5 ms·

They fail because of severe checklist fatigue according to my wife (a surgeon). Checklists are great - so let's do them for everything, ALL the time. People sta

by conorh 7y ago

They fail because of severe checklist fatigue according to my wife (a surgeon). Checklists are great - so let's do them for everything, ALL the time. People start to tune them out because they do the same checklist hundreds and hundreds of times and they often have many irrelevant things on them. The people using the checklists have little ability to change them or to improve them and so they start to suffer from checklist fatigue. As they say in the article: > “There's no point in having an item that says, 'Have the antibiotics been given?' if there are no antibiotics in the hospital,” says Dixon-Woods. The checklists that my wife uses are apparently filled with these types of irrelevant checks. Not to say that they aren't useful, they are, but as this article points out the implementation of checklists often leaves a lot to be desired.

y0ghur7_xxx 7y ago
> They fail because of severe checklist fatigue > checklists often leaves a lot to be desired. You say yourself that checklists are great, and it is proven that they save lives. So if there is fatigue in using them over and over, and they are not perfect, well... get over it? Sure i can understand that it's boring to go through the same checklist 5 times a day, but come on, there are lives at stake here. If one of your wife patients gets an infection and dies because she forgot some important, simple, step because of "checklist fatigue" how would she feel?
- fgonzag 7y ago
  You're not going to cure the human condition. If checklist fatigue is a real problem, telling people to suck it up and do their jobs is not going to work. The process needs to be improved to account for check list fatigue, it's that simple. Be it read aloud each item before checking it off, have a secondary scribe confirming and checking it off, or any other improvement that minimizes the effect of the fatigue.
- Balgair 7y ago
  The Messiah/God complex is a very real thing with MDs. It's dependant upon the enviroment and training, but a lot of them really do think that they are 'special' and that they have 'proved' themselves via the rigours of school and residency. Their sense of self is tied up into their job preformance. Like in other professions, if you 'attack' their job and their work, you are attacking them personally.
  - WalterBright 7y ago
    > The Messiah/God complex is a very real thing with MDs. That's true with pilots, too, especially fighter pilots. But they rigorously use the checklists. The pilots also know that many crashes have been traced to skipping an item on the checklist. For example, John Denver's fatal crash was due in part to failing to fuel the airplane before flight.
    - Scoundreller 7y ago
      Fighter pilots aren’t going to get paid more if they cram in an extra mission by skipping steps.
      - WalterBright 7y ago
        Fighter pilots aren't in it for the pay. They often remark that they're amazed that people actually pay them to fly. I'd forgive them for skipping the checklist if their airfield is under attack and they have to get their crates in the air or die on the field.
        Scoundreller 7y ago
        > aren't in it for the pay. Nobody ever is. But if their contract negotiator ever opens with that line...
      - rtkwe 7y ago
        It's also probably partially attributable to the fact that it's their own life on the line if they skip a checklist step like lowering landing gear. That in combination with training. It's just the cultural thing to do, everyone uses checklists, a pilot from the moment they start training is always doing check lists. It also helps that a checklist for a plane is always relevant where a checklist for a procedure is more variable.
        WalterBright 7y ago
        Their career is also on the line, even if they live through the incident. Nobody wants to keep on a pilot who is careless with at $100m machine.
- crazygringo 7y ago
