Checklist Usage in High-Risk Situations By Rick Dixon Industrial & Systems Engineering.
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Transcript of Checklist Usage in High-Risk Situations By Rick Dixon Industrial & Systems Engineering.
Checklist Usage Checklist Usage in High-Risk in High-Risk SituationsSituations
By Rick DixonBy Rick Dixon
Industrial & Systems Industrial & Systems EngineeringEngineering
Overview Hudson River Plane CrashHudson River Plane Crash
Strengths of Using Checklists in ICUsStrengths of Using Checklists in ICUs
Resistance to Checklists Usage in Aviation Resistance to Checklists Usage in Aviation and ICUsand ICUs
Human Factors IssuesHuman Factors Issues
Recommendations and ConclusionRecommendations and Conclusion
Hudson River Plane Crash
150 passengers 150 passengers and 5 crew and 5 crew members members
Birds struck Birds struck planeplane Canada GeeseCanada Geese
Source: http://commons.wikimedia.org
Hudson River Plane Crash
Plane landed in Hudson Plane landed in Hudson River within a mile of River within a mile of Times Square in NYTimes Square in NY
Survival rate was 100%Survival rate was 100%
Emergency landing Emergency landing procedure checklist procedure checklist used used
Source: http://timeinc8-sd11.websys.aol.com/time/photogallery.html
Human Factors and Human Factors and DesignDesign
Using complex equipment such as Using complex equipment such as airplanes calls for having good design.airplanes calls for having good design.
Some general design considerations:Some general design considerations: Use simplest display concepts possibleUse simplest display concepts possible Minimize the memory loadMinimize the memory load Provide good error messages and feedbackProvide good error messages and feedback Speak the user’s languageSpeak the user’s language Be consistentBe consistent
MemoryMemory
Short-term memory Short-term memory Acts like RAM on a computerActs like RAM on a computer We generally remember seven bits of We generally remember seven bits of
information.information.
Emergency Landing Emergency Landing Checklist ExampleChecklist Example
Concerns in ICUs
Currently 2 million Currently 2 million patients are held in patients are held in ICUs in United States.ICUs in United States.
About 28,000 patients About 28,000 patients die from catheter-die from catheter-related bloodstream related bloodstream infections (line infections (line infections) each year.infections) each year.
Many patients also die Many patients also die from ventilator-from ventilator-associated pneumonia associated pneumonia (VAP)(VAP)
Source: http://solutions.3m.com
Strengths of Using Checklists in ICUs
Assurance that Critical Steps are Assurance that Critical Steps are taken in medical procedurestaken in medical procedures
Reduction of Line InfectionsReduction of Line Infections
Reduction of Ventilator-Associated Reduction of Ventilator-Associated Pneumonia (VAP) CasesPneumonia (VAP) Cases
Assurance that Critical Assurance that Critical Steps are TakenSteps are Taken
Acts as a memory guideActs as a memory guide Put more knowledge in the world instead of in Put more knowledge in the world instead of in
the head.the head.
Enhances Coordination in Stressful Enhances Coordination in Stressful SituationsSituations Good to use when your in a hurry Good to use when your in a hurry Good for activities that involve lots of repetitionGood for activities that involve lots of repetition
Redundancy FactorRedundancy Factor
Line InfectionLine Infection Through the use of catheter Through the use of catheter
tubes (lines), many patients are tubes (lines), many patients are able to drink fluids and receive able to drink fluids and receive necessary medications.necessary medications.
