Far too many patients are harmed rather than helped from their interactions with the health care system. While reducing this harm has proven to be devilishly difficult, we have found that checklists help. Checklists help to reduce ambiguity about what to do, to prioritize what is most important, and to clarify the behaviors that are most helpful.
The use of checklists helped to reduce central-line associated bloodstream infections at The Johns Hopkins Hospital, in hospitals throughout Michigan, and now across the United States. Clinicians have begun to develop, implement and evaluate checklists for a variety of other diagnoses and procedures.
Patients can also use checklists to defend themselves against the major causes of preventable harm. Here are a few you can use:
Health care-associated infections
- Ask about your hospital’s rates of central-line associated bloodstream infections in the intensive care unit. The best hospitals use the definitions provided by the Centers for Disease Control and Prevention and have rates less than one infection per 1,000 catheter days. A rate above three should cause concern.
- Whenever clinicians enter your room, ask if they have washed their hands. Request that visitors also wash their hands often. Washing can be with alcohol gel or soap and water.
- If you have any type of catheter, ask every day if that catheter can be removed.
- If you are admitted to the hospital, check your ID bracelet to make sure all information is correct. Staff should use this bracelet to confirm your name before any treatments or tests.
- If you are making an outpatient visit, staff should ask you to confirm your name and another unique identifier, such as your date of birth, before treatments or tests.
- Verify that blood and other specimens taken from your body are labeled in front of you.
- Ask a nurse about your fall risk level and what steps are being taken to reduce that risk.
- Keep the nurse call bell, eyeglasses and other items within reach, and wear non-skid footwear.
- If you need assistance walking, request help before the need to use the bathroom becomes urgent.
Venous thromboembolism (blood clots)
- Ensure that you are screened by clinicians to identify your risk for blood clots.
- Given your risk category, ask what treatments you should receive.
- Ask every day if you are getting the treatments you should to reduce blood clots.
Communication and teamwork errors
- When you enter the hospital, be familiar with what medications you are taking, your allergies, and your complete medical history.
- Ask to participate in daily interdisciplinary rounds.
- If you are confused about something regarding your treatment, ask for a “bedside huddle” with the care team to make sure they come to you to address your concerns.
- Ensure you will be able to care for yourself when you leave the hospital by reading back your discharge plan and ensuring that you know:
- Your treatment
- What risks to watch out for and what to do if they occur
- Follow-up instructions— Which provider you should visit, how soon, and when this provider will receive the records from your hospital stay
To help reduce harm, clinicians must partner with patients and families. Patients can use this checklist, as well as the information and tools listed below, to help keep them safe.
- 20 Tips to Help Prevent Medical Errors(Agency for Healthcare Research and Quality)
- Don’t Become the Victim of a Surgical Error (CNN)
- Medical Errors: Tips to Help Prevent Them (American Academy of Family Physicians)
- My Health Notebook (Johns Hopkins Medicine)
- Patient Handbook (Johns Hopkins Hospital)
- Patient Safety Video (Johns Hopkins Hospital)
- Patient Safety Checklists (Campaign Zero: Families for Patient Safety)
- Taking Charge of Your Healthcare (Consumers Advancing Patient Safety)
Director of the Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality, Peter Pronovost, MD, PhD is a practicing anesthesiologist and critical care physician who is dedicated to making hospitals and health care safer for patients. Pronovost has chronicled his work in his book, Safe Patients, Smart Hospitals: How One Doctor’s Checklist Can Help Us Change Health Care from the Inside Out. His posts will appear occasionally on THCB and on his own blog, Points from Pronovost.
This is an interesting topic which sees both room for improvement and simultaneously illustrates the amazing things our healthcare system has accomplished.
As a medical student, I have been impressed at the efficiency and systematic manner in which checklists are used in the operating room. Surgical checklists, introduced years ago, have become more widely adopted. From before the surgery, when “time out” is done to confirm details of the surgery, to a rapid-fire oral checklist of every surgical instrument including sponges, etc are done at the end of the surgery, there seems to be almost no room for error.
I was impressed to find that during one surgery, it was unclear whether a particular surgical instrument had been accounted for and the nursing staff literally sifted through bags and bags of trash in the OR searching every single bloody glove, sponge, etc until it was found, prior to the patient being closed up.
Regarding hand-washing, I have been impressed to see that a quick pump of purell has become second-nature for the vast majority of health care providers I see around the hospital. While there is so much room for improvement, I have to say that the introduction of checklist and such regulations in hospitals have done wonders.
Peter, what this flags is an important topic: how can and should individuals be involved in patient safety beyond the “Did you watch your hands?” question on the one hand and hiring an advocate/nurse to sit by the bed 24/7 on the other.
Having gone through a bit of this recently with my wife (see my post on this site a few months ago: https://thehealthcareblog.com/blog/category/michael-millenson-contributors-2/), I would suggest that the approach you suggest works best in hospitals that have already started down the road to better patient safety and have begun to look at patients as their partners. Others — perhaps even the most dangerous — will sometimes not respond very positively to questions from patients or their families. Which doesn’t mean you shouldn’t ask the questions.
An increasingly sophisticated doctor-patient partnership is the direction in which we need to go.