H e lCo ol AMa Ca
orglow1. Static parallel checklists typically are
of magnesium sulfate for neuropro-
Thesolely those of the author(s) and do notrepresent an endorsement by or the views oftheDe
ecoffecis rionl he
Reviews www.AJOG.orgread and performed by a single indi-vidual. Published oxytocin adminis-tration checklists and those govern-ing the use of anesthetic equipmentare examples of this approach.3,16
2. Static sequential checklists with verifi-
tection of premature infants and themanagement of hypertensive crisis inobstetrics (Figure 2).2,20 Checklistscurrently being developed for themanagement of category II fetal heart
United States Air Force, the Department offense, or the United States Government.
authors report no conflicts of interest.
2-9378/$36.00blished by Mosby, Inc.TIENT SAFETY SERIES
ow to develop an effl M. Bardett Fausett, MD, USAF, MC; Cjor Karin Van Doren, MSN, USAF, NC;
n recent years, the use of protocolsand checklists to guide care in select,tical situations has become a major fo-s of efforts to improve patient safety inth medical and nonmedical profes-nal endeavors.1-6 We present in thisdy a review of general principles of
ecklist development, and an examplethe process as implemented in a mod-te sized health care systemtheited States Air Force Medical Corps.
As early as 1999, the use of checklistss advocated by the Institute of Medi-e as an integral part of a larger effort tovent medical error in the US healthe system.7,8 The Institute of Medicine
s stated that the standardization of keycesses with the use of checklists andtocols is a key to the prevention of
ors in health care systems and listeddefinition of standards of practice as a
mary role professional organizationsuld take in creating a culture of
ety.7 Many specialties have adoptedse recommendationsFigure 1 de-
ls the exponential growth of publica-ns indexed by PubMed under safetyecklist in the past 3 decades.
m the Wilford Hall Medical Center (Colsett, MD), Lackland AFB, TX;iformed Services University of the Healthences (Col Propst, MD), Bethesda, MD;iano Air Base (Major Van Doren),iano, Italy; McGuire Air Force Baseaptain Clark), Lakehurst, NJ.
ceived Feb. 14, 2011; revised May 19,1; accepted June 2, 2011.
prints not available from the authors.
opinions expressed on this document arei: 10.1016/j.ajog.2011.06.003ctive obstetric checknthony Propst, MD, USAF, MC;ptain Benjamin T. Clark, USAF, JAGC
The use of checklists has been demon-ated to be effective in improving out-mes in a variety of clinical settings, in-ding the prevention of central-lineociated infection, reduction in venti-or associated pneumonia in adultsd children, improved compliance withnical recommendations for the man-ment of acute myocardial infarction
d stroke, the administration of generalesthesia, diabetes care, and improvedcision making in the diagnosis of brainath.1,2,9-16 General acceptance of theed for checklist-guided care in obstet-s has been slower, and largely limitedthe past few years. Most efforts haveen modeled after the groundbreaking
grams developed by the Hospitalrporation of America to standardize
monitoring and administration ofytocin, misoprostol, and magnesiumfate, and the documentation of thenagement of shoulder dystocia.3,4
ese approaches have been shown tonificantly decrease both adverse out-mes and obstetric litigation in the na-ns largest obstetric health care deliv-system.4
Checklists adopted by high-reliabilityanizations typically take 1 of the fol-ing 4 forms2,17:
Checklists to guide critical procedures are bmedical practice. These tools have proved eof medical settings, including obstetrics. In thsuccessful checklist creation and implementatdevelopment in a worldwide, multiinstitutiona
Key words: checklists, obstetric emergency,(USAF)cation involve a challenge and re-
SEPTEMBER 2011 Americist
sponse approach in which one in-dividual reads a list and a secondverifies completion of the requisitetasks. Many aircraft safety check-lists, as well as those used for centralline insertion and the administrationof blood products are examples of thistype of checklist.2,10,18
Static sequential checklists with verifi-cation and confirmation are typicallyused in larger team settings in con-trast to a team of 2 as above. Suchchecklists are typically read by oneteam member with verification oftask completion by multiple addi-tional team members. Comprehen-sive operative room time outs oftenuse this approach, which may also beapplied to the management of shoul-der dystocia (Figure 1).2,19
Dynamic checklists generally take theform of flow charts to guide clinicaldecision making. Flow charts lend toa visual display that is particularlyuseful when dichotomous decisionsfollow to different subsequent check-list items. Such checklists have beenused to guide the intubation of pa-tients with difficult airways, and morerecently to assist in clinical decisionmaking regarding the administration
ming an increasingly important part oftive in improving outcome in a varietyeview, we outline essential principles ofand review our experience with checklistalth care delivery system.
