I am married to an electrical engineer that loves to fly around in a small airplane. Because I hang out with him, I’ve been forced to observe the intricacies of not crashing into other planes and landing safely. I’ve learned a lot.
Pilots have a check list for everything. Plane manufacturers include an entire book of checklists for every contingency, from take off, to landing, to what to do if there is an emergency. ( It is a BOOK, mind you!) My husband straps the needed check list to his leg and goes through it every time we land or take off or preflight. He actually LOOKS at the list, touches each instrument and taps on the applicable gauges. It is not a passive process. Hence my hubbie and I have logged over 1000 hours safely in the cockpit of our tiny plane. (Don’t look at me. I don’t know a dang thing about flying. I just kiss the ground when we land.)
Why do we physicians not utilize more check lists as we go through our day? The medical profession has been (reasonably) stubborn on adapting algorithms and treatment pathways, arguing that each patient is different and no one algorithm can apply to every patient. But from a patient safety stand point, I will side with the check list every time. When a patient goes to the OR a check list is utilized, and when a patient is transported in one of the hospitals where I work, there is a “ticket to ride.” Why don’t we have some simple checklists for ourselves, listing important but (sadly) forgettable to do items for each patient? Now, some hospitals have an EMR that will generate order sets, but they are usually not as robust as they could be, and frequently only cover one disease state. These order sets are good, but incomplete, and lead to “drop offs” on treatment plans. Hence the need for the check list.
When one of the hospitals I work at transitioned to order entry, I had to develop a check list that I carried around with me, because going back and forth between multiple screens is onerous. It included the following:
- Order labs for next day (first screen)
- Review current meds (screen #2)
- order new meds (screen #3)
- order radiology studies (screen #3)
- make sure note is entered in the EMR (screen #4)
- review labs (screen #5)
- read other doctor’s notes (screens 6 and more, each note a different screen)
- review radiology studies (screens 7 and 8, depending on if you actually looked at the image.)
It’s quite easy to drop the details we internists live for. Seems silly, but given it was a new EMR for me, I had to develop a system to make sure my work flow was preserved and important information and procedures were addressed. Most of us used check lists as medical students, and then gave up the habit as we grew more comfortable with medicine. You don’t have to have a check list for everything, but it’s helpful when you are encountering a different situation then usual, like the new EMR I described.
I encourage you to add to your history and physical check list the following things:
- Prophylaxis: e.g. have you written for GI prophylaxis (if warranted) and DVT prophylaxis (don’t forget that DVT is now one of the medicare “no pays”)
- “Treatment plan discussed with patient and family, and they are in agreement.”
- Note the time spent with patient and coordinating care. (A must, for billing. Heck, have this tattooed on your hand if you can’t remember it!)
- Pressure ulcer present/absent at _____________(location). (I have a skin category in my physical exam and include the pressure eval here. Pressure ulcers that develop during a hospital stay are another Medicare no-pay. More on that in a later post.)
One of my hospitalist colleagues uses the following check list at discharge, necessitated because the EMR we use makes us go between several screens and logins:
- write discharge summary
- write discharge orders
- send note to PCP
- set up follow up
- write scripts
Useful primary care check lists would be:
- State of undress for each exam: (female pap: the full Monty, male: off with the tighty whities for the prostate check, diabetics: off with their shoes and socks!)
- Check list clipped to chart as to what screenings are done at what age, or in each room.
- Check list on cabinet door detailing what items go in each cabinet.
- Check list at discharge for assistant to review: does patient have scripts, referrals, test info, and know when to come back.
- List of items your front desk staff needs to check at each check in (check address, insurance card, HIPPA).
- List of items your assistant needs to check as they room the patient (chief complaint, allergies, meds etc.)
When I wrote this post, I considered making a “write post” check list, which would include looking for typos. It seemed like a good idea, but I wuz too bzy so I didn’t have tim to go threw my list witch wud have reminded me to make sur I didn’t have no tipos.
We can learn a lot from the world of aviation. Should we have a check list for Code Blue/COR-0? Nah, we’re physicians, we know it all. Besides, the guidelines will change in two years anyway.