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Checking all the boxes: a checklist for when and how to use checklists effectively
  1. Myrtede Alfred1,
  2. Laura H Barg-Walkow2,
  3. Joseph R Keebler3,
  4. Alex Chaparro4
  1. 1Mechanical and Industrial Engineering, University of Toronto, Toronto, Ontario, Canada
  2. 2Children's Hospital Colorado, Aurora, Colorado, USA
  3. 3Human Factors and Behavioral Neurobiology, Embry-Riddle Aeronautical University, Daytona Beach, Florida, USA
  4. 4Embry-Riddle Aeronautical University, Daytona Beach, Florida, USA
  1. Correspondence to Dr Alex Chaparro, Embry-Riddle Aeronautical University, Daytona Beach, FL 32114, USA; chapara3{at}


Checklists are a type of cognitive aid used to guide task performance; they have been adopted as an important safety intervention throughout many high-risk industries. They have become an ubiquitous tool in many medical settings due to being easily accessible and perceived as easy to design and implement. However, there is a lack of understanding for when to use checklists and how to design them, leading to substandard use and suboptimal effectiveness of this intervention in medical settings. The design of a checklist must consider many factors including what types of errors it is intended to address, the experience and technical competencies of the targeted users, and the specific tools or equipment that will be used. Although several taxonomies have been proposed for classifying checklist types, there is, however, little guidance on selecting the most appropriate checklist type, nor how differences in user expertise can influence the design of the checklist. Therefore, we developed an algorithm to provide guidance on checklist use and design. The algorithm, intended to support conception and content/design decisions, was created based on the synthesis of the literature on checklists and our experience developing and observing the use of checklists in clinical environments. We then refined the algorithm iteratively based on subject matter experts’ feedback provided at each iteration. The final algorithm included two parts: the first part provided guidance on the system safety issues for which a checklist is best suited, and the second part provided guidance on which type of checklist should be developed with considerations of the end users’ expertise.

  • Human factors
  • Patient safety
  • Checklists

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  • Contributors All authors contributed to the conceptualisation of the work, drafted and revised the manuscript, and approved the final version.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.