Table 1

Simple versus complex narratives in checklist rationale, design and use

Simple narrativeComplex narrative
RationaleChecklists reduced aircraft accidentsAircraft accidents were reduced through a range of physical and procedural design changes, of which checklists were one component
They ‘plug the holes’ in the Swisscheese9There are many solutions to a problem; checklists may solve problems and/or introduce new ones
They encourage safer behaviourThey may encourage ‘mindless’ checking, promote automaticity and discourage conceptual thinking about a task
They reduce undesirable human variabilityVariable human responses address contextual variability, essential for safety system function
They are ‘evidence based’They are one part of the underlying mechanism of effect, which is often poorly defined
They are an exemplar of ‘systems thinking’They are used to modify behaviour instead of applying broader systems thinking
They encourage teamwork and communicationThey can help to promote shared awareness and team discussions where sufficient team skills and a supportive working environment already exist, but cannot achieve this alone
They are for checking something is correctThey are for checking something has been done
They encourage ‘pause for thought’ or discussionThey are most effective when requiring immediate stimulus-response behaviour
They reduce the effects of interruptionsThey are most error-prone when interrupted
DesignThey are a simple piece of paperThey are a complex socio-technical intervention
They can be developed easilyThey take considerable effort to be effective, with many design dimensions to consider
They are a ‘stand-alone’ solutionA checklist is part of a wider engineered process, including other checklists
They define how a task should be performedThe user should be skilled and well practiced at the task. A checklist should assist them in doing it
They are a simple set of statements and boxesThere are a wide range of design parameters
They must have a tick boxA tick box is not always necessary and does not guarantee full or proper use
Text is descriptive of desired performanceThe text should be a reminder for a motivated user, already skilled and experienced in the task
They should be ordered in terms of function (ie, All similar process items together)They should be ordered in terms of geographical and temporal proximity (ie, tasks done in the same time and space)
They can be used for general tasks (‘empower staff’)They should be used for specific tasks (‘manual start switch…off’)
UseThey can be implemented easilyImplementation is a complex and challenging process that also requires ongoing maintenance
They are a cost-effective solutionThe resources required to implement, perform and maintain a checklist are rarely calculated
They need to be followed by everyoneA challenging dichotomy arises where experts, who may perceive them as wasteful and patronising, use them as a reminder only. This may or may not be appropriate
They should always be complied withA poor design, implementation or context might make it impossible to be compliant
They should be signedSigning does not guarantee appropriate use, accountability, compliance or audit accuracy, and can promote ‘gaming’ and false views of safety
Lack of professionalism and a culture of safety are the causes of non-complianceNon-compliance may be because of inappropriate designs, use cases, implementation, training, perceived utility, threats to professional identity/autonomy/expertise, power-play by managers and time/cost burdens incongruent with other system demands
Their use can be easily and reliably auditedReal-time observations of checklist use typically reveal lower levels of compliance than those suggested by organisational audits. True compliance refers to ‘how’ checklists are being used, not just ‘if’, and this should be measured to maximise understanding of the barriers and facilitators to uptake and buy-in