More than 3,000 hospitals around the world have
registered with the World Health Organization
(WHO) to implement the use of a pre-procedure
safety checklist. This is not surprising given the
widely publicized data proving the use of safety checklists reduces
complications, errors, infections and mortality. With documented
results like these, more than 300 professional societies, health
organizations, ministries and non-governmental organizations
have endorsed the concept of using checklists to provide safe care.
Dental practices are also taking advantage of safety checklists
to make dental care safer for their patients, and more efficient,
profitable and trouble-free for their offices. How? Proactive dental
offices are using a detailed checklist protocol similar to the safe surgery
checklist developed by the WHO - which is itself based on
the checklists that professional pilots have used for years to prevent
human error and accidents. The aviation checklist system has significantly
reduced airline mishaps.
Dentists are finding that checklists work as well in their practices
as they do in commercial aviation. It's not hard to see why.
Both professions rely on teamwork and attention to detail to
achieve the best result. And, both have serious consequences for
The dental checklist system is used to failsafe personnel, equipment
and data. It helps office staff to think ahead during each case
and catch errors early in the processes used in dental practices.
Catching human error becomes very important as one unchecked
early error can snowball into a catastrophe for dental patients,
especially if the practice is using conscious sedation. One error
caught early not only prevents catastrophe and lawsuits, it also
improves the efficiency of office operations. Thus, safety checklists
are not only the right thing to do for patient safety, they are the
right thing to do for a practice's bottom line.
A professor of dentistry and two practicing dentists - who are
also commercial airline pilots - spearheaded the development of
by Captain Stephen W. Harden, BS, ATP, B-737, B-727, MD-11
and John B. Roberson, DMD
the dental checklist system. They created a checklist that optimally
standardizes dental procedures for pre-emptive error discovery.
Their checklist is categorized into five typical timeframes:
- Appointment summarization
- Prior to procedure
- During procedure
- Prior to patient release
- Following patient release
Using this checklist system as a starting point, each dental
practice adapts and revises the checklist to fit its own office procedures
and culture. The customized, office-specific checklist
establishes standard, optimum protocols.
While creating and implementing a safety checklist seems
intuitively easy, experience has shown that implementation mistakes
are common and can ruin the effectiveness of checklists.
Having helped more than 110 organizations around the world
create and successfully implement checklists, author Harden
offers eight tips to boost the success rate of the checklist implementation
process in dental practices.
Tip 1: Ensure your checklist is user-built
The most important phrase on the current WHO Surgical
Safety Checklist is located on the bottom of the page: "This
checklist is not intended to be comprehensive. Additions and
modifications to fit local practice are encouraged." Administrators
ignore this piece of advice at their peril. Effective checklists
borrow heavily from the "Kaizen" methodology of the Toyota
Manufacturing Process. In Kaizen, the people who actually do
the work are best suited and most responsible for creating the
standard for how the work is accomplished. Checklists created
by other people at other facilities will rarely work well. There is
no emotional investment and no pride of authorship in an "offthe-
shelf " checklist.
To overcome this, put a small team together with representatives
from each work group that will participate in using the
dental safety checklist. Allow them the freedom to customize
the tool in a way that makes sense for them and that aids their
work flow. As an administrator, give them the resources and
support they need to be successful, then get out of their way
and allow them to do their customization. Want to avoid the
"not made here" syndrome and all the problems that it brings?
Ensure your checklist is built and implemented by your clinical
staff - not your administrators, and certainly not the staff from
a different facility.
Tip 2: Keep it short.
Not everything has to be on a dental safety checklist.
Checklists are used to verify only the critical items of a procedure.
Critical items are those that if not done correctly will cause
harm to patients or caregivers before that error can be stopped.
For example, there are approximately 65 items for an airline captain
to check to prepare a modern airliner for engine start and
flight. However, most "before start" checklists have only 11 or
12 items to be reviewed. These are the items, that if missed, will
not be self-correcting before some harm to the aircraft, passengers
or crew is caused. With checklists, shorter is better.
Tip 3: Don't confuse your checklist with an
Great checklists are not designed to use as an audit tool.
Dental Safety Checklists are not about creating a paper trail,
they're a critical job aid to help the team (not the individual)
cross check and verify, with two or more sets of eyeballs, that critpractice items haven't been missed. This cross check by multiple team
members creates the needed engagement and mindfulness by the
dental team during the checklist process, and is much more valuable
to overall safety than having tick marks in the appropriate
boxes. In fact, you should seriously consider getting rid of the
tick boxes on your checklist. A check-in-the-box makes it easy to
pretend something has been done when it really hasn't.
Tip 4: Include speaking parts for the team on
Effective checklists will trigger a scripted conversation and verbal
cross check of critical steps in the procedure. The more speaking
parts different members of the team have, the more
mindfulness and involvement you'll have in the checklist process.
