Checklists

by Honolulu Mother

Atul Gawande now has a book out based on his 2007 New Yorker article on the use of checklists in medicine, piloting, and other fields:

THE CHECKLIST

The Checklist Manifesto: How to Get Things Right

His basic take is that although those doing complex work are reluctant to adopt a tool so simple as a checklist, they have proved a very worthwhile way to reduce costly errors and improve outcomes.

Do you use checklists for work or home tasks, or do you create checklists for others to use? How helpful do you find them?

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86 thoughts on “Checklists

  1. I find checklists crucial in accounting, we have a consolidation checklist, even though I am sure I could do the process without it, it is so very important not to miss a step and is also useful for the audit

  2. After reading that New Yorker article, I became a total believer!

    Agree with winemama in its use in Accounting/Finance. I have had very good luck using checklists at work for tasks that are done every month. It’s a good internal check and also useful for audits of all kinds (internal, client, etc). I find that they are most useful for tasks that have a lot of steps, but are not difficult. In that situation, it is too easy to go on autopilot and forget a simple step that throws everything off or miss one small thing that will have a big impact.

    I don’t use them at home. Nothing is that critical. But I do use lists.

  3. People tend to think of ERs as the place where the sickest patients are in the hospital. That is rarely true – usually the ICU has the patients most likely to die. It makes sense to bring order to their chaos. They have 1 nurse for every 1-2 patients, and control over their flow. No more nurses/beds? Refuse to take new patients! Shift change? No new patients!

    I have come of age in the checklist period, and I don’t find them helpful. Unlike with anesthesia, airline flights, and central lines in the ICU, we cannot guarantee adequate staff, supplies, etc and refuse to proceed if we can’t meet all the conditions. Patient not fasted? No surgery! Pilot not rested? No flight! No one can find the full body drape? No central line!

  4. I think often the word “checklist” seems too simplistic. When I think of checklist, I think of list of words or short phrases that is used as a reminder vs a more detailed list of steps. In my work life, I tend to have more detailed process lists. For example, in my prior job I had about 10 tasks that only were performed once a year or once every other year. When I took the job no checklist or process or even a file from the prior time the task was performed was available. So, I documented the processes I used and in some cases included print outs of certain sources where certain data came from highlighted to it was easier to find again.

    At home, I use lists a fair amount. From grocery lists to lists of things the DDs need to do to lists of things I need to do for a volunteer group.

    A long time ago, I went to a training. The speaker said, the more you have on your plate, the less likely you are to remember to do everything you need to do and/or you committed to do. Writing it down – in a list or as a deadline on a calendar or whatever makes sense to you – frees you up from the worry you will forget or worse the embarassment or other negative consequence.

  5. I remember that New Yorker article. It was as good a justification as I’d ever seen for why we had to be so checklist-oriented for the stuff we did on the boat.

  6. I, too, am a big user of lists for my daily tasks, groceries, and what to cook for the week. I do not use check-lists at work, though.

  7. I agree with Ivy–the article was enough to convince me, and checklists are best for the kind of “easy” things where it’s easy to screw up.
    ” Patient not fasted? No surgery!”. I had that happen to me once, for a colonoscopy. I had done the shorter fast, but there was also a longer period with restricted foods. I ate one of them towards the beginning of the time. They put me under, took a look, woke me, and told me to fast the whole time, do the “cleanse” routine in the morning, and come back at some incredibly early hour the next day. I did not see what their would be to clean out with no food going in for so long, but I absolutely followed those instructions.

  8. I’m definitely a list person – I have “to-do” lists at both home and work and a pad of paper at home for the grocery list. I’ve trained both my kids to use the grocery list – just wish I could get DH to do the same.

  9. I like checklists or process lists. I am not super detail-oriented by nature esp. when it comes to the mundane admin stuff (probating an estate is a good example), so having a checklist of tasks for that is really helpful.

