American Organization of Nurse Executives (AONE)

Hannah Komedja • I am for checklists. They have helped me tremendously during my clinical rotations. I used the same concept while working as a nurse assistant. I went through the website and it looks good. Is your checklist invention an app for cellphone?

Rudy Martinez • Geat idea to formalize a nurses checklist. Nurses have been using many home made lists forever. A focus on patient safety and care coordination would improve outcomes.

Laurie Levknecht • Hi colleagues-This is likely not a problem to solve. We both need "checklists as described" above for times when that is necessary. AND we need something "beyond the checklist" for those times when we need individualized care and do not want to be focused on task-based care. There are downsides to thinking that by using a checklist it will solve issues around safety and outcomes. I suggest Suzanne Gordon's work relating to how aviation uses checkllists as a necessary tool, yet have not depended on them to do things that they are not designed to to. This is parallel pair thinking where we recognize the upsides of each and the downsides of each. Both together reach a higher goal of improved outcomes and pt safety.

Mary Lou O'Grady • I'm not certain that "checklists" for patient care are the total answers to improving patient care.
For those seasoned nurses trained to critically think thus developing pathways of care based on ones physical assessments of their patients.
For instance apps. on a nurses phone in the OR or PACU leads to again managing screens and not observing the patient, team members, and maintaining safety throughout procedurally based areas.
We have more patients injuries and RN/MD errors in procedurally based areas then ever before. Why is that?????
Lack of focus, production pressure, and adjunct technical support team members.
The more screens we look at the more mal-practice cases I look at for patient avoidable injury!!!
That's my real opinion......

Angie Soden • Agreed. Although I only worked in the healthcare industry for a short period of time, a checklist system is what I often needed to complete my job properly without worrying that I did something right and second-guessing myself. Luckily, I've found that there are solutions out there. In fact, I work for a company that provides a solution. I work for Readiness Rounds, based out of Eudora, KS with an international client base, and it provides a customizable checklist system for hospitals. Our service isn't limited at checklists, however. We provide real-time data to those conducting the checklists and prioritize the areas they need to work on most based on their top failing items. It's an extremely detailed process, but we've found that our system can sustainably improve patient safety, quality of care and experience within hospitals as well as relieve headaches for the staff.

Gayle Omansky • A few comments after checking out the NurseMind.com link:
Is this for a personal or institutional iPhone? HIPPA issues w/ storing pt info in a personal phone?
How much time is taken to set up the screens at the start of a shift? It seems like a lot of time is needed - I do though appreciate the references to our "paper brains" & do know that everyone is very distressed if the paper brain is misplaced.
Is this only for students? My MAJOR problem is that nursing care is listed as tasks.
Care consists of assessments & response to assessments - i.e. vital signs are an assessment not a task. We are diminishing ourselves & our care by listing it as a bunch of tasks to be completed.

John Martin • I use a variety of checklists within perioperative services. They help drive hardwiring through constant reminders and practice. They are not an audit tool but a mental reminder of what needs to be accomplished for quality and safety. They also help along with oversight the continual reinforcement of the behaviors and actions needed.

Jan Hastings, RN MSN • I have utilized checklists in my role as a nurse educator, but have found that this does not promote the critical thinking needed for the tasks. Changing a surgical dressing is a fairly simple task, but the critical thinking that goes along with this task is not captured in a checklist. For example especially for the new nurse or any new orientee, critical thinking questions should be asked regarding what they are looking for as they change the dressing (swelling, redness, abnormal drainage, more pain than expected, what is the patient's vital signs - fever? What does the patient's lab work indicate - is the white count elevated? etc.) To meet the evaluation criteria, each and every time the new nurse changes a dressing, they should be able to verbalize why and what they are looking for. Goals, resources for the preceptor and evaluation criteria should be set.

Laurie Levknecht • Jan is bringing the issue I brought earlier. There are some things a checklist is designed to do, and other things that need critical thinking, decision making and judgement. It is a "both/and" - attend to both sides of the parallel pair to gain the upsides of each and stay out of the downside. There are some tools to guide this process - Polarity maps.

Mary Lou O'Grady • Agreed as I stated above in my commentary.

Mary Lou O'Grady • Hmmm is there a doctormind.com with checklists for the MD????

