Advancing patient safety through the use of cognitive aids.

To cite: Merry AF, Mitchell SJ. BMJ Qual Saf Published Online First: [please include Day Month Year] doi:10.1136/bmjqs-2015004984 The WHO Surgical Safety Checklist (the WHO SSC) has had a profound impact on thinking in respect to the safety and reliability of surgery, in particular, and healthcare, more generally. It is both a cognitive aid and a tool to improve communication and teamwork. The systematic use of cognitive aids has long been embedded in many other industries, notably high-reliability industries such as aviation and the nuclear industry, but has been largely neglected in healthcare until recently. Few (if any) airplane pilots would think of taking off without making a series of important checks, and few would attempt to do this without a cognitive aid (in the form of a checklist): not only would they have an appropriate checklist available, but they would use it, every time. It is interesting that the same cannot be said with confidence of medical practitioners, including anaesthesiologists, despite the fact that anaesthesia renders patients highly vulnerable to risk and is still associated with occasional deaths or injuries, and despite mounting evidence for reduction of such events through the effective use of checklists. The latter is hardly surprising since events leading to harm during anaesthesia often result from omission of key planning steps (such as failure to anticipate and plan for a difficult airway) or other forms of basic oversight (such as failure to note an important allergy). Wetmore et al have described another strategy that seeks to change this problem. The Anesthesia Patient Safety Foundation (APSF) has developed a Pre-anesthetic Induction Patient Safety (PIPS) checklist from information gained through surveying over 2000 anaesthesia providers. Wetmore et al embedded the PIPS checklist into the Anesthesia Information Management System (AIMS) used in their institution in a manner that obligated users to electronically indicate compliance with the checklist in order to access the AIMS functionality. They randomly allocated anaesthesia residents to use the PIPS checklist (or not) during time-pressured preparation for a simulated anaesthetic induction and demonstrated greater reliability in completing the relevant checks when the PIPS was used—at least in the context of their simulated clinical setting. This was an encouraging result. It was both interesting and important that subjects using the PIPS checklist did not appear to succumb to any temptation to tick the electronic boxes and move on without actually doing the checks even after repeated use over a 6-month period. Whether this would remain so if use became routine over a longer period or with a more senior (and self-confident) cohort of users remains to be seen. The obvious point here is that checklists do not work by themselves: they must be used, and used in an engaged fashion with the mind focused on the issues at hand. 9 This is certainly true of the WHO SSC, which actually goes beyond the strict confines of checklists in general. Many checklists (including the PIPS checklist investigated by De Maria et al) are largely that—lists of items to check. The WHO SSC, on the other hand, includes prompts for certain activities to promote teamwork and communication that might not otherwise occur, notably introductions during the ‘Time Out’ pause immediately prior to the first surgical incision. These introductions, in effect, are an exercise in ‘speed dating’ that aims to activate everyone in the room and prime them to speak up if anything of concern is noticed. The belief is that if people have spoken once, they are more likely to speak again, particularly if an atmosphere of collegial supportiveness has been created. The use of names is also important— because a name is better than a label EDITORIAL