  10. When we started sailing, kind of late in life, we created a checklist for when we went out. The “old salts” remembered things like it was obvious, but for us, it was hard to remember the dozen or so “quick checks” we should do before setting off. It made us laugh that between the two of us, we just couldn’t remember every one. – so many distractions, different conditions, preoccupation with weather, guests, food, etc. The checklist was vital!

  11. I use checklists at work, just to make sure I don’t forget anything. However, I do find that people use them too rigidly and don’t think outside the list or realize when something on the list doesn’t apply.

    What I find more useful though, are to do lists, prioritized by “must do today” to “due tomorrow” to “can wait”. I use those both at home and work. I may have picked that up from Franklin Covey.

  12. I clearly need a checklist, because I came back from a trip into the second workday of close and failed to make an entry I make once per quarter because it never entered my mind.I cannot carry the volume of info in my head that I once could, and am much more affected by lack of sleep than I once was. I did make a checklist for packing for the trip, then never consulted it. I do use lists for shopping, but I consider a checklist to be a little different.

  13. I use shopping lists and to-do lists. Like Ada, I don’t find default checklists to be very helpful at work, in large part because I work in a nonstandard area for which the default checklists don’t apply. Then I have to spend time/hassle explaining my situation to the checklist police.

    We have lists for camping and backpacking but one of the challenges of a baby is that the list you used last time doesn’t fully apply this time.

  14. Some positions I have worked in, came with well documented checklists with information on where the files were located, instructions on what to do in the files and a list of contacts. This type of information was required because at some point there was a “knowledge gap” and if this wasn’t written down somewhere, there would be lots of time wasted figuring out what all to do, let alone actually doing it.
    Some positions had nothing written down. One of my colleague’s career was derailed completely by lack of a work list. She was taking over from a woman perceived to be a star performer who was going on maternity leave. That woman had nothing written down nor did she give my colleague any time to go over things. Also, that woman’s work was a mess. The result was that my colleague floundered in the role, her reputation suffered and she was let go in the first downsizing.

  15. I’ll add to my previous comment that I find the documentation helpful when I start a role but don’t use it after I have been there a while. I do keep things updated in case I have to transition things in a hurry.

  16. I am looking at my “to do list” right now. It’s silly things like make stock, vacuum, what I need to get at Publix and calling the contractor for our kitchen reno. It’s not that I can’t remember these things, it just keeps me on track because I like to cross the items off of the list.

  17. Atlanta, you foresaw the question I was going to ask: do list-makers here get satisfaction from crossing things off that list? Life advice that emphasizes list-making nearly always talks about that great feeling. It doesn’t happen for me, partially because most tasks can be broken into so many parts (cleaning the living room includes picking up stuff, vacuuming, and dusting. Picking up includes things from various tables and things from the floor, which then have to go to their respective homes. Vacuuming includes pulling certain pieces of furniture out and putting them back., etc) If I break everything down to such detail, it’s silly. If I leave it in big chunks, there is rarely a moment when I can say it’s done. There are often days between those various parts of a job, such that one part needs repeating by the time the last is done.

    When I do make lists, I tend to be like MBT and not look at them again. Their function is to help me organize my thoughts and get everything in one place. Once I’ve done that, I’m usually good to go.

    WCE, that’s the best and worst part of little ones! It is so fun to see them grow and learn new things, but just when you think you’ve figured out a good way to make everything click, they grow and change everything on you!

  18. The kids (even the one who can’t read yet) have lists for their morning, after school, and evening routines. I post them on the bedroom doors and on the refrigerator.

    For a while I had them check off each item but that got messy, and then we moved to magnetic and Velcro tokens. None of that worked for us so we just have the lists as a reference.

    I also have a list of chores I am supposed to do every day on the refrigerator. It is ignored :)

  19. “it just keeps me on track”

    Exactly. Checklists are my life. Every day I make a list of of things to do (TTD) with an asterisk by the most critical tasks. Prioritizing by the asterisk method has been a real game changer in improving my productivity.

