BMJ Qual Saf 22:333-338 doi:10.1136/bmjqs-2012-001537
  • Original research

Do you have to re-examine to reconsider your diagnosis? Checklists and cardiac exam

  1. Jeroen J G van Merrienboer3
  1. 1Faculty of Health Professions Education, Maastricht University, Maastricht, The Netherlands
  2. 2Department of Medicine, HoPingKong Center for Excellence in Education and Practice, University Health Network, University of Toronto, Toronto, Canada
  3. 3Department of Educational Development and Research, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
  4. 4Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Canada
  1. Correspondence to Dr Matthew Sibbald, Toronto Western Hospital, East Wing 8-420, 399 Bathurst St, Toronto, ON M5T 2S8, Canada; mattsibbald{at}
  • Received 21 September 2012
  • Revised 2 January 2013
  • Accepted 6 January 2013
  • Published Online First 5 February 2013


Background Few studies have investigated whether clinicians can use checklists to verify their diagnostic decisions. Checklists may improve accuracy by prompting clinicians to reconsider or recollect information but might impair decision making by adding to clinicians’ cognitive load. This study assessed whether checklists improve cardiac exam diagnostic accuracy, and whether this benefit is dependent on collecting additional information.

Methods 191 internal medicine residents examined a cardiopulmonary simulator. They provided a diagnosis, subjective rating of certainty, and key findings before and after using a checklist. Residents were randomised; half were allowed access to the simulator and half were prohibited access to the simulator while using the checklist. Residents rated their cognitive load in each step: prechecklist diagnosis, checklist use and postchecklist diagnosis.

Result Verifying with a checklist resulted in improved diagnostic accuracy; 88 residents (46%) made the correct diagnosis before using the checklist compared with 97 (51%) afterwards, p=0.04. The benefit of checklist use was restricted to residents allowed to re-examine the simulator (10 changed to correct diagnosis and one to an incorrect diagnosis) whereas no net benefit was seen among residents unable to re-examine the simulator (two changed to a correct diagnosis and two to an incorrect diagnosis, p=0.03). Those able to re-examine the simulator were slightly more confident after checklist use, whereas those unable to re-examine were slightly less confident after checklist use (p=0.01). The opportunity to re-examine the simulator had no effect on the accuracy of key findings reported. Of the three steps, checklist use was associated with the lowest cognitive load (F1,189=68 p<0.001).

Conclusions Verifying diagnostic decisions with a checklist improved diagnostic accuracy. This benefit was only seen when more information could be collected. Checklist use was not associated with increased cognitive load.

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