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Trust the Checklist
By Sara Freiberg

Twenty years ago, the Institute of Medicine published a report, To Err is Human: Building a Safer Health System, which called for efforts to reduce the epidemic of healthcare-related complications, stating that healthcare in the U.S. is not as safe as it should and can be. The report stated that as many as 98,000 people die each year in hospitals due to medical errors that could have been prevented.1

Fast forward to 2013 when patient safety experts at Johns Hopkins analyzed the medical death rate data over an eight-year period and calculated that in the U.S. more than 250,000 deaths per year are due to medical errors. This figure surpasses the third leading cause of death according to the Centers for Disease Control and Prevention (CDC), chronic respiratory disease (150,000 deaths per year).2

As we can see, these completely preventable event numbers are rising. Despite advances in training or new technology, human factors continue to play a large role in our healthcare arena. Human factors involve recognizing human limitations and allowing for variability in human performances. We recognize that fatigue, stress, poor communication, knowledge, and skills can affect healthcare professionals, and this is important in helping us understand how adverse events can occur. While we cannot eliminate human error completely, we can act to moderate and limit the risks. Checklists are one way to limit risks.

In 2008, the World Health Organization (WHO) launched a Global Patient Safety Challenge: “Safe Surgery Saves Lives.” The program centered on a single-page safety checklist with four main sections: Surgical Site Infection Prevention, Safe Anesthesia, Safe Surgical Teams, and Measurement of Surgical Care and Quality Assurance Mechanisms.3 The introduction of an important surgical safety checklist came forth, known as the surgical time-out.

The WHO believed that routinely checking common safety issues and allowing for better team communication can improve perioperative morbidity and mortality. The introduction of the checklist identified three distinct phases in surgery, each corresponding to a specific period in the normal workflow: before the induction of anesthesia, before the skin incision, and before the patient leaves the operating room. Confirmation is conducted at each step. When the WHO launched the Global Patient Safety Challenge: “Safe Surgery Saves Lives,” they approached Dr. Atul Gawande and his team, asking if they could work on a project to help reduce adverse events and deaths in surgery because they found that while the volume of surgeries had spread around the world, safety did not. Dr. Gawande agreed to help.

A pioneer in checklists
Dr. Atul Gawande is a Harvard-trained general and endocrine surgeon at Brigham and Women’s Hospital in Boston. He is a healthcare researcher, advisor for healthcare policies, staff writer for The New Yorker, he won the MacArthur Foundation “Genius” award, and is the author of numerous books.4 In his book The Checklist Manifesto: How to Get Things Right, Dr. Gawande shares “how easy it is for any one of us to make mistakes even when we are carrying out simple, familiar procedures; or maybe especially when we are carrying out such procedures.” He shares that while the usual tactics of this request typically offer additional training or bringing in more technology, but “in surgery, you couldn’t have people who are more specialized and you couldn’t have people who are better trained.”5 So he looked at other high-risk industries, such as aviation, and found an important item that airlines use: checklists.


Airline travel is noted as the safest form of travel, but it wasn’t always this way. Aviation first came up with checklists in the 1930s; however, pilots routinely discarded their use and after multiple crashes, deaths, and one airline nearing bankruptcy, they finally began to change their culture and recognized the need of checklists for all flights. Boeing has more than 100 checklists that, when used correctly, have proven successful.

This prompted Dr. Gawande to reach out to the lead safety engineer from Boeing to learn from their checklists and move them into the surgical arena. He launched the checklists at eight hospitals in eight cities around the world and found that by designing a 19-item checklist with pause points, complication rates fell 35% and death rates fell 47%. He described the results as “bigger than a drug.” The surgical time-out came forth with proven reduced errors and is recognized in hospitals worldwide.6 

Still not convinced in checklists? In a study of 100 hospitals in Michigan, Dr. Pronovost, an anesthesiologist at Johns Hopkins University Medical School, created a checklist on how to safely insert a central line into a patient’s chest because they found that as many as 4% of these cases were becoming infected. He discovered why. He found that 30% of the time, surgical teams skipped one of these five imperative steps: hand washing, donning surgical attire, cleaning the site, draping the patient, and applying a sterile dressing. After 15 months of using a simple checklist, the hospitals “cut their infection rates from 4% of cases to zero, saving 1,500 lives and nearly $200 million.”7

Perception of checklists
Some believe that using a checklist or cheat sheet is a form of weakness, that others will lose confidence in their abilities, undermine their expertise, or prevent them from quick decision-making. In one survey, only 45% of anesthesia providers said they felt comfortable using a checklist in front of colleagues, while 17% were uncomfortable doing so. Those with fewer years of experience were significantly less comfortable using checklists, while seasoned providers stated they were indifferent and comfortable using them. Overall, 64% of anesthesia providers strongly agreed that they felt competent in always preparing and performing routine anesthesia care based on memory and experience alone.8

Surgery is complex. There is no specific recipe and many things can go wrong. Should we consider becoming more systematic about what we do when it comes to healthcare and patient safety? Our routines may be familiar, yet it is easy to become overconfident, causing us to overlook an important step that leads to errors or failing to prevent them. Believing that we can perform important tasks seamlessly every time by relying on memory alone is poor thinking.