    I have long relied on lists in all aspects of my life. My babies’ diaper bags had a list tucked inside to help me make sure I had all needed items as I went out the door. One job I had required me to be on 24-hour call in the field and to notify muckety mucks when important decisions needed to be made. I quickly learned to create checklists to make sure I had covered all bases and had all the critical facts lest I wake up the head honcho at 2am needlessly because I couldn’t answer his questions. It only took one time for that to happen to make me realize I needed a list.

    I do worry that relying excessively on lists contributes to the decline of my memorization skills.

  20. Louise – One of the main lists I use now started out as a list for my replacement while I was away on maternity leave. It was very short then and now is very detailed. Even with it, my boss is nervous (used to be a full blown panic) every time I am out of the office. I deal with a lot of short deadlines.

  21. “I do worry that relying excessively on lists contributes to the decline of my memorization skills.”

    To prevent this, I will store a few things in memory and not write them down. My list has grown because of being the point person for my family. What I have tried to do, is get people to do their own tasks. So, I tell kids and parents/in laws where to find the information, make the calls/talk to the teacher etc. and move items off my list onto theirs.

  22. ” I will store a few things in memory and not write them down. ”

    Incomplete lists are the worst, imo! When there is a list, I rely on it and often don’t think through everything myself–I figure that’s what the list is for. I do better with no list than a partial one.

  23. I am actually a big list maker. I like to-do lists, packing lists, etc. My dad had a single camping trip list that came out everytime we took the trailer anywhere (axe, gun, hot dog skewers, etc.) – he used that same list for years.

    In medicine, we have long relied on and passed along mnemonics for remember what needs to be done for a procedure. I never prepare to intubate without invoking the SOAP mnemonic – I need Suction (is it hooked up and working), Oxygen (is there a bag-valve-mask hooked up), Airway (plastic tube) and Pharmacopeia (drugs to paralyze and sedate). However, the hospital checklists are created, validated and applauded based on studies of places where you always have a Respiratory Therapist available, you always have a pharmacist for critical care applications, and the nurse is experienced in critical care.

    What comes down the pipeline for us is something like this: http://scghed.com/2013/05/the-emergency-department-pre-intubation-checklist/ – which indicates 45 separate boxes to check prior to starting, as well as assigning roles to six different people. I intubate infrequently these days, due to my work environment, but I never have six people to assist me. Also, if no one can find the capnography wires or I don’t have great IV access, do I just wait for those things while the patient gets inadequate oxygenation?

    So, I love checklists. I probably will make one right now so that I accomplish some things in the lull I have before heading into work in a few hours. But the “well-validated”, checklist by committee that is required before I do procedures? Not helping.

  24. WCE – when our babies kept getting older, I would revise the packing list every time and save it as a new doc (I use Google Docs for these) – then when 2 years later we had another, I could go back to the previous list for that stage. :)

    Ada – what does the hospital/practice management say if you point out that following the checklists is impossible?

  25. L, I am impressed. The detritus of my everyday life, including lists, disappears into oblivion. I tend to be kind of disorganized electronically, plus stuff happens (dropped iPhone in toilet) that has caused me to be reluctant to rely on electronics.

    I write lists for the boys to pack from when we go somewhere.

    I conscientiously write the groceries we need on the refrigerator whiteboard and then sort it by area of the store when I copy it to paper. At my favorite store, I know where everything is by aisle.

  26. Also, if no one can find the capnography wires or I don’t have great IV access, do I just wait for those things while the patient gets inadequate oxygenation?

    No, you just need to know that those things aren’t available and proceed accordingly.

    I get what you’re saying though. People get way too caught up in the process and lose sight on what they are actually doing so you need to find a balance.

