The origins of the checklist!

On October 30, 1935, at Wright Air Field in Ohio, the U.S. military held a competition for aircraft manufacturers interested in building the next generation of long-range bombers. Several high-ranking military officers and aerospace industry executives were in attendance. The gleaming Boeing 299 rolled onto the runway. Made of aluminum alloy, the B299 can carry five times the bomb load the military requested; it can fly faster than previous bombers and almost twice as far. During initial assessments, a journalist dubbed it the "Flying Fortress," and the name stuck. The aircraft roars on the tarmac, takes off smoothly, and climbs to 300 feet before stalling, spinning on one wing, and crashing in a blaze of fire. Two of the five crew members are killed, including the pilot, Major Hill. The subsequent investigation reveals no mechanical problems. The accident was due to "pilot error." In practice, the new aircraft required the pilot to manage all four engines, retractable landing gear, new wing flaps, electric trim tabs that needed to be adjusted to maintain control at different speeds, and constant-speed propellers... among other things. While doing all this, the pilot forgot to release a new locking mechanism on the elevator and rudder controls. The Boeing model was deemed “too complex for a single pilot to operate,” and the military declared another model the winner, ordering only a few aircraft for testing. Boeing nearly went bankrupt. It was difficult to demand more extensive training for the pilots, as Major Hill was one of the most expert and experienced pilots in the U.S. military. Instead, an ingeniously simple approach was proposed: a checklist with step-by-step verifications (ignition, takeoff, flight, landing, and taxiing). Its very existence demonstrates how far aviation has progressed. In the early years of aviation, getting an airplane airborne could be nerve-wracking, but it was hardly complex. The idea of using a takeoff checklist would have crossed a pilot’s mind any more than a driver’s would cross their mind when taking their car out of the garage. But this new aircraft was too complicated to be left to the memory of any pilot, however expert. src="https://cdn.prod.website-files.com/61f1c5bbc327ec3679e7457c/6218dc4b36144b26cfb18ed0_vBA0s97KapRLKLSygC5PIFU71hTd4P9m276QRbigMUcMdssJA_SGFzwHZhsTzbS8eob_khWsvth7Vc8J7NSdJeFWL3oVnQpzhAmxAJTE9oX9OftkpIGeGMIwRR96jX-f0vSiwYNb.png" width="auto" height="auto" loading="auto">

One conclusion to be drawn from this story: expertise and experience do not prevent accidents!

Does this sound familiar?

What a striking parallel there is between that and today's medicine, nearly 100 years later!

In 2022, patient safety has become a major healthcare issue, and the entire SafeTeam Academy team is working to address it by developing innovative training programs. Indeed, many tools are available, but they are not always known or even used by healthcare professionals.

An example? The surgical checklist, known to French healthcare professionals as the HAS checklist, was historically promoted by the WHO and a team led by Atul Gawande, whom our founders, Dr. Martin and Dr. Jaulin, had the opportunity to meet in Boston in 2017. Atul Gawande is one of the principal authors of the seminal article published in the New England Journal of Medicine, which we encourage you to read. The surgical checklist is a tool that helps structure teamwork and provides a status update through briefings and debriefings. The checklist establishes a shared mental framework with clear objectives at each stage of the patient’s care pathway. It consists of three phases: Phase 1: Before anesthetic induction—the pause before anesthesia. This involves checking several points, including the patient’s identity, the nature of the procedure and the surgical site, the patient’s positioning, skin preparation, equipment and supplies, as well as the risks of allergies, respiratory problems, and bleeding. Phase 2: Before the surgical procedure, the pause before the incision. This phase allows for a final check of the procedure, as well as a verbal exchange of essential information regarding any potential critical issues.

• Phase 3: After the surgical procedure, the moment before leaving the operating room.

The final phase, before the patient and staff leave the operating room, provides an opportunity to verify that the objectives have been met and that the postoperative instructions are being followed.

When performed routinely, completing the surgical checklist takes an average of 3 minutes.

If this is not completed, the healthcare team exposes patients to risks that can, in turn, delay their care by several hours or even seriously endanger the patient.

Why optimize its implementation?

This surgical checklist is not always used, and when it is, it is not always implemented effectively, particularly with regard to information sharing within the team. However, when properly implemented, the surgical checklist can reduce serious perioperative complications by approximately 50%.

It also encourages all stakeholders to discuss the upcoming procedure by holding a briefing and a debriefing, thereby promoting teamwork and communication.

How can we optimize its implementation?

Our tips for improving compliance with the surgical checklist

First, it’s about raising awareness among frontline workers about teamwork and communication. This is the primary objective of our flagship training program, the one that made the SafeTeam Academy a success. This training is also the first ever designed around the checklist and was presented in 2019 at the Patient Safety Movement Foundation by the founders of the SafeTeam Academy, following President Bill Clinton’s speech, which notably led to the publication of the famous report, “To Err is Human.” It revisits the key principles of successful execution and also addresses other essential topics such as task interruptions, feedback, and other aspects of the HAS V2020 certification. We also recommend that you adapt the checklist, as surgical procedures vary significantly in terms of risk management. What are the risks in upper limb orthopedic surgery, cardiac surgery, pediatric surgery, and so on?

A case study from the Patient Safety Database, involving cardiac surgery, clearly illustrates the need to adapt the checklist. You can read about it in this patient safety report: http://www.patientsafetydatabase.com/pdf/fr/2021-01-PSR18-fr.pdf‍

Adaptation also helps the team embrace the changes more readily.

Changes to the checklist can be suggested by analyzing accidents or near misses (situations that were resolved before they caused harm).

Encourage your caregivers to share their experiences, which are very valuable to the organization because they facilitate a discussion of the effectiveness of safety measures. If all of these measures failed or if luck played a role, then the team must review the activity model.

Furthermore, in the third step of the checklist—which we recommend treating as a debriefing—participants are encouraged to think of a potential event to share with their organization. Feedback is therefore also part of the checklist.

‍SafeTeam Academy and the Checklist

Through its innovative training programs, SafeTeam Academy aims to support healthcare professionals and equip them with the tools they need to use the surgical checklist effectively. Advice, warnings, best practices… from expert healthcare professionals in other high-risk industries!

If you’d also like to help improve the quality of care at your facilities, choose SafeTeam Academy training and contact us to learn more.