Table 1

Lessons learnt from 30 years of personal experience with and reflection about the Anesthesia Equipment Pre-Use Checklist*

1Poorly designed checklists will be less likely to be used and more error prone.
2It is critical to involve those who are going to be using the checklist in its design and iterative refinement.
3Checklists need to be promulgated as useful cognitive or decision aids, not as tools to enhance compliance with mandated procedures.
4A checklist that is poorly implemented or not well integrated into workflow will have low or variable levels of adherence.36
5Successful checklist implementation will depend on whether its use is adequately aligned with the users’ values, priorities and mental model of their everyday work.
6Self-reported or documented adherence (consistently high with the FDA checklist) is always higher than actual observed adherence.
7Use of (well-designed) computerisation of the checklist generally improves but does not assure adherence.37
8Even with 100% adherence, checklist benefit will diminish if users simply go through the motions or are not fully engaged. This can be due to many factors including inadequate buy-in, poorly understood leadership mandates, power dynamics, distractions and competing priorities.
9Due to myriad contextual or confounding factors as well as challenges with study design, there will often be variable evidence of effectiveness, even across well-designed randomised controlled studies (eg, 31).
10Despite all of the above, with incremental iterative improvements in the checklist and associated processes and technology over time, the problem(s) the checklist was intended to address will steadily improve as long as that remains a system priority. For anaesthesiology, FDA checklist use has been accompanied by: (A) improvements in the underlying machine technology; (B) automated self-checking of many checklist items; (C) inclusion of technicians to assist in assuring that items are proactively addressed; and (D) a culture that strives to prioritise safety over production.
  • *This list applies equally well to other safety tools and processes including computer-based decision support systems.

  • FDA, Food and Drug Administration.