  27. I write a list on a sheet of paper whenever I’m packing for a trip. Making the list is part of the fun, I’ve mentioned before my love of list making

  28. We put our grocery lists on Google Keep. It is shared among house email accounts, so everyone old enough can add things to the list.

  29. I conscientiously write the groceries we need on the refrigerator whiteboard and then sort it by area of the store when I copy it to paper.

    I do exactly the same thing. Do you also portion the whiteboard into Costco/Sam’s, regular grocery, and other? (And do your kids keep putting stuff in the wrong section?)

  30. My kids write in letters an inch high and they don’t understand the sections yet. I apportion the whiteboard into groceries, non-grocery stuff I need to buy, and occasionally have a corner for Costco/Trader Joe’s if we need something there. Mr WCE works by Trader Joe’s so he often will stop there if I want a few things.

    Part of my problem on list re-use is that sledding, crabbing, fishing, trips to Iowa, camping in the camper, traveling on vacation and backpacking all have different requirements. For example, the boys need to wear their snowpants when crabbing or they get cold, wet and cranky.

  31. WCE – I also have different packing docs – summer, winter, camp vs beach house, etc. I use my chromebook or laptop at home (or at work, if I forget something!) to edit.

  32. Things I swore I would never do/Things I’m doing right now: be that person hitting “refresh” over and over again when swim lesson sign up time comes around, so I can get exactly the right class.

  33. Why did you swear you would never do that, Ada? Seems perfectly sensible. I swore I would never do stuff like smoke meth, and so far, so good.

  34. We used packing lists after one of the boys was allowed to pack on his own, sans list, for a beach trip and had no shorts in his bag.
    I did not get a white board for grocery lists until just this summer, long after I really needed it, but I just take a picture of the list instead of writing it down. Sometimes, I forget to take that picture and have to rely on my mental memory of the list, which is better than nothing but still.

    On the larger checklist issue, coming up with short, easily remembered mantras helped a lot. For swim goggles, I told the boys that the goggles should be ON their head, IN their hand, or IN their swim bag. Nowhere else. That stuck, for some reason. One of the loops on the video monitor at Ohio Turnpike rest areas features a state trooper saying “Drivers need to keep their HANDS on the wheel, their EYES on the road, and their MIND on driving. Texting while driving violates all three rules.” That was another keeper for youngest DS, who unfortunately witnesses his father as a very bad example. I repeated it several times after we got back into the car, mostly for the benefit of DH rather than DS.

  35. Because I always figured the kind of people that did that were crazy and had too much time on their hands. Also, that level of planning is really outside my comfort zone. And it interferes with time I could better use to check things off my lists, like “smoking meth”.

  36. Ada – I went down that path with pre-K private school admissions. I did not stand in line outside one of the Montessori schools like some of my neighbors, but addictive checking of online stuff, yes, completely. You have to do what you have to do.

  37. Ada – the admission form receiving office for the elementary school I wanted DS to attend was close to my office, so I dropped off the forms in person bright and early on the first possible day to make sure they reached safely. The woman was astonished and kept protesting that I should have just mailed them in.

  38. Writing grocery lists according to store layout doesn’t work for me because there are several grocery stores in a couple different change that I might go to, depending on what else is happening/where we are. I write the lists in any old order, go through the store tossing in things by memory, and then double-check by consulting the list while waiting for the cashier. Yes, I am occasionally that person dashing back for “one more thing”. Last week I was reminded before I got to the register, as I passed a women wearing a shirt with a cartoon about coffee. I thanked her and headed to that aisle. If we pull the list out while shopping, it is because DS has cut coupons. He will assign me a few items at a time, which must fit descriptions on the coupons. It’s probably been sliver a year since he was interested in doing that, although he does plan to look up coupons for his school supplies, so he can get a price adjustment. He bought them and the groceries himself while I was in the store bathroom.
    My mom puts her grocery list in store order the first time around. Items that come later in the route through the store are written further down the page. It works for her.

