Checklist Flows

In 2001, though, a critical care specialist at Johns Hopkins Hospital named Peter Pronovost decided to give a doctor checklist a try. He didn't attempt to make the checklist encompass everything ICU teams might need to do in a day. He designed it to tackle just one of their hundreds of potential tasks, the one that nearly killed Anthony Defilippo: central line infections.

On a sheet of plain paper, he plotted out the steps to take in order to avoid infections when putting in a central line. Doctors are supposed to

1. wash their hands with soap,
2. clean the patient's skin with chlorhexidine antiseptic,
3. put sterile drapes over the entire patient,
4. wear a mask, hat, sterile gown, and gloves, and
5. put a sterile dressing over the insertion site once the line is in.

Check, check, check, check, check. These steps are no-brainers; they have been known and taught for years. So it seemed silly to make a checklist for something so obvious. Still, Pronovost asked the nurses in his ICU to observe the doctors for a month as they put lines into patients and record how often they carried out each step. In more than a third of patients, they skipped at least one.

The next month, he and his team persuaded the Johns Hopkins Hospital administration to authorize nurses to stop doctors if they saw them skipping a step on the checklist; nurses were also to ask the doctors each day whether any lines ought to be removed, so as not to leave them in longer than necessary. This was revolutionary. Nurses have always had their ways of nudging a doctor into doing the right thing, ranging from the gentle reminder ("Um, did you forget to put on your mask, doctor?") to more forceful methods (I've had a nurse bodycheck me when she thought I hadn't put enough drapes on a patient). But many nurses aren't sure whether this is their place or whether a given measure is worth a confrontation. (Does it really matter whether a patient's legs are draped for a line going into the chest?) The new rule made it clear: if doctors didn't follow every step, the nurses would have backup from the administration to intervene.

For a year afterward, Pronovost and his colleagues monitored what happened. The results were so dramatic that they weren't sure whether to believe them: the ten-day line-infection rate went from 11 percent to zero. So they followed patients for fifteen more months. Only two line infections occurred during the entire period. They calculated that, in this one hospital, the checklist had prevented forty-three infections and eight deaths and saved two million dollars in costs.

Source: Gawande, pp. 37-39

The final WHO safe surgery checklist spelled out nineteen checks in all. Before anesthesia, there are seven checks. The team members confirm that the patient (or the patient's proxy) has personally verified his or her identity and also given consent for the procedure. They make sure the surgical site is marked and that the pulse oximeter — which monitors oxygen levels — is on the patient and working. They check the patient's medication allergies. They review the risk of airway problems — the most dangerous aspect of general anesthesia — and that appropriate equipment and assistance for them are available. And lastly, if there is a possibility of losing more than a half a liter of blood (or the equivalent for a child), they verify that necessary intravenous lines, blood, and fluids are ready.

Source: Gawande, pp. 140-157

• We collected data on the surgical care in up to four operating rooms at each facility for about three months before the checklist went into effect. It was a kind of biopsy of the care received by patients across the range of hospitals in the world. And the results were sobering.
• Of the close to four thousand adult surgical patients we followed, more than four hundred developed major complications resulting from surgery: Fifty-six of them died. About half the complications involved infections. Another quarter involved technical failures that required a return trip to the operating room to stop bleeding or repair a problem. The overall complication rates ranged from 6 percent to 21 percent. It's important to note that the operating rooms we were studying tended to handle the hospital's more complex procedures.
• Then, starting in spring 2008, the pilot hospitals began implementing our two-minute, nineteen-step surgery checklist.
• We began to hear some encouraging stories, however. In London, during a knee replacement by an orthopedic surgeon who was one of our toughest critics, the checklist brought the team to recognize, before incision and the point of no return, that the knee prosthesis on hand was the wrong size for the patient-and that the right size was not available in the hospital. The surgeon became an instant checklist proponent.
• In India, we learned, the checklist led the surgery department to recognize a fundamental flaw in its system of care. Usual procedure was to infuse the presurgery antibiotic into patients in the preoperative waiting area before wheeling them in. But the checklist brought the clinicians to realize that frequent delays in the operating schedule meant the antibiotic had usually worn off hours before incision.
• In October 2008, the results came in.
• He laid a sheaf of statistical printouts in front of me and walked me through the tables. The final results showed that the rate of major complications for surgical patients in all eight hospitals fell by 36 percent after introduction of the checklist. Deaths fell 47 percent. The results had far outstripped what we'd dared to hope for, and all were statistically highly significant. Infections fell by almost half. The number of patients having to return to the operating room after their original operations because of bleeding or other technical problems fell by one-fourth. Overall, in this group of nearly 4,000 patients, 435 would have been expected to develop serious complications based on our earlier observation data. But instead just 277 did. Using the checklist had spared more than 150 people from harm-and 27 of them from death.

