Dental Director Dr Raj Rattan MBE discusses the value of checklists

Read this article to:

• Understand why all professionals can make mistakes
• Discover the advantages of using checklists

All professionals are vulnerable to making mistakes – even the very best. Our brain is full of knowledge and experience and it is challenging to analyse and apply that information during our work without the risk of sometimes getting it wrong. There has been a proliferation of research in recent years to identify root causes, human factors and the impact of systems design within healthcare.

Workload

There are many ways we can prevent errors arising, ranging from the design of clinical procedures and effective communication to the broader aspects of working conditions and culture. Many dentists work under the time pressures created by their workload and the need to achieve targets.

Research has shown that working under these conditions can increase the likelihood of errors significantly. Many members cite time pressure as the root cause of omissions and/or mistakes as a significant factor in adverse outcomes.

In a recent case a member observed “I just wasn’t thinking properly. I was running late and we were short staffed…this was waiting to happen”. He faced a surgical complication at a time when the nurse was out of the room to locate some instruments he required for the procedure.

When mistakes arise, we must determine why the human error occurred. In other words, we must review and reflect upon the so-called causal chain. It could be a system-induced error (for example, an omission like failing to take a peri-apical radiograph for a planned difficult extraction because of time pressure) or at-risk behaviours (using an inappropriate instrument to elevate a retained root resulting in instrument fracture). For every human error in the causal chain, there must have been a corresponding reason. It is the cause of the error which then leads to prevention-based strategies, not the error itself.

One simple and effective method to reduce error incidence is to use checklists. Checklists can be easily designed according to evidence based and personal working preferences to include pre-procedure elements (such as list of required instruments, patient consent or the need for a pre-operative radiograph assessment), in-procedure elements (this may include patient communications and adherence of clinical protocols) and post-operative requirements (patient advice and follow-up care requirements, for example).

Do checklists work?

In his book, The Checklist Manifesto, Atul Gawande, Professor of Surgery at Harvard Medical School, draws on his experience as a surgeon and notes that checklists “not only offer the possibility of verification but also instil a kind of discipline of higher performance.”

He discusses errors of ignorance (lack of knowledge), and errors of ineptitude (we don’t make proper use of what we know) and suggests that clinical procedures are now so complicated that mistakes are inevitable in the stress of the moment.

In everyday decision making in clinical practice, we rely on our experience and lean towards what has been described as “fast thinking” by Nobel Prize winner Daniel Kahneman. His work on human judgment and decision making is based on the premise that people have two systems of thought – fast and slow – which are described as system one and system two thinking.

Two systems of thinking

System one – fast thinking – is largely automatic and intuitive, whereas system two thinking is more deliberate and effortful. Most of the time we rely on system one thinking; we could not cope with everyday life if every decision and act had to be logically thought through. In the context of clinical care, he surmises that physicians are taught to toggle between system one and system two thinking. He contends that workload pressures may make this very difficult to achieve, forcing us to default to system one based judgments and diagnoses.

What then is the connection between Gawande and Kahneman? The discipline of using checklists forces us towards system two thinking. It means that our decision making and intervention are fully thought out and rational.

Whilst checklists can serve as useful “aides memoire”, we must remember they are not a panacea and do not replace process simplification and critical reflection.

Resources

• Atul Gawande, The Checklist Manifesto: How to get Things Right, Metropolitan Books; 2009
• Daniel Kahneman, Thinking, Fast and Slow, Penguin Books; 2012