1. TOOLS FOR PERFORMANCE IMPROVEMENT – Can the checklist BE the answer?

2. Institute of Medicine Report
Consequences of Medical Errors:
44,000–98,000 annual deaths
resulting from medical errors

3. Institute of Medicine Report
Consequences of Medical Errors:
More Americans die from medical errors than from
breast cancer, AIDS, or
car accidents

4. Institute of Medicine Report
Consequences of Medical Errors:
7% of hospital patients experience a
serious medication error

5. Institute of Medicine Report
Consequences of Medical Errors:
Cost associated with
medical errors is
$8–29 billion annually

6. Communication Failure is Leading Root Cause

7. Communication Verbal or Written
Sender Receiver
Barriers

8. Communication Barriers
Noise and distractions
Personality conflicts
Complex nature of the information
Fatigue due to inadequate staffing
Time constraints
Information overload

9. Communication failures
Misinterpretation
Misunderstanding
Inattention
Not remembering

10. RN Communication failures
May involve:
Medications
Allergies
Treatments
Physicians orders

11. Ctic top 5 communication failures
Current health status
Current name and phone for Family/Emergency Contact
Current Med List (including date and time of last dose
Respiratory needs (includes setting)
Known allergies

12. error management
Checklists are key tools in reducing mistakes, improving outcomes and reducing cost.

13. Use of Checklists
Aviation- checklist highly regulated and a mandatory part of practice.
Aeronautics- best practices were based on several checklist.
Product manufacturing- checklist ensures proper operating procedures and maintains standards of quality
OR – prevention of wrong: side, site, procedure, person

14. Research on checklist intervention and its impact on patient safety
Safety Attitudes Questionaire (SAQ):
Evaluated coordination of care
Risk for wrong site surgery
Results showed a reduced risk for wrong-site surgery and improved collaboration

15. Checklists can: Provide guidance
Act as a verification after completion of a task
Decreased complexity
High reliabilty

16. Checklists objectives:
Memory recall
Standardization and regulation of processes
Provides a framework for evaluations
Prevent errors
Maintain focus and clarity

17. Purpose of checklist Defense strategy to prevent errors
Memory aid to recall task
Facilitate team coordination
Create and maintain a safety culture

18. Checklist method Call-Do-Response Do-Verify Combination of Both
Examples: wrong site surgery, unknown med hx, unknown baseline functional and cognitive

19. Diagram of checklist implementation

20. Frequency-by-consequence table

21. conclusion
Communication Failures can have severe consequences on patient safety.
It takes a team effort to communicate effectively.

22. References
Hales, B.M., Pronovost, P.J. (2006). The checklist- a tool for error management and performance improvement. Journal of Critical Care. 21, doi: /j.jcrc
Verdaasdonk, E.G.G., Stassen, L.P.S., Widhiasmara, P.P. Dankelman, J. (2009). Requirements for the design and implementation of checklists for surgical processes. Surgical Endoscopy. 23:
Hales, B., Terblanche, M., Fowler, R., Sibbald, W. (2007). Development of medical checklists for improved quality of patient care. 20, 1,