May 25, 2020By Dr. Kim Baily

Using Medical Simulation to Evaluate Checklists: Part 2

Continuing from last week’s article Using Healthcare Simulation to Evaluate Checklists: Part 1, Dr. Kim Baily PhD, MSN, RN, CNE, previous Simulation Coordinator for Los Angeles Harbor College and Director of Nursing for El Camino College, explored how medical simulation can be used to evaluate the potential of patient safety and procedure checklists. Today in Part 2 of using Medical Simulation to evaluate checklists, she looks at several more research studies on the topic to better understand how the methodology plays an important role in patient safety, patient assessment and team-based communication.

In one study involving healthcare simulation, Sevilla-Berrios et al., developed a novel electronic tool, the Checklist for Early Recognition and Treatment of Acute Illness (CERTAIN) to facilitate standardized evaluation and treatment approach for acutely decompensating patients. This study included a “prompter” who was a team member separate from the leader who records and reviews pertinent CERTAIN algorithms and verbalizes these to the team.

Volunteer clinicians with valid adult cardiac life support (ACLS) certification were invited to test the CERTAIN model in a high-fidelity simulation center. The first session was used to establish a baseline evaluation in a standard clinical resuscitation scenario. Each subject then underwent online training before returning to a simulation center for a live didactic lecture, software knowledge assessment, and practice scenarios. Each subject was then evaluated on a scenario with a similar content to the baseline.


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All subjects took a post-experience satisfaction survey. Eighteen clinicians completed baseline and post-education sessions. CERTAIN prompting was associated with reduced omissions of critical tasks (46 to 32%, p < 0.01) and 12 out of 14 general assessment tasks were completed in a more timely manner. The post-test survey indicated that 72% subjects felt better prepared during an emergency scenario using the CERTAIN model and 85% would want to be treated with the CERTAIN if they were critically ill.

Prompting with electronic checklist improves clinicians’ performance and satisfaction when dealing with medical emergencies in high-fidelity simulation environment. (The authors note that this study did not compare the effectiveness of CERTAIN prompting vs training and addition of a staff member in the role of a prompter may be cost prohibitive in some institutions however, the prompter role can be assigned to an active team member).

Atul Gawande’s book entitled “The Checklist Manifesto” makes an enjoyable read. The author reviews the use of checklists in high reliability organizations such as the airline industry highlighting the famous landing of the US Airways Flight 1549 on the Hudson River. Captain Sullenberger modestly claims that survival of the passengers and crew was a team effort of highly trained individuals who all followed an appropriate checklist which they had practiced in a simulator. Gawande believes one crucial step in the successful landing was the initial initial checklist completed prior to take off. He felt that this bonded the crew as a team and identified past experiences and potential problems.

The co pilot Skiles was actually flying the Airbus A320 at the moment when it hit the flock of Canada geese however, because in the initial check Sullenberger had been identified as the individual with the most experience on the A320 and because the captain and co pilot were established as a team, Sullenberger immediately took over control and the co-pilot completed the emergency checklists valiantly attempting to restart one of the engines, prepare for ditching and checking for fires. Meanwhile the cabin staff prepared the passengers for an emergency landing. A team effort and checklists played a huge role in saving 155 lives.


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Gawande goes on to make the case for the use of checklists in complex medical case management. He played a significant role in the development of the WHO presurgical check list. Of the 4000 patients in the study, 435 would have been expected to deveop serious complications based on previous data however, only 277 did. Using the checklist had spared more than 150 people from harm and 27 of them from death.

Gwande proposes a checklist for checklists which involves 3 phases, development of clear concise objectives for the checklist, drafting and validation. Healthcare simulation often plays a key role in checklist development and validation. Finally, once a checklist has been developed and checked, medical simulation may be used to train healthcare professionals in the use of the checklist and monitor for needed changes as practice itself changes.

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