    WCE, I see it the other way around: anything on paper can and probably will be lost or ruined, but data bits are forever, and can be retrieved with a simple “search” command.

  39. I loved the original article and have often thought that I would be suited to establishing processes for hospitals, a job that doesn’t exist.

    It’s interesting to see what different grocery shopping styles we have. Especially when I have to grocery shop with all 4 kids, I am extremely rigid- try for only one stop, conscientiously plan to make one trip through the store, avoid going during the first 3 days of the month and don’t hunt for anything nonessential. Fortunately, the boys are headed back to school so I won’t have to grocery shop with everyone for a while.

  40. I would be suited to establishing processes for hospitals, a job that doesn’t exist.

    What makes you think that job doesn’t exist?

  41. WCE, 4 kids is as big as my son’s fourth and fifth birthday parties. When it was just the two of us, and he was little, grocery shopping was a learning experience with lots of sweet discussion. Were you to attempt that, it would be like a preschool class with differentiation for nearly every student.

  42. when I have to grocery shop with all 4 kids

    Do any of them ever make a sudden break for it when you’re stuck in the checkout lane? I had that happen at least once shopping with 3. I sometimes have a pause-and-be-grateful moment when I realize that no matter how far back into the aisles the Costco line is stretching, I don’t have to worry *at all* about keeping any accompanying helpers detained while I wait.

  43. “Especially when I have to grocery shop with all 4 kids, I am extremely rigid- try for only one stop, conscientiously plan to make one trip through the store,”

    We do most of our grocery shopping at Costco, which has a book section, and usually has a furniture section. When they were younger, the kids would treat it like Border’s, and grab a book and head to the furniture section while DW and I browsed through the store and got our groceries.

  44. I took all of the kids grocery shopping today. I pushed around one of those terrible carts with a cozy coupe attached. As a reward to myself, they are all watching a cartoon right now. It was a beautiful day when the youngest has the attention span to get through an entire show.

  45. Rhett, I was told by a local hospital IT guy at an informational interview that process improvement was considered a career-advancement for nurse’s here and that no localish hospitals will consider people without medical backgrounds. Maybe the job exists, but I don’t have the credentials or an easy way to get the credentials to do it.

    HM, only Baby WCE is at a destructive age. Going now makes me glad I no longer have to go with three destructive children.

    Fred Meyer (Pacific Northwest Kroger affiliate) has started offering online grocery shopping at some Portland locations, where you can just order and pick up your groceries. It’s not here, though.

  46. @RMS – I like picking out my own produce & meat, checking the expiration dates on the eggs and bread, and all that kind of good stuff. But I’ll use Peapod or Instacart if I’m really short on time.

    I also rarely have to take even my one kid to the store with me, so it’s easy for me. I use electronic lists because it’s easier to check things off by clicking on them in the store, and everyone can add to the list from all devices.

  47. Does anyone else have a really hard time getting screens, in general, to click/respond where you want them to? I have the problem occasionally on phones and my Kindle. It’s one of the reasons I don’t like using electronics very much. I don’t know if part of it is my handedness (I’m left-handed- do I come at it from a weird angle?) or my coordination or what. In some cases, I’ve found my Kindle is just “busy” and it works after a pause. But I’m not patient.

  48. WCE, yes. I’m still trying to get used to my iPhone keypad, which I think is the reason their ‘autocorrect’ is so aggressive. I miss the Blackberry keypad, which was so much better, but got me into habits not compatible with an iPhone.

    I’ve had that issue with my kindle too. I find that shutting it down completely helps, as does deleting some stuff when the drive is getting pretty full.

    I don’t think your handedness should matter. Do you just use your left hand? I think most people use both thumbs.

    BTW, anyone else have problems with ear dialing?