Mabel Duffus • A checklist is useful in some respect especially for new graduates; but it cannot be the substitute for nursing skills, critical thinking and compassion. What happen if a patient experience a problem that is not on a check list? Checklists are not global or patient specific.

John Martin • Checklists are nothing more then a mental reminder to help reinforce actions that are necessary for consistency and safety. It is not a substitute for good judgement based on experience and critical thinking skills

Jeannie P. Cimiotti • Some health care institutions have checklists that doctors, nurses, and other providers are expected to follow. Peter Pronovost at Johns Hopkins has spearheaded this effort.

Carmencita Mercado - Poe, EdD, RN, OCN, APRN-BC • Checklists serve a purpose for procedures that are being learned or new to the nurse. For example, I would highly recommend its use for nurses to assist who are being pulled/floated to another unit and not familiar to that unit's procedures. It is equally helpful to ensure that processes and procedures are followed in high risk procedures, such as checking chemotherapeutic drugs by 2 nurses prior to these drugs' administration. But checklists should never be made a substitute for the critical thinking skills nursing professionals are expected to possess. Checklists generally outline tasks to complete. Delivering compassionate patient care and ensuring an excellent health care experience to patients requires assessment and identifying individualized patient needs and should not be dictated by checklists. It can be a deterrent to the professional nurse's authentic, knowledgeable and astuteness to meet the patients' needs in a compassionate as well as safe manner.

Dan Keller • Thanks Jan, Laurie, Mary Lou. Your comments are astute. Just as checklists in aviation (good metaphor, Laurie, also discussed in detail by Dr. Atul Gawande in "The Checklist manifesto" -- required reading!) improve safety by ensuring that simple cognitive burden does not become the cause of fatal errors, they are no substitute for the skill and experience of the pilot. Rather, by removing the distractions of routine details, they free up the pilot's brain for the high-level aspects of the job. Similarly, in nursing, when we are at our best, we have "presence" with our patients; we are not distracted by details and can really focus on them. That is the true goal here. It is subtle and not easily explained, but the experienced nurses -- and the new ones, too -- know exactly what I'm talking about.

Dan Keller • Thanks, Jeannie, for pointing out the work of Dr. Pronovost. He is a true pioneer in this area. I cite his important work here: http://nursing.keller.com/whatshard.html#prono

Dan Keller • Gayle, your questions are excellent. Some are answered in FAQs:
How much time is taken to set up the screens at the start of a shift? Please see http://www.nursemind.com/faq-page#n60
Is this only for students? No, nurses at any level of experience find it useful. By making sure no details are overlooked (Kalisch's classic 9 commonly-missed nursing care activities: turning the patient Q2H, ambulation, hygiene, surveillance, etc.) the nurse's mind is freed for the activities that require critical thinking, clinical judgment, experience, and, as you correctly observe, assessments and response to assessments. Let's focus our energy where it can do the most good!
Is it for a personal or an institutional iPhone? Both. The nurse can buy it for himself, and/or the unit can buy it for nurses to use there.
And what about HIPAA issues on a personal phone? Since it is not a medical record -- it is not patient-centric, it is nurse-centric -- no HIPAA data is collected. The app doesn't need to know, for example, the patient's name (initials or a nickname suffice), DOB, or other PHI.
Thanks, Gayle, for these great questions!

Kate O'Neill, MSN, RN • Checklists are essential in task or process driven procedures in healthcare. In Atul Gawande's book, the "Checklist Manifesto" he pointed out that checklists help to standardize care processes and reduce clinical variations. I would definitely agree... checklists are used in process improvement and Lean methodology to get rid of MUDA which is variations to streamline processes, improve care and reduce costs. As front-line providers, Nurses are in an ideal place to "Close Gaps in Care" delivery, use checklists to reduce errors and standardize care delivery . Thanks Dan for the lively discussion.
Kindly see our website that discusses checklists that are supported by IHI. www.closecaregap.org

Read our White Paper:Aligning Clinical Practice with Performance Improvement http://closecaregap.org/downloads/Aliging%20Clinical%20Practice%20&%20PI%20final.pdf

thank Kate

Bernadette O'Halloran RN, MSN • Checklists are just tools that act as alerts, reminders, and may assist in completing our tasks. Nurses have become so task-oriented that our critical thinking skills are put to the wayside. We need not be too dependent on checklists. I guess with too much policies and procedures created due to certain regulations we need to adhere, checklists are a necessity.....