  I don't think that's what checklist fatigue means -- it's not about boredom or tedium. It means that the more you keep having to skip over irrelevant items and the more you still depend on remembering other things that aren't on the checklist, the less likely any human being is to reliably follow the checklist -- because they accidentally skip over an item thinking it was the irrelevant one, or jump back to the wrong item (skipping others) because they got "off" the checklist to do steps that weren't on it. The point of a checklist is that it's supposed to be a single idiot-proof source of truth in a specified area, reducing mental complexity and therefore reducing errors. Once it stops being that because it isn't perfect, it can easily increase mental complexity which requires more brain use and increases errors. That's the fatigue. So it's not a question of just "getting over it".
  - UK-AL 7y ago
    Keeping a checklist up to date is incredibly important. If you have skip items on a list, then human error pops up again
- CathedralBorrow 7y ago
  No matter how right you might be, "get over it" is not an effective way to change human behavior.
extrapickles 7y ago
I'm currently in the process of introducing checklists into a process, and the hardest part of the entire endeavor is giving the people who are using the checklist the power to modify them, and keeping other people from forcing the system to have chiseled into stone type checklists. So far, the biggest contributor to 'checklist fatigue' among people using the system is from them not being able to modify the checklist to suit the task at hand. Checklists really need to be living documents, so errors and usability improvements can be made. The article does mention that the more proscribed from on-high the checklist was, the more the performance of the checklist was degraded.
- privateSFacct 7y ago
  100% agreed! There is the attitude of "get over it" and follow the list - that does NOT work. What does work is exactly that - make the thing useful and people will actually love it. That means local adaption, ability to update and refine. What works wonders is if you can introduce policy changes and improvements through the list. Ie, the list leads rather than follows and gets outdated.
privateSFacct 7y ago
Also did some work ages ago with a safety critical element. Checklist fatigue is real. Especially in govt compliance areas - a lot of folks have attitude of parent, get over the fatigue because this is "important". I once went to a presentation where they showed someone in handcuffs because they didn't follow the procedure. There are 100s of irrelevant items (yes - 8 track data standards compliance in some docs still) on some of these lists and people know it is total BS. The authors of the article make a great point, local adaption and implementation. The checklists that work are carefully curated and honed. I currently work in a space with lots of checklists, and I take that approach, do we still need this item? Things change. If you make the checklist useful MUCH higher compliance. That means updating and refining it so it's the reference guide for what should be happening not an endless list of all possible things one could do.
- scarejunba 7y ago
  I had a 138-page checklist during a software engineering gig. It was too ensure that my software was secure. While it was being approved (it passed, of course, the checklist being out of date and easy to meet), the legacy software (only fragments of which had source left) fulfilled the function. The legacy software was known to crash on constructed input that wasn't hard to guess. The checklist had come after the software so any software that was better than legacy software couldn't displace it if it wasn't better in every way. So if you fixed one bug and attempted to deploy you couldn't because your new version had to pass the checklist. Fascinating stuff.
JoeAltmaier 7y ago
There are solutions for that (e.g. point-and-say). Surgeons need to stop making excuses.
noneeeed 7y ago
> "The people using the checklists have little ability to change them or to improve them" I was listing to an interview with the author of The Checklist Manifesto, Atul Gawande, and he cited this as one of the main reasons why attempts to use them fail in some organisations. He seems a big proponent of the people using checklists being the ones who should write and imporve them or at least be involved, and that they be kept short and focused. They shouldn't be stuffed with needless detail, they are not instruction manuals. Checklists imposed from above without input from those who use them is just another version of beauracratic organisations imposing processes on people.