Infections can be obtained by:Infections can be obtained by: Leaving Catheter in for too Leaving Catheter in for too
longlong Not Properly Cleaning Not Properly Cleaning
Catheter SiteCatheter Site Even germs from your own Even germs from your own
skin skin
Symptoms include:Symptoms include: Fever/ChillsFever/Chills Shortness of BreathShortness of Breath Pain/Redness near catheterPain/Redness near catheter
Key Fact about Line Key Fact about Line InfectionsInfections
ICUs place 5 million lines/yearICUs place 5 million lines/year
After 10 days After 10 days 4% infection rate or 4% infection rate or 80,000 line infections80,000 line infections
Fatality Rate Fatality Rate 5 – 28% 5 – 28%
Survivors spend on average an extra week Survivors spend on average an extra week in ICUin ICU
Keystone InitiativeKeystone Initiative
Study performed by Study performed by Physician Peter Provonost Physician Peter Provonost and his colleaguesand his colleagues
Conducted in 103 Conducted in 103 Michigan ICUs from 2001-Michigan ICUs from 2001-20032003
Reduced the number of Reduced the number of line infections by using line infections by using checklist in ICUschecklist in ICUs
Saved over $75 million in Saved over $75 million in cost of care for hospitalscost of care for hospitals
Over 1500 lives were Over 1500 lives were saved saved
Line Infection ChecklistLine Infection Checklist
Source: http://www.ntinewsonline.org/2007/Th/Th2007_CE.htm
Ventilator-Associated Ventilator-Associated Pneumonia (VAP)Pneumonia (VAP)
Variation of common Variation of common pneumoniapneumonia
Infection of the lung Infection of the lung
Affects patients who Affects patients who are assisted by are assisted by mechanical mechanical ventilators (breathing ventilators (breathing machines)machines)
High death rateHigh death rateSource: http://www.topnews.in/health/regions/washington?page=4
Reduction of Ventilator-Reduction of Ventilator-Associated Pneumonia VAPAssociated Pneumonia VAP
During Provonost’s study, there were 21 fewer During Provonost’s study, there were 21 fewer cases of death from VAP than in the previous cases of death from VAP than in the previous year by using checklists.year by using checklists.
During Debose’s study, the number of patients During Debose’s study, the number of patients staying on ventilators > 72 hours fell from 74% staying on ventilators > 72 hours fell from 74% to 62%. to 62%.
Resistance to Checklists Resistance to Checklists Usage in Aviation and ICUsUsage in Aviation and ICUs
More PaperworkMore Paperwork
Length of Length of ChecklistChecklist
Source: http://www.csallergy.com/Forms.html
Length of ChecklistLength of Checklist Long checklist may Long checklist may
take away time take away time from patient carefrom patient care
Checklist may be Checklist may be confusingconfusing
Source: http://ntl.bts.gov/DOCS/etis.html
Other ProblemsOther Problems
Misuse of ChecklistMisuse of Checklist Overlooking/Skipping StepsOverlooking/Skipping Steps
Being temporarily distractedBeing temporarily distracted Thinking that a procedure on checklist has Thinking that a procedure on checklist has
already been completed when it had not.already been completed when it had not.
Waste of time for PhysiciansWaste of time for Physicians
Human Factors IssuesHuman Factors Issues
Top-Down Processing (TDP)Top-Down Processing (TDP) What you expect to seeWhat you expect to see
Mental Model Mental Model Becomes more rigid over timeBecomes more rigid over time May adjust perception and May adjust perception and
mislead brain into “seeing mislead brain into “seeing what one is used to seeing”what one is used to seeing”
TDP can override and TDP can override and contradict the physical contradict the physical evidenceevidence
Checklists could resolve this Checklists could resolve this issueissue
Source: Wickens, Lee, Liu
RecommendationsRecommendations
Use a paper checklist that is short in lengthUse a paper checklist that is short in length
Checklists should be clear, concise, and Checklists should be clear, concise, and straight to the pointstraight to the point
Have a checklist for each processHave a checklist for each process
Intervention necessary if procedures on Intervention necessary if procedures on checklists are not being performed correctly.checklists are not being performed correctly.
ConclusionConclusion
Checklists can help:Checklists can help: Assure critical steps are taken in high Assure critical steps are taken in high
risk situationsrisk situations Save lives and money in aviation and Save lives and money in aviation and
medical fields.medical fields.
SimpleSimple and and inexpensiveinexpensive tool to tool to implement in our falling economy.implement in our falling economy.
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