The aviation and medical communities have reached a “critical threshold” with checklists, according to Flight Paramedic Dave Weber of Intermountain Life Flight in Salt Lake City, Utah. During the most recent Air Medical Transportation Conference (AMTC), Weber discussed checklist use in both professions, focusing on problems such as detail saturation, problem mismatch, and skill deterioration due to checklist dependency.
“We’ve reached the point that we have checklists for checklists,” Weber said. “We have so many things hanging off a belt binder, or in our iPad, that we can't find the item that we're actually supposed to be using as a checklist.”
The first use of checklists in aviation occurred after a highly publicized 1935 crash of the Boeing 299, the precursor to the B-17 Flying Fortress World War II-era bomber when the pilots failed to disengage the elevator trim tab lock. While checklists became common in aviation soon thereafter, they didn’t regularly appear in medical facilities until the mid-2000s, after Dr. Peter Pronovost published a five-step checklist for inserting catheters that reduced catheter-induced infections in intensive care units from 2.7 per 1,000 patients to zero in three months.
“The original checklists were made for completing routine procedures,” said Weber. “They were not intended for emergent procedures [such as those faced by first responders]. Later, the military started using boldface and red type to indicate tasks that must be trained and committed to memory, not looked up while fumbling around in an emergency.”
Weber said checklists have crossed the line from ensuring the most important routine tasks are done correctly to becoming “the solution” for nearly every problem. “We have become this reactionary work culture where we need fail-safe solutions immediately,” said Weber. “We have committees and meetings, and ultimately there’s another checklist instead of taking the time to find out how prevalent the problem really is, and what is the root cause of the problem.”
When the solution for every problem is another checklist, cognitive skills begin to diminish as critical thinking becomes unnecessary. Weber cited a 2013 study issued by the FAA’s Commercial Aviation Safety Team that indicated “an insufficient depth of system knowledge and/or over-reliance of automated checklist systems could lead to problems when managing unspecified failures.”
“We’re seeing rapid skill diminishment across all fields when checklists are substituted for judgment,” said Weber. “Critical faculties wither quickly once judgment is discouraged, and people are now becoming paralyzed when the problem doesn’t fit the checklist. They can’t process past that point in the checklist if there’s a problem mismatch.”
Weber’s solution for “checklist absurdity” is to streamline checklists down to include only the highest-risk procedures, and then edit those checklists to consist of five to nine bullet points. He said checklists in the field should be designed as reminders for experts who already know how to perform the tasks, not as “recipes” for beginners who are trying to use the checklist to figure it out.
“We can’t make checklists for every part of our environment,” Weber said. “Education and training are key. Boldface items need to be trained and memorized. You need to know how to nail that stuff.”