  49. Checklist for syllabi being taken very seriously in higher education. I assume the prof is using this to make a point about all the ways instructors are encroached upon and asked to jump through an ever-growing series of hoops, and his chair has his point too. https://www.insidehighered.com/news/2016/08/08/should-professor-lose-his-job-over-refusing-put-learning-outcome-his-course-syllabus?utm_content=buffer85b0a&utm_medium=social&utm_source=facebook&utm_campaign=IHEbuffer#.V6jXVd-mgAY.twitter

  50. WCE, a similar-sounding job, but not in a hospital setting. “Peter Ewell, president emeritus of the National Center for Higher Education Management Systems, an institutional management research center, “

  51. WCE is right – people who work intensely on process are usually RNs, in my experience (however, that may be different in larger systems). I can’t imagine a health care process job that didn’t require some clinical experience (and probably rightly so). Sometime we have consultant swoop in to tell us about improving patient satisfaction or decreasing treatment time or creating a safe culture – but those people usually have some medical degree before their fancy consulting gig.

  52. Ada, the reason I was talking to a healthcare IT person is that I coordinated the transition from paper to electronic records in our fab. When I spent a month in the hospital (admittedly within 2 months after the hospital opened), there seemed to be tons of things (timely visits from phlebotomists so physicians could get test results and discharge patients on time, where to find needed items, optimizing room assignments so nurses didn’t have to walk 7 miles in a shift) that could be improved with no medical knowledge.

    When I delivered Baby WCE several years later, I still couldn’t get supper because I hadn’t filled out a menu request sheet that morning. I was annoyed, because I was hungry after delivering a baby.

  53. After spending too much time in medical facilities over the last couple of months (mostly accompanying other people, not for myself) I must say that even back-to-basics checklists would seem to be a way to improve both experience and outcome. This is just my experience from the outside, and I appreciate Ada’s perspective from the inside. Plus some of the problems undoubtedly arise from other issues and need remedies that go beyond checklists.

    After reading how Watson correctly diagnoses woman after doctors were stumped it occurs to me that the increasing use of AI and other technology could address the checklist aspect.  Bring on the robot doctors.

    One of the best experiences was when I accompanied a friend to her colonoscopy a few weeks ago. Now that I think about it, there was a robotic aspect to how we were treated. Everything was quick, efficient and appeared very systematic. Friendly enough, but not overly warm and fuzzy. I liked it. It appeared to be a high-volume facility, so that may have been an important factor.

  54. Now that we are home from our summer travels and have our heads back in the game of real life, I’m updating my travel packing checklist.

    And for those of you with “places to go” lists, Alaska should absolutely be at the top of it. One of the most beautiful places I’ve ever been in my life, and so rich with history.

  55. I love checklists for simple things. My brain tends to scoot right on past the boring-but-necessary stuff into the more-interesting/exciting things, so checklists tend to make sure the simple stuff doesn’t get missed. I suspect this is why they work so well for what seems like “medical basics.”

    Groceries: Wegman’s app is da bomb [I can hear DD now: “mom, don’t SAY that”]. Here’s the thing: I almost never shop at Wegman’s right now, because the camp bus is right next to a Giant, and my hair guy is next to a Weis (and Safeway delivers). But I still use the app. A, because that way I always have it with me. And B, because it’s the most efficient way to translate from store to store. For a long time I used to rewrite my list in the order of the aisles to expedite the shopping, but there is just no way I am going to memorize the layout of 3-4 different stores (plus the whole copying stuff over is just boring and inefficient). The beauty of the app is that my list is always *organized by section* — so it doesn’t matter that Giant has produce on the right and Weis has it on the left, whenever I get to that section, I just scroll up or down to that section of the list and go check-check-check.

  56. My past few experiences in medical experiences for both myself and family members would have been greatly improved by the use of a checklist. At least, it would be nice if there is some sort of ap for family members to see if all the procedures that were supposed to be done before the patient leaves the hospital are actually done. The last two out of three times someone has been in the hospital for either an ER visit or a scheduled procedure, we have gotten home, then gotten a call that the hospital forgot something and we had to return.