by conorh 7y ago

y0ghur7_xxx 7y ago

> They fail because of severe checklist fatigue > checklists often leaves a lot to be desired. You say yourself that checklists are great, and it is proven that they save lives. So if there is fatigue in using them over and over, and they are not perfect, well... get over it? Sure i can understand that it's boring to go through the same checklist 5 times a day, but come on, there are lives at stake here. If one of your wife patients gets an infection and dies because she forgot some important, simple, step because of "checklist fatigue" how would she feel?

fgonzag 7y ago
You're not going to cure the human condition. If checklist fatigue is a real problem, telling people to suck it up and do their jobs is not going to work. The process needs to be improved to account for check list fatigue, it's that simple. Be it read aloud each item before checking it off, have a secondary scribe confirming and checking it off, or any other improvement that minimizes the effect of the fatigue.
Balgair 7y ago
The Messiah/God complex is a very real thing with MDs. It's dependant upon the enviroment and training, but a lot of them really do think that they are 'special' and that they have 'proved' themselves via the rigours of school and residency. Their sense of self is tied up into their job preformance. Like in other professions, if you 'attack' their job and their work, you are attacking them personally.
- WalterBright 7y ago
  > The Messiah/God complex is a very real thing with MDs. That's true with pilots, too, especially fighter pilots. But they rigorously use the checklists. The pilots also know that many crashes have been traced to skipping an item on the checklist. For example, John Denver's fatal crash was due in part to failing to fuel the airplane before flight.
  - Scoundreller 7y ago
    Fighter pilots aren’t going to get paid more if they cram in an extra mission by skipping steps.
    - WalterBright 7y ago
      Fighter pilots aren't in it for the pay. They often remark that they're amazed that people actually pay them to fly. I'd forgive them for skipping the checklist if their airfield is under attack and they have to get their crates in the air or die on the field.
      - Scoundreller 7y ago
        > aren't in it for the pay. Nobody ever is. But if their contract negotiator ever opens with that line...
    - rtkwe 7y ago
      It's also probably partially attributable to the fact that it's their own life on the line if they skip a checklist step like lowering landing gear. That in combination with training. It's just the cultural thing to do, everyone uses checklists, a pilot from the moment they start training is always doing check lists. It also helps that a checklist for a plane is always relevant where a checklist for a procedure is more variable.
      - WalterBright 7y ago
        Their career is also on the line, even if they live through the incident. Nobody wants to keep on a pilot who is careless with at $100m machine.
crazygringo 7y ago
I don't think that's what checklist fatigue means -- it's not about boredom or tedium. It means that the more you keep having to skip over irrelevant items and the more you still depend on remembering other things that aren't on the checklist, the less likely any human being is to reliably follow the checklist -- because they accidentally skip over an item thinking it was the irrelevant one, or jump back to the wrong item (skipping others) because they got "off" the checklist to do steps that weren't on it. The point of a checklist is that it's supposed to be a single idiot-proof source of truth in a specified area, reducing mental complexity and therefore reducing errors. Once it stops being that because it isn't perfect, it can easily increase mental complexity which requires more brain use and increases errors. That's the fatigue. So it's not a question of just "getting over it".
- UK-AL 7y ago
  Keeping a checklist up to date is incredibly important. If you have skip items on a list, then human error pops up again
CathedralBorrow 7y ago
No matter how right you might be, "get over it" is not an effective way to change human behavior.

extrapickles 7y ago

I'm currently in the process of introducing checklists into a process, and the hardest part of the entire endeavor is giving the people who are using the checklist the power to modify them, and keeping other people from forcing the system to have chiseled into stone type checklists. So far, the biggest contributor to 'checklist fatigue' among people using the system is from them not being able to modify the checklist to suit the task at hand. Checklists really need to be living documents, so errors and usability improvements can be made. The article does mention that the more proscribed from on-high the checklist was, the more the performance of the checklist was degraded.

privateSFacct 7y ago
100% agreed! There is the attitude of "get over it" and follow the list - that does NOT work. What does work is exactly that - make the thing useful and people will actually love it. That means local adaption, ability to update and refine. What works wonders is if you can introduce policy changes and improvements through the list. Ie, the list leads rather than follows and gets outdated.

privateSFacct 7y ago

Also did some work ages ago with a safety critical element. Checklist fatigue is real. Especially in govt compliance areas - a lot of folks have attitude of parent, get over the fatigue because this is "important". I once went to a presentation where they showed someone in handcuffs because they didn't follow the procedure. There are 100s of irrelevant items (yes - 8 track data standards compliance in some docs still) on some of these lists and people know it is total BS. The authors of the article make a great point, local adaption and implementation. The checklists that work are carefully curated and honed. I currently work in a space with lots of checklists, and I take that approach, do we still need this item? Things change. If you make the checklist useful MUCH higher compliance. That means updating and refining it so it's the reference guide for what should be happening not an endless list of all possible things one could do.

scarejunba 7y ago
I had a 138-page checklist during a software engineering gig. It was too ensure that my software was secure. While it was being approved (it passed, of course, the checklist being out of date and easy to meet), the legacy software (only fragments of which had source left) fulfilled the function. The legacy software was known to crash on constructed input that wasn't hard to guess. The checklist had come after the software so any software that was better than legacy software couldn't displace it if it wasn't better in every way. So if you fixed one bug and attempted to deploy you couldn't because your new version had to pass the checklist. Fascinating stuff.

JoeAltmaier 7y ago

There are solutions for that (e.g. point-and-say). Surgeons need to stop making excuses.

noneeeed 7y ago

> "The people using the checklists have little ability to change them or to improve them" I was listing to an interview with the author of The Checklist Manifesto, Atul Gawande, and he cited this as one of the main reasons why attempts to use them fail in some organisations. He seems a big proponent of the people using checklists being the ones who should write and imporve them or at least be involved, and that they be kept short and focused. They shouldn't be stuffed with needless detail, they are not instruction manuals. Checklists imposed from above without input from those who use them is just another version of beauracratic organisations imposing processes on people.