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Checklist Manifesto for Nurses


Checklist Manifesto

I took the time out to read the highly rated book, Checklist Manifesto by Atul Gawande. No murder, no mystery, just the chronicle of how a pre-surgical checklist was developed and the research that went into it. And yet, I loved it.

Now, nurses are the kings and queens of checklists. Everything we do, practically, can be described as a checklist. Visit notes with prompts for complete head to toe assessments, OASIS assessments, and transfer/discharge documents are all checklists for the most part. We have no shortage of checklists. And it takes a lot for me to suggest one more piece of paper for nurses to include in their daily lives. But that is exactly what I am suggesting.

The Checklist Manifesto explores how a pre-surgical checklist was developed and implemented in multiple countries across the globe. The results were universal. Surgical outcomes improved. Much attention is given to pre-flight checklists for pilots with the result of decreasing plane crashes. Gawande’s supposition is that the more complex our daily tasks become, the harder it is for us to remember all the steps necessary.

The difference as I see it between pre-flight checklists and pre-surgical checklists is that surgeons and pilots pause before cutting or flying and ensure that the necessary steps have been taken to improve the chances of a good outcome. Additionally, because the checklist usually includes multiple parties working together, coordination of efforts is greatly enhanced.

As nurses, we pull out our checklists once we arrive at a patient’s home for a visit. It is when we are isolated without peers that we realize we forgot a teaching guide. Or we have driven 20 miles in bad weather only to find out that the patient was at the MD office. Where is our Pre-Visit checklist?

I have to wonder if a short checklist for home health and hospice nurses might actually improve our outcomes and reduce our utilization. In the coming years, health care reform is going to demand that we use our time with the patient as efficiently as possible.

Of course, each nurse and each agency has its variables. I don’t know if it would be possible to develop a universal checklist for all hospice and home health nurses. But, within your agency, I bet it is worth a try to come up with a short pre-visit checklist. A good start might be:

  1. Patient called prior to visit to confirm.
    1. New drugs in home?
    2. Any concerns that need to be addressed before visit?
    3. If not able to confirm, why?
  2. If another nurse made the visit prior to this visit, has report been given?
  3. Has the current 485 and all orders been reviewed prior to visit?
  4. Are all teaching materials printed and available for patient?
  5. Is there any lab or supervisory visits due?

None of the above items are missed with great frequency by most nurses. However, when reviewing clinical records, it is precisely one of these missed steps that can cause errors, duplicate teaching, missed supervisory visits, etc. In fact, it is precisely BECAUSE these errors are infrequent on an individual basis that they occur.

Nine times out of ten when I discover a trend in clinical records, education is suggested as the remedy. Like surgical teams that do not need to be taught to verify patient identity, some nursing mistakes are not the result of lack of education. Rather the complexity of our tasks is daunting and occasional oversights result in lost revenue, poor care coordination and diminished outcomes.

If you have a quiet weekend ahead of you, please read the Checklist Manifesto by Atul Gawande and let me know what you think. Or if you have already read it, please share your thoughts below in the comments section or email me.

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