Implementing checklists is not simply reading through and checking off boxes; it’s inciting a cultural change by increasing teamwork and communication. Checklists require buy in from leadership, flexibility to modify if needed, and periodic testing to be successful.We are all held to the standards in healthcare. If we can overlook a sponge left inside of a patient, fail to ensure sterility of a surgical tray, or witness an instrument breaking off and falling into a patient’s wound, it necessitates a solid plan for us all to consider in reducing the potential for adverse events to occur. Checklists provide a backup to human memory and “serve as a formal reminder to help to prevent errors of omission and contribute to a safer environment.”9

Errors can risk our reputations and the reputation of the hospital. Errors can lead to patient infection, injury, or death. Dr. Gawande states that sometimes it isn’t until a tragic error results from not using a checklist that others come around to seeing its value. When Dr. Gawande conducted his checklist survey, he found that 80% of surgeons were in favor of checklists and considered the surgical time-out to be important. The remaining 20% said they thought the checklists “were a waste of time and didn’t add value.” When the same surgeons who resisted continuing to use the checklist were asked if they wanted their own surgeon to use one if they were having surgery, 94% said they would.10

Before getting on a flight, I would like to know that the pilot is using a checklist prior to take off, prior to landing, and in emergency situations. As a patient, I want know that my healthcare team is also following the same protocols before, during, and after my care. Checklists provide us with a cognitive safety net, catching mental flaws that are inherent to us all.11

If you were having surgery, would you prefer one of the 80% of surgeons who would incorporate the checklist or one of the 20% who wouldn’t? I may know your answer.


  1. https://www.ncbi.nlm.nih.gov/books/NBK2673/
  2. https://www.hopkinsmedicine.org/news/media/releases/study_suggests_medical_errors_now_third_leading_cause_of_death_in_the_us
  3. https://www.apsf.org/wp-content/uploads/newsletters/2008/summer/pdf/APSF200806.pdf
  4. https://www.cnbc.com/video/2018/07/09/atul-gawande-buffett-bezos-dimon-health-care.html
  5. https://www.bing.com/videos/search?q=atul+gawande+checklist+manifesto+TED&&view=detail&mid=650FA79BF5357E22EB11650FA79BF5357E22EB11&&FORM=VRDGAR
  6. https://www.apsf.org/article/who-launches-safe-surgery-saves-lives/
  7. https://www.hsph.harvard.edu/news/magazine/fall08checklist/
  8. http://anesthpain.com/en/articles/17484.html
  9. https://www.checklistboards.com/index.cfm?Page=about
  10. https://www.techwell.com/2013/09/why-even-experts-and-professionals-should-use-checklists
  11. https://blog.safetyculture.com/checklist-best-practices/lessons-we-can-learn-from-aviation-checklists



Dr. Gawande TED video:

World Health Organization checklist:

Centers for Disease Control and Prevention checklists:







Sara Freiberg, CST, CBSPDT, CER, has more than 15 years experience working as a certified surgical technologist, with five of those years spent traveling to various operating rooms across the U.S. Following Sara’s time in the clinical arena, she worked as a surgical technology didactic and lab instructor at Rasmussen College. Sara holds bachelor degrees in science and business and marketing, which led to her work with various medical device companies as a clinical specialist, product manager, and clinical training manager. She has experience working on quality and regulatory teams, monitoring patient-adverse events, and postmarket surveillance activities.

Sara currently works for Northfield Medical as a clinical education manager where she provides education which is based on current manufacturer and regulatory guidelines regarding various healthcare topics for SPD, OR, and GI staff. Training entails the care and handling of medical devices to ensure patient safety, as well as targeted education addressing departmental cost concerns. Her passion is working with SPD, OR, and GI departments; providing assessments; and sharing best practices with respect to patient and staff safety, surgical instruments, and medical devices. Sara is a voting member of the AAMI ST/WG84, ST91 flexible endoscope committee, and she has developed several CEU presentations approved through CBSPD, CBRN, NCCT, and IAHCSMM. Sara also authors a biweekly healthcare article for Ultra Clean Systems.

Sara is currently studying for the Certification Infection Control (CIC) exam through APIC.

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