Healthcare today has evolved and specialized and we have accumulated tremendous know-how and accomplished extraordinary things. We live in a world of great and increasing complexity, where even the expert professionals struggle to master the tasks they face. ICUs are high technology environment which are intensive, complicated and complex. The focus of care in ICU is increasingly on patient safety which sounds intuitive and has been a major focus point for all quality accreditations. Avoidable failures are common and persistent, not to mention demoralizing and frustrating, across many fields – from medicine to finance, business to government.
Checklists are vital tool in Healthcare industries which helps to guide health care professionals through accurate task completion. In hospitals, checklist plays important role in patient safety, error prevention and management. Implementation of checklists in a hospital requires a systematic and comprehensive approach. Checklists have been important tools in ensuring reliable standard of patient care. Checklists are simple and efficient tools to help comprehend, manage and improve standard of care, often puzzling care in busy hospital setting.
The Institute of Medicine’s report “To err is human” was an eye opener on the number of preventable errors in hospitalized patients which lead to mortality and morbidity. The volume and complexity of what we know has exceeded our individual ability to deliver its benefits correctly, safely, or reliably. It is important not just making the right treatment choice but making sure we apply the knowledge we have consistently and correctly – “Right care at the Right time and consistently”.
Israeli scientists published a study where they noted an average patient in ICU required 178 individual actions per day, ranging from administering a drug to suctioning, turning and every one of them posed risks. Remarkably, the nurses and doctors were observed to make an error in just 1 percent of these actions but that would still be two errors a day with every patient. The fundamental puzzle in a modern ICU is that we have a very sick patient and in order to safely save him, we have to possess the right knowledge and then make sure that 178 daily tasks are done correctly despite monitor alarms going off, patient crashing in the next bed and multiple simultaneous requests while performing a task. Guess what has made the highest impact on quality and safety of ICU care – not medications, not new procedures, but something much simpler to do but harder to implement – Checklists.
Peter Pronovost in 2001 observed steps to avoid infections when putting in a central line. Doctors are expected to wash their hands with soap, clean the patient’s skin with chlorhexidine antiseptic, put sterile drapes, wear a mask, hat, sterile gown and gloves, sterile dressing after completing. The steps are ‘no- brainers’ but it was noted that there was a breach in more than a third of patients where at least one step was skipped.
Broadly two types of checklists exist. The ‘READ – DO’ Checklist where people carry out the tasks as they check them off. With a ‘DO-CONFIRM’ checklist, team members perform their jobs from memory and experience, often separately but then pause to run the check list and confirm that everything that was supposed to be done was done. Our own experience with central line check list and ICU progress notes has been successful and efficient. The rule of thumb while creating a Check list is that it cannot be lengthy and preferably between five and nine items. Training is important but often a challenge in the real world. Using simulation similar to the airline industry the best option.
ICU checklist includes several parameters related to patient assessment and monitoring to ensure patient safety. ICU checklist primarily covers three-part including basic information, patient monitoring, and assessment. The informative part contains patient details and labeling, analgesics and sedation, Consultant’s plan of care, significant lab investigations, glycemic control and insulin dose. Patient monitoring data includes mode of feeding, Intake and Output, Ventilator settings and Oxygen requirement etc. Assessment part comprises the Glasgow Coma Scale (GCS) and pain assessment.
Checklists can serve as the methodology for reducing medical errors and improving standards of patient care. Utilization of checklists mainly focuses on patient safety. Feedback from the checklist users is imperative in checklist development since it is not static and but an ongoing process which requires expert group involvement, review and periodic updates.
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