Use Medical Checklists as Tools, Not Cure-Alls, for Patient Safety Problems

Janice Simmons, for HealthLeaders Media , February 18, 2010

Berenholtz says that when implementing checklists, it’s helpful to use the Comprehensive Unit-based Safety Program (CUSP) to help focus efforts to "improve culture and context." This initiative includes steps to:

  • Educate providers on the science of safety—to help them understand that "the vast majority of errors aren't the result of one provider...[but] rather it's a whole system that allows that error to occur."
  • Use a written survey with staff on how the next patient could be harmed and what can be done to reduce that harm.
  • Partner with senior executives to help bridge any gaps between senior leaders and frontline providers.
  • Help staff learn from defects or problems.
  • Implement teamwork tools (with daily goals) and talk about the whole program that goes along with the checklists.

The eventual goal, the researchers wrote, is that checklists should be created that are "succinct, unambiguous, focused, and ultimately effective, and efficient." And, when ultimately faced with a crisis, "we can react quickly and decisively, knowing that the items we act out from the checklist are well thought out, tested, and will provide us with the results we want."

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Janice Simmons is a senior editor and Washington, DC, correspondent for HealthLeaders Media Online. She can be reached at

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