  57. My favorite innovation in health care is ERs that take patients back immediately, then have someone come in with a laptop on a cart to do paperwork once things have calmed down. Beats the heck out of a waiting room where we once spent an hour, most of the time hearing a mom snap at her kid to be quiet. Poor child had nothing to play with, read, or do and apparently something hurt. Hospital staff said they’d already given her one of their activity books, but mom wasn’t giving it to her. I couldn’t figure out what to do about it.

  58. WCE – you weren’t fed after you gave birth, not because the hospital forgot, but because they simply didn’t care. No checklist can fix that. The much griped about patient satisfaction scores to help with issues like that, though they cause their own host of difficulties.

    I’m genuinely curious what checklists people think would help in healthcare. Problems that can be solved with checklists are errors of accidental omission. I think these are fairly rare.

    I call people back to the ER about one time per year, and always with a sense of embarrassment. This year’s event happened last week, and could have possibly been prevented with a list. However, it was because I forgot to give a medication that I give about one time out of 20 that I see this complaint. This complaint accounts for about one out of 30 visits. If I had a checklist for the top 100 complaints, I would have likely not forgotton to give the appropriate medication. There is a multi-day window for giving the medication, so there was no bad outcome. EMR could drive these things better, but it doesn’t.

    My call back last year was because I considered a new diagnosis several hours after the patient was discharged. It was a life-threatening, but rare diagnosis, and I did not feel I had appropriately worked it up. I called the patient late at night, explained my concerns, and requested they go to an emergency department. I can’t imagine any checklist that would have prevented that.

  59. I’m genuinely curious what checklists people think would help in healthcare.

    Checking that the number of sponges used in surgery are accounted for before they sew them back up. Checking at every stage and getting verbal confirmation by all parties that the left knee is the one being replaced.

  60. I’m genuinely curious what checklists people think would help in healthcare.

    Some way of verifying that the doctor’s orders for post treatment tests are actually done before the patient is discharged.

  61. Cordelia – those things exist. All hospitals have a policy of how orders are “taken off” (and by whom) and I’m fairly confident that EMRs won’t allow a patient to be discharged without all orders being acknowledged.

    That doesn’t mean it doesn’t happen. However, it’s a deviation for policy, and a deviation from the order of operations. A checklist won’t fix that – people will check off all the boxes with the same thoughtlessness that led them to take off orders without actually doing them.

  62. “Cordelia – those things exist. All hospitals have a policy of how orders are “taken off” (and by whom) and I’m fairly confident that EMRs won’t allow a patient to be discharged without all orders being acknowledged.

    That doesn’t mean it doesn’t happen. However, it’s a deviation for policy, and a deviation from the order of operations. A checklist won’t fix that – people will check off all the boxes with the same thoughtlessness that led them to take off orders without actually doing them.”

    I guess my thought is that this checklist should be given to the patient or patient representative, because that person is likely to be much more concerned that the operations occur.

    EMRs ???

  63. “have someone come in with a laptop on a cart”

    The laptops are so heavy they need to be on carts?

  64. The laptops are so heavy they need to be on carts?

    No, they are just hard to type on with one hand while standing up.

  65. The laptops are so heavy they need to be on carts?

    And this is why someone who has never worked in an exam room might not be the best at process re-design.

    I guess my thought is that this checklist should be given to the patient or patient representative, because that person is likely to be much more concerned that the operations occur

    This may be true in your case, but you are very unlike the average patient (at least in the ER). We have been trying for decades to convince patients that they are responsible for knowing their medications and allergies, with a less than 50% success rate. I can’t imagine telling patients that they are responsible for making sure that post procedure orders are complete (or that they should fill out a checklist) is helpful the vast majority. In general, patient populations skew older, poorer and less educated than the country as a whole – as those people tend to be the heaviest users of health care services.

