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Recipes for checklists and bundles: one part active ingredient, two parts measurement
  1. Vineet Chopra1,2,
  2. Kaveh G Shojania3
  1. 1The Hospital Outcomes Program of Excellence and The Center for Clinical Management Research, Ann Arbor VA Medical Center, Ann Arbor, Michigan, USA
  2. 2Department of General Medicine, University of Michigan Health System, Ann Arbor, Michigan, USA
  3. 3Sunnybrook Health Sciences Center, University of Toronto Centre for Patient Safety, Toronto, Ontario, Canada
  1. Correspondence to Dr Vineet Chopra, 2800 Plymouth Road, Building 16, Room 430W, Ann Arbor, MI 48109-2800, USA; vineetc{at}

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Central venous catheter-related bloodstream infection (CVC-BSI) is common, costly and potentially fatal.1 For decades, conventional wisdom regarded these infections as inevitable complications of care. This view changed following landmark studies2 ,3 that demonstrated substantial reductions associated with the CVC-BSI ‘bundle.’4 ,5

Investigators at Johns Hopkins University designed an improvement model that featured (1) a checklist, or bundle, of evidence-based practices (proper hand hygiene, chlorhexidine for skin antisepsis, use of maximal sterile barriers, avoidance of the femoral site); (2) education regarding these infection-control practices; (3) a catheter-insertion cart; (4) daily review and prompt removal of unwarranted CVCs and (5) empowerment of nurses to enforce adherence to these practices.3

An initial evaluation of this bundled intervention revealed an impressive decrease in CVC-BSIs from 11.3 infections/1000 catheter days to 0/1000 catheter days at Johns Hopkins. Seeking external validation, investigators partnered with the Michigan Keystone Health and Hospital Association to evaluate the CVC-BSI bundle in 103 intensive care units (ICUs) across 77 hospitals.6 This study again showed a large and statistically significant reduction in CVC-BSIs, from a baseline mean of 7.7 infections/1000 catheter days to 1.4/1000 catheter days. The CVC-BSI bundle had arrived.

The success of the CVC-BSI bundle stimulated interest in checklists for surgical safety.7 WHO's Surgical Safety Checklist led to substantial improvements in operative outcomes in diverse clinical settings.8 A study of multiple checklists at different stages in the perioperative period showed impressive improvements in surgical complications and mortality at six hospitals in The Netherlands.9 These dramatic results—in ICUs and operating rooms—made checklists virtually synonymous with safer innovative care.

How may checklists work?

Early in the checklist movement, some investigators suggested that treating checklists as ‘tick-box’ exercises may lead the field astray. They argued that checklists contain not just technical elements, but also ‘socioadaptive’ ones.10 …

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  • Competing interests Dr. Kaveh Shojania is the Editor-in-Chief of BMJ Quality and Safety.

  • Provenance and peer review Commissioned; internally peer reviewed.

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