Ambitious checklist app comes as hospitals struggle with basic checklists

This summer, Johns Hopkins Medicine in Baltimore plans to test an ambitious new application for tablet devices that its developers hope will significantly enhance its clinicians' use of patient checklists to avoid preventable medical errors.

The Emerge app consolidates and automates checklists associated with seven patient-safety events, including blood clots and central-line associated bloodstream infections, into one centralized database. When a physician pulls up a patient's chart on a tablet or monitor, a display shows the seven potential harms. Physicians can click on them to see a clock-like display. Items in red indicate a safety concern that needs to be addressed, while green means risks have been mitigated.

For example, if patients are immobile for too long, a red light will appear showing they are at risk for a blood clot. If the daily audit of a central line has not occurred, the chart will show in red that the patient is at risk for a central-line infection.

The name Emerge comes from the concept of “emergent behavior,” meaning unanticipated behavior shown by a system. The term is used by engineers designing complex mechanical systems such as submarines, where there is zero room for error. Engineers start with the end goal—for instance that the sub won't implode under deep sea pressure—then build backward and address all the factors, or emergent behavior, that could cause that undesired event.

The Project Emerge team is applying that approach to hospital safety checklists. They start with the seven events that could imperil patient safety, then work backward to ensure that the hospital's technology and staff prevent negative outcomes. By fall, the Emerge checklist app also will be in pilot use at UCSF Medical Center in San Francisco.

The project's attempt to advance the sophistication of checklists comes as many U.S. hospitals struggle to implement even basic, often paper-based checklists. Experts say many of those difficulties arise from a failure to create an organizational culture of safety. A mandate to use checklists does not change the culture, they say. It takes strong leadership involvement to motivate and organize the changes.

“Meaningful change takes time and effort,” said surgeon-writer Dr. Atul Gawande, a professor of health policy and management at the Harvard School of Public Health, who popularized the checklist concept with his 2009 book The Checklist Manifesto. “If there hasn't been a concerted implementation, it's unlikely to succeed.”

Patients who enter the hospital may be exposed to a number of harms at different points of care. Instead of looking at one problem at a time, it's better to look a multiple problems, which fits with patients' true experiences and risks in a hospital, said Dr. Peter Pronovost, director of the Armstrong Institute for Patient Safety and Quality at Johns Hopkins Medicine, who is working on Project Emerge.

The original medical checklist concept was borrowed from aviation and applied first to surgery. The goal was to ensure that operating room teams performed all safety steps before, during and after a procedure or other patient encounter, such as confirming the patient's name, allergies, site of surgery and checking that all surgical tools had been removed from the patient's body. Such checklists now go beyond the OR setting to address other possible types of patient harm, such as falls and central line-associated bloodstream infections.

The World Health Organization, in association with the Harvard School of Public Health, offers a 19-item surgical-safety checklist that has been adopted by hospitals globally. Harvard also offers templates for five kinds of checklists used by South Carolina hospitals as part of a statewide safe-surgery initiative.

But the implementation of checklists by hospitals and clinicians has not been easy. WHO estimates that only 25% of U.S. hospitals use checklists. Some experts say the reason checklists have met with mixed success is that hospitals often have implemented them hastily, without any larger strategy for creating a culture of safety, one that emphasizes improved communication, collaboration and transparency.

“People have underestimated what an immense culture change this is,” said Dr. Lucian Leape, adjunct professor of health policy at the Harvard School of Public Health who served on the Institute of Medicine committee that produced To Err is Human, the landmark 1999 study on medical errors. “We know what needs to be done, but getting it done is turning out to be quite a job.”

A study published in March in the New England Journal of Medicine found that mandated use of surgical-safety checklists in Ontario was not associated with significant reductions in complications or deaths following surgery. In light of that study, prominent U.S. patient-safety experts are proposing new strategies for how to use checklists more effectively. Project Emerge is one such approach.

In 2006, Pronovost headed a checklist-based collaboration involving 103 hospital intensive-care units in Michigan, which produced a significant decline in central line–associated bloodstream infections. But now he thinks it's time to rethink and re-engineer checklists. Hospital staffers today must remember to use the right checklist for each situation, he said, such as using one before an operation and another when dispensing medications. The Emerge project at Johns Hopkins is an effort to make appropriate checklists available to hospital staff at just the right moment.

To develop Emerge, a team including patients, nurses, physicians, engineers, data analytics experts and bioethicists compiled more than 200 potential harms a patient could face in the hospital. For the pilot, the list was narrowed to seven: delirium due to over- or under-medication; weakness acquired in the ICU; ventilator-associated harms; blood clots; central-line associated bloodstream infections; loss of dignity; and failure to respect patients' treatment goals and preferences. The checklists for preventing these harms were automated into software and linked to electronic health records.

While many U.S. hospitals have voluntarily adopted checklists, in 2011 Nevada became the first state to require medical facilities to implement checklists to confirm patients' identity before treatment is provided and to ensure that conversations about medications and other follow-up care occur before discharge.

In South Carolina, there is a statewide effort underway as part of the Safe Surgery 2015 initiative, spearheaded by the Harvard School of Public Health and the South Carolina Hospital Association. Every hospital in the state voluntarily agreed to use checklists in its ORs by the end of 2013. Hospitals were encouraged to tailor checklists to meet their specific needs. The state plans to examine their effectiveness by 2015.

But creating culture change, especially in the operating room, isn't easy. The OR is the “last bastion of hierarchy in medicine,” said Leape, a co-founder of the National Patient Safety Foundation. The surgeon traditionally directs the team in that culture, and too often there has not been an atmosphere of collaboration, communication or willingness of other team members to speak up.

“This is not a download it and stick-it-on-the-wall kind of thing,” Gawande said. “Planning and protocol can be incredibly powerful.” But it won't work if it's just “mindless efforts to check boxes,” he said.

In South Carolina, Dr. Chad Rubin, staff surgeon for Providence Hospitals in Columbia, said multidisciplinary teams at each hospital worked to tailor WHO's surgical-safety checklist for specific procedures, and for the culture and workflow of their own hospital. Many hospitals held one-on-one training sessions with their OR staff and tested the customized checklists in simulated scenarios before implementing them.

Even with the best possible checklist though, Dr. John Birkmeyer, professor of surgery at the University of Michigan Health System in Ann Arbor, said physicians and other hospital staff still have to use their best judgment and skill. If staff are just going through the motions with checklists and are not focusing on their actual content, the checklist becomes background noise. “It's like saying five Hail Marys,” he said. “The words are coming out, but nobody is paying attention any more.”

Another expert stressed that checklists are no substitute for building a strong patient-safety culture. “You can have a checklist on an app, you can have it on the computerized physician-order entry system. That's fine,” said Frank Federico, executive director of strategic partners at the Cambridge, Mass.-based Institute for Healthcare Improvement. “But a checklist is only a tool and does not replace the teamwork that should be happening.”

Dr. Bob Wachter, associate chairman of the department of medicine at UCSF, which will be using the Emerge checklist app by this fall, said he doesn't expect the first version to be flawless. But he's optimistic because he thinks the app reflects a major advance in making checklists smarter, more like those used in aviation.

While researching a book he's writing about health IT, Wachter spent a day with Boeing engineers who design cockpit safety alerts for airline pilots. That experience, he said, was eye-opening. “They have thought extraordinarily hard about what should be on checklists,” he said. “That degree of care and integration into the electronic workflow is a lesson we can learn in healthcare.”

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