There is ever greater interest in mitigating medical errors, particularly through cognitive aids and checklist-system long-used in the aviation industry.

Jelacic and team instituted a computerised pre-induction checklist, using an observational before-and-after study design across 1,570 cases. This is the first study of a computerised anaesthesia checklist in a real clinical environment.

They found an absolute risk reduction of almost 4% of failure-to-perform critical pre-induction steps, along with reduction in non-routine events and several examples of pre-induction mistake identification through checklist use.

Although the researchers claim the results “strongly argue for the routine use of a pre-induction anaesthesia checklist” this overstates the case a little. This study, like many similar, struggles with confounder effects on anaesthesia vigilance that may explain some of the results, particularly as arising from observational, non-randomised, non-blinded research.

Be careful

The challenge for cognitive aid research is that commonly it must use surrogate markers (workflow step failure; behavioural deviations; efficiency; time spent on task etc.) rather than the safety outcomes that actually matter to patients: death and injury.

There is no easy way around this other than large multi-center studies focusing on outcomes, such as the WHO surgical safety checklist study – which even then, has not escaped criticism!

Thinking deeper...

There will continue to be tension between those pro-checklist and those against. The irony is that both camps share a similar rationale for their position: the advocates for routine checklists point to the safety benefits of reducing cognitive load, whereas those opposing argue that enforced use is anti-individual and itself adds additional task and cognitive burden for clinicians.

summary

• S Jelacic, A Bowdle, B G Nair, K Togashi, C Wu, D J Boorman, K C Cain, J D Lang, and E P Dellinger.
• Department of Anaesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA.
• Anaesthesia. 2019 Sep 1; 74 (9): 1138-1146.

AbstractThis prospective, observational study compared the proportion of cases with missing critical pre-induction items before and after the implementation of an aviation-style computerised pre-induction anaesthesia checklist. Trained observers recorded the availability of critical pre-induction items and evaluated the characteristics of the pre-induction anaesthesia checklist performance including provider participation and distraction level, resistance to the use of the checklist and the time required for completion. Surgical cases that met the criteria for inclusion in the National Surgical Quality Improvement Program at a single academic hospital were selected for observation. A total of 853 cases were observed before and 717 after implementation of the checklist. The proportion of cases with failure to perform all pre-induction steps decreased from 10.0% to 6.4% (p = 0.012). There was also a significant decrease in the proportion of cases with non-routine events from 1.2% cases before to none after checklist implementation (p = 0.003). In 17 cases, the checklist alerted the anaesthesia provider to correct a mistake in pre-induction preparation.© 2019 Association of Anaesthetists.

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