The limits of checklists: handoff and narrative thinking

Abstract

Concerns about the role of communication failures in adverse events coupled with the success of checklists in addressing safety hazards have engendered a movement to apply structured tools to a wide variety of clinical communication practices. While standardised, structured approaches are appropriate for certain activities, their usefulness diminishes considerably for practices that entail constructing rich understandings of complex situations and the handling of ambiguities and unpredictable variation. Drawing on a prominent social science theory of cognition, this article distinguishes between two radically different modes of human thought, each with its own strengths and weaknesses. The paradigmatic mode organises context-free knowledge into categorical hierarchies that emphasise member-to-category relations in order to apply universal truth conditions. The narrative mode, on the other hand, organises context-sensitive knowledge into temporal plots that emphasise part-to-whole relations in order to develop meaningful, holistic understandings of particular events or identities. Both modes are crucial to human cognition but are appropriate responses for different kinds of tasks and situations. Many communication-intensive practices in which patient cases are communicated, such as handoffs, rely heavily on the narrative mode, yet most interventions assume the paradigmatic mode. Improving the safety and effectiveness of these practices, therefore, necessitates greater attention to narrative thinking.

Mobilising or standing still?A narrative review of Surgical Safety Checklist knowledge as developed in 25 highly cited papers from 2009 to 2016

“…Such insight suggests that using checklists requires a scientifically grounded understanding of how organisations and people work,33 34 including whether there is explicit awareness of the multifactorial underlying mechanisms of safety, mainly around the ways in which organisational values drive communication and teamwork practices 28 35. And given that organisational values are made explicit via stories, Hilligoss and Moffatt-Bruce remind us of the affordances of narrative methods to explore the complexities of checklist-driven practices 27. One such complexity pertains to the relationship between team mobilisation practices and participation in safety checks.…”

Crossing the Communication Chasm: Challenges and Opportunities in Transitions of Care from the Hospital to the Primary Care Clinic

“…45 The tool systematizes the hospital course content into a logical series of steps that encourages perspective taking and holistic, narrative-based modes of communication. 52 Further evaluation is necessary, but the tool has been tested on one cohort of residents and has been recommended on a trial basis by the graduate medical education division as a model for improving discharge communication across disciplines.…”

Participatory design of a preliminary safety checklist for general practice

“…17,37 The related development process should also be dynamic and flexible and continuously incorporate feedback from users, experts, and the latest research evidence in order to enhance its front-line relevance, feasibility, and impact. [38][39][40][41][42] Similarly, when implemented as a single intervention, checklists are often inadequate 'technical fixes' to what is in effect a sociocultural safety problem that is related, among other factors, to how seriously the issue of checking processes is taken within a team or organisation, particularly in complex working environments. A CVI ratio of ≥0.8 is necessary to minimise the possibilities of chance agreement on content validity and merit item inclusion in the checklist content.…”

“…users may also resist or feel threatened by checklists because they are perceived to replace their expertise or decision making, or oversimplify the complexity of the working environment. [37][38][39][40][41][42][43][44] Allied to user commitment and the support of healthcare leaders and promotional champions, checklist success is therefore more likely where structured step-by-step instructions for comparatively simple or straightforward technical tasks are necessary, variations in related performance already exists, and reliance on human memory is a known problem. 17,32 A study limitation was the potential for bias as is evident through the pragmatic use of convenience samples of volunteer participants who over-represented specialty training practices, which are arguably more likely to be interested in learning and safety activities than nontraining practices.…”