    I know we have a lot of places we can improve delivery of care. I think Rhett highlights some of the low hanging fruit that has been picked. The problems that remain don’t have simple solutions. However, making the average patient responsible for checking that certain things have been done correctly or to completion doesn’t seem like it would help.

  66. However, making the average patient responsible for checking that certain things have been done correctly or to completion doesn’t seem like it would help.

    In my experience, relying on staff to do this doesn’t work either.

  67. My physician always brings a laptop along when he examines me, but carries it in one hand, without a cart. When he gets into the examining room, he puts it down and types with two hands.

  68. “However, making the average patient responsible for checking that certain things have been done correctly or to completion doesn’t seem like it would help.”

    IME, this is the situation we currently have. I have become the “go-to” person in my network of friends and family who are dealing with serious health issues, and the number-one piece of advice I pass along is that, as a patient, you and your family have to be your own advocate. You cannot assume that ANYONE has done what they were supposed to do, especially in a hospital.

  69. Finn, it’s probably easier to put a standing desk in a treatment room than in an ER, which has to be configurable for different kinds of patients with different needs, a cart can have a small printer to have patients sign hard copy, and one cart one printer are a heck of a lot less expensive than outfitting every treatment room!

    “trying for decades to convince patients that they are responsible for knowing their medications and allergies, with a less than 50% success rate.”
    All our physicians are connected with the same university hospital, per the advice of an MD I met in cyberspace, and they can all access our records from their offices. I cannot believe the number of times I’m asked to tell them our allergies and meds. It would be reasonable to ask if we have started any meds besides the ones that show in their records, but my memory of exactly what who is taking when, and how much, is much less reliable than the record that is written down. I once looked up the meds we’ve reacted badly to and made sure it was entered in the record correctly. Asking me to remember it on the fly whenever we show up for anything is likely to introduce incorrect information. For a while, ‘saac was getting weekly allergy shots at a place that asked about allergies to medicines every single time, while they took his vitals. I finally pointed out what I just said–memory is less reliable than records (isn’t that how this post started?), and the tech showed me that the allergies were in fact written on the inside cover of the folder. I maintained polite composure, but wouldn’t be surprised if steam came out my ears when I heard that.

  70. “one cart one printer are a heck of a lot less expensive than outfitting every treatment room!”

    Is it?

    At DD’s orthodontist’s office, there’s a laptop at each dental chair. It looks like they’re all thin clients accessing the same server. Many years ago, when I went to Kaiser, they had a similar setup in all the exam rooms.

    My guess is that the dental chairs, or exam rooms, are heavily booked, the number of laptops needed would be the same either way, and keeping them where they’re needed is less expensive, and probably makes for less crowded aisles.

  71. At my dentist’s office, after the cleaning the hygienist loads and displays your most recent X-rays on the screen, with the “keep an eye on” spots circled so that it’s quickly apparent for the dentist to cross reference during her exam. Something like that could be helpful in a physician’s office: the patient’s “chart” goes up on a screen with allergies, etc., and they can ask if the patient knows of anything that should be added.

    As an aside, while I have a female dentist, I’ve never known any males to work in a dental office if they were not the dentists. Have you? Why have men successfully infiltrated the ranks of nurses and medical techs, but not hygienists and dental techs?

  72. Finn, but don’t you think that treatment rooms, where one kind of specialist does one sort of thing, can be outfitted with a system more easily than ER rooms, which have to be configurable in lots of different ways, depending on what the case is?
    Ada, am I into something here?

  73. Milo, or just read the list they already have or show it to the patient and ask if there are changes. It’s that they already have it that gets to me. If I go to an urgent care that doesn’t have access to the system, fine, it’s my responsibility to tell them that. Once I’ve done that, I think it should be their job to keep track of it.

    Autocorrect complaint: it just switched “their” to “there” in my last sentence there. Grrr. It’s out to get us all!

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