ient safety, United States Air Forcerate tracings will also likely take thisform.
an Journal of Obstetrics& Gynecology 165
Fau tet G
Reviews Patient Safety Series www.AJOG.org
16Despite the evident importance ofecklists to patient safety and qualityprovement, no universally acceptedcesses exist for the effective develop-nt of medical checklists. Publishedommendations regarding checklist
velopment tend to suggest the impor-ce of several key areas of checklist de-opment.1,2,4,11,15 This approach mayoutlined as follows:Choose your clinical processes care-fully. Not all medical conditions orprocedures are amenable to manage-ment by checklist. In selecting pro-cesses or procedures for checklistdevelopment we suggest followingclosely the requirements set forth bythe National Quality Forum forquality metric development.21 Thefollowing questions should be criti-cally addressed for each potentialchecklist topic:a. Is the topic of high importance? Is
it currently associated with signif-icant numbers of poor outcomes?Is there a gap between recom-mended and actual performancein your facility or community?
b. Is there a scientifically acceptableapproach to effective diagnosisor treatment of the condition inquestion? Although the manage-ment of shoulder dystocia meetsthis criterion for checklist devel-
FIGURE 1PubMed safety checklist articles
sett. How to develop an effective obstetric checklist. Am J Obsopment, the management of am-niotic fluid embolism does not.
6 American Journal of Obstetrics& Gynecology SEc. Does the development and im-plementation of a checklist havethe enthusiastic support of se-nior and respected departmentmedical and administrative lead-ership? Without such support,change will be slow, painful, andineffective.
d. How intrusive will such a protocolbe in the overall scheme of patientcare? Will its implementation in-terfere with other, more criticalprocesses? Will resource use bematched by expected clinical ben-efit? Does implementation of thechecklist run the risk of devaluingother, more important checklists,and the development among clini-cians of checklist fatigue.
Processes are ideally developed byrepresentatives of all groups (physi-cians and nurses) expected to imple-ment the checklists. Often, an arbi-trary initial straw man protocolwill serve as an effective templatefor effective and efficient discussionand modification. Efforts of suchworking groups must be supportedby strong clinical and administra-tive leadership.Checklists should be short and unam-biguous. It is better to break a com-plex process into several short, spe-cific checklists rather than deal with a
ynecol 2011.single cumbersome process.resto
PTEMBER 2011Leave room for clinical judgment inexceptional cases. With a properly se-lected topic and a properly con-structed checklist, such exceptionswill be rare, and should be routinelysubject to peer review.Checklists should be reviewed fre-quently to assure ongoing compli-ance with new data and changingstandards of care.
Incorporation of a checklist-basedtocol approach to high-risk obstetric
nditions seemed especially well suitedpatient safety efforts of the US Airrce Medical Corps for several reasons.First, military aviation was the birth-ce of the checklist-based approachreducing error in critical and com-x situations, and is commonly cited
the inspiration for such practices ad-ted by other high-reliability organi-ions.1,2,4,18,22,23 This concept wasrn out of the experience of the USmy Air Corp with the B-17 bomber inorld War II. After the crash in 1935 oforiginal prototype during an initialht demonstration, the B-17 was
emed too much plane for one man to.24 This realization led to the devel-ment of an entirely new approach toing in which most critical portions of
operation were guided by uniformecklists; pilot autonomy was purpose-ly made subordinate to guidance bych protocols. In the next few years,
B-17 went from an abject failure toworkhorse of the American war ef-
t and was a major factor in the even-l Allied victory. Ever since this ex-