of crossing items off of those lists…

However, this checklist fever that I have caught is not just due to my personality quirks. The fuel that is really stoking my excitement in developing and testing these checklists is that I think they hold the potential to make me a better physical therapist (future tense, that is…still just a student physical therapist for now…).

Gawande builds many arguments for the utility of checklists in reducing medical errors, building/construction errors, and flight errors (one of the examples of successful use of checklists that he elegantly weaves through his medically themed book is the data regarding reduction in plane crashes and airline deaths due to use of checklists by airline pilots). Within this intriguing and inspiring book, the 3 keys that I took away were his assertions that:

1-Memory is NOT infallible

(Human memory and attention are prone to “predictable” errors and have limited capacity to meet the complex demands imposed by modern day medical care without external support) 

2- Expertise is a double-edged sword
(Experts often have a “false sense of security” and are lulled into skipping steps even if they remember those steps!)

3- Checklists may reduce errors

(Proposed benefits of checklists include: use as a memory aid or decision aid, reinforcing positive team cohesion, and “instilling a discipline of higher performance”)

As a student physical therapist in a hospital setting for one of my clinical experiences, I found that the more patient evaluations that I had in a row, the worse my memory was for the important details of each patient. You may be thinking to yourself, “well, duh!” But, let me ask you this: as a medical professional (or translate this into expertise or profession) do you ever find yourself overestimating your ability to remember details about patients? Do you feel like you are too busy to jot down notes about patient encounters?

If you were to critically assess your own professional practices and compare them with what we know (the collective “we” being what scientific research studies tell us), you would find that we as humans consistently overestimate our abilities and this includes overconfidence that leads to medical errors in diagnosis and treatment.¹ As the authors of one study on medical errors and overconfidence write, “There is substantial evidence that overconfidence-that is miscalibration of one’s own sense of accuracy and actual accuracy-is ubiquitous and simply a part of human nature.” ¹

Furthermore, the process of evaluating multiple patients in a row (and perhaps more and more patients in one day as productivity demands increase), sets up the problem of retrieval interference. This is similar to the situation that happens when you park your car in the same parking lot every day but in different parking spaces. At the end of the work day, when you try to remember where you parked your car that morning, there is “interference” from competing memories for all the 364 days before when you parked in a different space. Similarly, the more patients that we see with similar conditions, surgeries, etc., the easier it may be to mix up details about those patients without some very diligent attention and memory strategies (i.e., the memory for details about the patient who just had hip replacement surgery may have “interference” from the three other hip replacement patients that you saw this morning).

So, back to my experience working in the hospital (acute care). As I was concurrently reading Gawande’s pleas for checklist use, I started to view my performance in a different light. Once I realized that my memory was less than stellar for multiple patient encounters, and once I also realized that there was no way I could hand write or type a full evaluation during a treatment session unless I wanted to have terrible productivity and a slightly annoyed clinical instructor, I went to work to develop my checklists. The checklists that I came up with significantly improved my documentation, my productivity, and my ability to deliver quality patient care (at least I believe they did!). Interestingly, a systematic review that I read after using checklists in the hospital, named these as three main goals for electronic checklist use in health care settings: 1-patient safety, 2-improve documentation, 3-direct treatment interventions³

One of the improvements that I feel was most in line with Gawande’s overarching message in promoting checklists was that of improved safety. I (luckily or unluckily) do not have the problem of feeling the expert’s “false sense of security.” However, the checklists served their purpose nonetheless: helping me to perform “simple” skills that were within my skill set but that needed to be performed consistently, accurately, and documented. For example, one of the items on my joint replacement surgery checklist was the type of local anesthesia used, which is important when assisting patients after surgery in ambulation and functional mobility. The difference between an adductor canal block, spinal block, or femoral nerve block can have implications for type of therapy that may be appropriate as well as guiding decisions for appropriate assistive device use, both of which could potentially decrease fall risk or even falls during physical therapy sessions following surgery.

See below for an example of one of the checklists I developed to streamline my evaluations during my acute care rotation. Also, check out these posts for more about using checklists for  orthopedic physical therapy evaluations (and links to those checklists):

“Performance Hacks for Physical Therapy Evaluations: The Power of The Checklist”

“Checklists for Physical Therapists: Re-visited”

Just as checklists can reduce surgical errors and aviation errors, I feel that there is untapped potential for the use of checklists in physical therapy and the possibility for a large reduction in errors as well as improvements in patient care and outcomes.

*Note: though Gawande emphasizes that checklists are primarily a risk reduction strategy (and not meant to be used as a learning tool), my own use of checklists has been more of a combination of these 2 goals: 1- improved safety and 2-effective learning. I am currently promoting the use of checklists in the classroom setting to assist students in learning orthopedic evaluation processes and believe that they hold value for both aims, with the caveat that the format and content of checklists may differ significantly depending on their intended purpose and use.

References:

1. Berner ES, Graber ML. Overconfidence as a Cause of Diagnostic Error in Medicine. The American Journal of Medicine. 2008;121(5):S2-S23.
2. Gawande, Atul. The Checklist Manifesto: How to Get Things Right. (2009). Picador: New York.
3. Kramer HS, Drews FA. Checking the lists: A systematic review of electronic checklist use in health care. Journal of Biomedical Informatics. 2017;71:S6-S12.

Total Joint Surgery Evaluation Checklist

• Precautions
  • WB (UE/LE) (R/L)
  • Anesthesia: spinal/Fem/ADD/peri cath
  • ROM_________________
  • THA Post/THA Ant
  • Sling/Brace/Immob.
• Check Incision/Pain/Sense
  • Incision: intact/ACE
  • Pain ____/10_____N/T
  • Sensation: WNL/_______
• HEP Exercises/MMT
  • TSA (PROM/AROM)
  • THA (qud, glt, AB, SAQ)
  • TKA (qud, glt,SLR, SAQ, Heel, Ext)
• Cooling System Education
  • Cryocuff/Iceman
• Home Environment
  • Home/ECF/SNF
  • Alone/friends/family
  • 1^st floor/2^nd floor BR
  • Steps: up______/in_______
  • Railing: No/R/L/Both
• PLOF
  • Walking: house/comm
  • Driving: Y/N
  • AD use: No/WW/cane
  • CG/Help: ___________
• Bed Mobility/Transfers
  • Sup <>sit __________
  • Sit <> stand_________
  • Bed <> BSC_____+BRP
• Gait/Stairs
  • Assist: Sup/CGA/Min A
  • AD: WW/None/other
  • Distance: 20/50/100
• DC Plan/ PT POC
  • DC to ________/c PT: Y/N
• Goals
  • Min A /c Bed Mobility
  • Sit <> stand SBA
  • Amb 100ft/stairs SBA, AD
  • Ind Precautions/HEP
  • Knee strength/ROM60°