Source: Gawande, pp. 140-157

The creation of the checklist was delayed by an unrealistic reliance on the memory of pilots. This dated all the way back to 1903, with the Wright brothers’ intimate knowledge of airplanes.

By 1918, with vastly expanded pilot training in the United States, a special handbook was created by Curtis for the JN-4 “Jenny.” One section was titled “Hints on Flying” and provided a list of 18 items, each with considerable detail. Five items were devoted to actions to take before takeoff, nine covered in-flight procedures and safety precautions, two advised on landings, and two discussed ways to avoid stalls and spins.

As was the case with all of these checklist predecessors, pilots were expected to know the manual by rote. Sometimes this led to hubris, which led to accidents.

The nearest relative to a post-1935 checklist is found in “Hints on the Bristol Fighter,” dated March 30, 1918, and written by the officer commanding No. 39 Squadron. The section headings are similar to modern checklist, including specific sections designed to ensure pilots see that the pressure is holding, the ignition is fully advanced, the temperature is at least 65 degrees and not over 85 degrees, the oil pressure is OK, the blinds are open, and the tail lever is forward.

The Model 299 made its first flight on July 28, 1935, flown by Boeing’s chief test pilot Leslie R. Tower. Dubbed the “Flying Fortress” by Seattle reporter Richard L. Williams, the Model 299 was the prototype for 12,730 B-17s which followed. Then on Oct. 30, 1935, with the suddenness that characterizes experimental test flights, Boeing’s great gamble seemed to fail when the beautiful silver Model 299 crashed on takeoff from Wright Field. The tragic event seemed certain to lead to the cancellation of the program and an immediate change in Army Air Corps planning.

At about 9:30 a.m. on that October day, the Model 299 was manned by a very experienced crew, including Maj. Ployer P. Hill, Wright Field’s Flying Branch chief, and his copilot, 1st Lt. Donald L. Putt. Also on board were John B. Cutting, a flight-test observer; Mark H. Koogler, also from the Flying Branch; and Tower.

Observers described the initial run of the Model 299’s takeoff as normal, even though it broke ground at about 74 mph in a “tail low” attitude. As its speed increased, the bomber’s nose went up much higher than normal. Two men, 1st Lt. Robert K. Giovannoli and 1st Lt. Leonard F. Harman, sensed it was in trouble and ran forward as the airplane reached an altitude of about 300 feet.

The Model 299 stalled, turned 180 degrees, and fell back onto a field. It landed on its left wing, cushioning the impact, which probably saved the lives of several crew. Lying flat on the field, the bomber burst into flames. Amazingly, four crew members were able to crawl from the blazing wreckage.

Source: Boyne

A board of officers convened at Wright Field to investigate the crash. The presiding officer was Lt. Col. Frank D. Lackland, for whom Lackland AFB, Tex., was later named. The board determined the accident was “not caused by”: structural failure; malfunction of flight controls, engines, or propellers; the automatic pilot; or any faulty structural or aerodynamic design. Instead, it ascribed the direct cause to the elevator control being locked.

The tail section of the aircraft was virtually all that survived the fire, but it contained the cause of the accident: an internal control lock that controlled both the elevator and rudder.

The board stated that—due to the size of the airplane and the inherent design of the control system—it was improbable that any pilot, taking off under the same conditions, would discover the locked controls until it was too late to prevent a crash. Ordinarily, pilots make checks of their movement as a precaution, but apparently this did not occur.

To avoid another accident, Air Corps personnel developed checklists the crew would follow for takeoff, flight, before landing, and after landing. The idea was so simple, and so effective, that the checklist was to become the future norm for aircraft operations. The basic concept had already been around for decades, and was in scattered use in aviation worldwide, but it took the Model 299 crash to institutionalize its use.

Source: Boyne

3-3401 A. Definition. A checklist is a formal list used to identify, schedule, compare, or verify a group of elements or actions. A checklist is used as a visual or oral aid that enables the user to overcome the limitations of short-term human memory.

3-3402 B. Criticality of Checklist Items. Checklist items can be ranked in criticality according to the potential effect of the crewmember failing to perform the action. Critical items are those items which, if not correctly performed, have a direct, adverse effect on safety. Noncritical items are “housekeeping” items or systems management items, which for operating practices must be routinely accomplished during a specific phase of flight, but if omitted would have a minimal effect on safety.

3-3403 METHODS OF CHECKLIST DESIGN. Operators may choose from at least two accepted methods of checklist design: the “challenge-do-verify” (CDV) method and the “do-verify” (DV) method. Available evidence suggests that safety is enhanced when the operator adopts and applies a consistent checklist design policy. POIs should use the following informative guidance when reviewing the design of an operator’s aircraft checklists.

A. “Challenge-Do-Verify.” The CDV method consists of a crewmember making a challenge before an action is initiated, taking the action, and then verifying that the action item has been accomplished. The CDV method is most effective when one crewmember issues the challenge and the second crewmember takes the action and responds to the first crewmember, verifying that the action was taken. This method requires that the checklist be accomplished methodically, one item at a time, in an unvarying sequence. The primary advantage of the CDV method is the deliberate and systematic manner in which each action item must be accomplished. The CDV method keeps all crewmembers involved (in the loop), provides for concurrence from a second crewmember before an action is taken, and provides positive confirmation that the action was accomplished. The disadvantages of the CDV method are that it is rigid and inflexible and that crewmembers cannot accomplish different tasks at the same time.

B. “Do Verify.” The DV method (or “clean-up” method) consists of the checklist being accomplished in a variable sequence without a preliminary challenge. After all of the action items on the checklist have been completed, the checklist is then read again while each item is verified. The DV method allows the flightcrew to use flow patterns from memory to accomplish a series of actions quickly and efficiently. Each individual crewmember can work independently, which helps balance the workload between crewmembers. The DV method has a higher inherent risk of an item on the checklist being missed than does the CDV method.

C. Selection of Design Method. Both the CDV and the DV methods of checklist design are currently being successfully used for normal checklists. Traditionally, operators have preferred the DV method for normal checklists and the CDV method for non-normal and emergency checklists. Operators have, however, successfully used the CDV method for all checklists. POIs may approve either method for normal checklists. In most circumstances, non-normal and emergency checklists are more effective when the CDV method is used. The correct accomplishment of the actions and procedures incorporated in the non-normal and emergency checklist categories is critical and warrants a methodical approach. Since these checklists are seldom used, however, crewmembers are usually not as familiar with the procedures incorporated into these checklists as they are with the procedures in normal checklists. In addition, many non-normal and emergency checklists do not lend themselves to developing flow patterns that crewmembers can readily recall. The CDV method also enforces crew coordination, cross-checking, and verification, all of which aid the crewmember in overcoming the adverse effects of stress. POIs should not approve or accept the DV method for non-normal or emergency procedures unless the operator can provide substantial evidence that the method is effective for this application.

3-3404 B. 7) In the taxi and pretakeoff phases, aircraft configuration (such as flaps, trim, and speedbrakes) and flight guidance items (such as heading, flight director, altitude select panel settings, and airspeed bugs) have proven to be critical. All flightcrew members should confirm these items, and at least two crewmembers should respond to applicable checklist items.

8) On approach, flight guidance checklist items have proven to be critical items. At least two crewmembers should confirm and respond to these items. A response should be required from each pilot when the same setting is required on two separate devices (such as computers, flight instruments, or altimeters).

9) All checklist items that are critical in the before-landing phase vary with the type of airplane involved. In the operation of small airplanes, the landing gear has proven to be a critical checklist item, and both pilots should confirm and respond to this item. Although the landing gear and flaps are critical items for large, transport category airplanes, the multiple warning devices and systems that are associated with these systems make the need for a response and confirmation by both pilots less critical.

10) All checklists, except the after-takeoff and after-landing checklists, should be accomplished by one crewmember reading the checklist items and a second crewmember confirming and responding to each item. POIs shall ensure that critical items on the before-takeoff and before-landing checklists are confirmed and responded to by at least two crewmembers.

Source: FAA Order 8900.1, Volume 3, Chapter 32

For single-pilot aircraft, the FAA recommends that operators mount the before takeoff checklist and the before landing checklist on the instrument panel by means of a placard. When aircraft characteristics allow, the operator should develop touch-verification procedures that contain a requirement that the pilot touch each control to verify it is in the correct position.

Source: FAA Order 8900.1, Volume 3, Chapter 32, ¶3-3404 B.1

Excellent article that hits close to home for any aviator willing to leave ego at the door... Experience is a ruthless de-briefer to those paying attention. The Marine Corps AH/UH community teaches you to have thick skin in the debrief or you won't survive the first year in an operational "gun squadron." Why? Because the lives of those we were charged with protecting depended upon was deadly serious business. That being said; eating our own also prevented "community learning" because we instinctively learned not to show weakness or admit mistakes for fear of dead-ending our progression in qualifications.

Contrast that with the training squadrons down in the Pensacola area: squadron-wide instructor emails telling the story of "you'll never guess what the student tried to do to kill us today." More than once, learning from some other instructor’s “Come to Jesus” moment saved me from a similar or worse fate.

A professional must admit: first to himself, then to his peers that lesson to save others from costly mistakes, near misses or worse. There is value to both schools of thought in the right environments.

Regardless, the true professional aviator acknowledges that the CHECK-LIST IS WRITTEN IN BLOOD. Disregard the seriousness of that statement at your peril. Much-ado about nothing: makes you wonder what happens in all those single-pilot IFR cockpits

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