The reason is simple - if team members know they have speaking
parts, they must pay attention to the checklist flow and be ready
with their verbal responses. No one wants to be the sour note in
the symphony of a well-executed checklist. No team member
wants the public embarrassment of being the one who declares an
item has been checked when it hasn't. The timely public declaration,
in front of a team of peers, that the item you are responsible
for has been checked, and is as it should be, creates a sense of
responsibility and mindfulness in each member of the team that
has a speaking role in the checklist.
Tip 5: Use standardized and scripted language.
Speaking parts only work if the exact language and words that
should be used for each item on the checklist are crystal clear and
standardized - down to the exact word or phraseology that must
be used. In other words, checklist dialogue should be scripted.
Scripting will answer a number of questions.
- Who is responsible to "call out" an item on the checklist?
- Does this statement or "call out" require a verbal response?
- Who should respond to "call outs," and what, exactly,
should their verbal response be?
- What should be cross-checked and confirmed before a verbal
response is made?
Without an exact script to follow here, staff will create a wide
variety of methods to accomplish steps in the checklist, introducing
time-consuming confusion, uncertainty and frustration.
Tip 6: Design your checklist as a "read and
There are essentially two types of checklists in use by high reliability
organizations (HROs) - Read and Do and Read and Verify. In a Read and Do checklist, the operator reads the item on the
checklist and then does that step immediately after reading it.
Then the next item is read and subsequently immediately accomplished. Checklists done this way are extremely time-consuming
and act as giant speed bump for workflow and efficiency.
This cumbersome approach to checklists will cause most
surgical teams to resist using a pre-procedure checklist.
Overcome this resistance by teaching your teams to
use a Read and Verify checklist system. With this method
the team accomplishes critical and routine actions from
working memory. They periodically pause and use the
checklist to verify that the most critical actions have been
accomplished. Used this way, it takes only seconds for the
team to cross check and verify that nothing critical has
been missed. The speed and efficiency of this method will
greatly reduce the resistance you experience with implementing
Tip 7: Use a slider board instead
of a paper checklist.
Once a customized office checklist is finalized, have the
checklist printed on an acrylic board with corresponding
"sliders" for each item on the checklist. These sliders must
be physically moved from "red" to "green" to complete the
checklist. The movement of the slider must be verified by
two team members from the office staff. Slider checklist
boards typically contain a blank section where staff can use
a dry-erase marker to make additional notes about the case
Dental offices find these checklist slider boards more
effective than paper checeklists because they:
- Create team engagement - as attention is focused on
a single place for verification of process;
- Provide a strong visual cue to begin the cross-check
- Create mindfulness and attention to detail as each
team member can see an instant visual indicator of
- Engage the visual senses through the use of color
(green for go, red for stop);
- Proactively eliminate error and improve efficiency; and
- Can be mentioned in dental office marketing as a
Tip 8: Make it dentist-led.
In HROs such as commercial aviation, checklists are
"owned" by the team leader - the captain of the crew. The
captain uses the checklist to manage workflow and team
performance. Checklists are one of the primary tools for
supervising the team. Airline captains understand the value
of checklists in creating teamwork, fostering communication,
and setting expectations that team members will be
vigilant and provide safety monitoring. In the case of the dental team, checklists are owned by the dentists performing the
procedure. Dentists, just like airline captains, have a vested interest
in ensuring checklists are used effectively and completely. As
team leaders, it's their responsibility to initiate the checklist at the
time of their choosing, and to insist on professional accomplishment
of the checklist in its entirety.
Bonus Tip 8½: Use checklists to avoid distractions.
A recent study conducted during invasive medical procedures
revealed that these fairly simple distractions caused an
eight-fold increase in major medical mistakes during those surgical
- Unexpected movement by an observer;
- A cell phone ringing and answered by an observer;
- An unrelated conversation between an observer and a
- Noise made by dropping a metal tray;
- A question about a problem that came up regarding a
recovering patient; and
- A question about a residents career choice
Additionally, more than 50 percent of the physicians in the
study forgot a key surgical task when these distractions were present.
In comparison, only 22 percent forgot a memory task when
there were no distractions. Properly constructed and used checklists
create a "no interruption zone" where dentists and their staff
can concentrate soley on the upcoming patient visit and ensure
everything is double checked for accuracy and efficiency. These
"no interruption zones" minimize distraction-induced errors and
improve the safety, quality and reputation of a dental practice.
No matter where you are on your checklist journey, these 8½
tips will improve the speed of your implementation process and
help you reap the patient safety rewards of a well-designed checklist
system. Properly created and implemented, your dental safety
checklist should offer these benefits:
- Increase patient safety
- Save patient lives
- Reduce overhead costs
- Reduce medical errors
- Reduce medications errors
- Improve your dental team's skills
- Improve the performance of yourself and your teams
- Reduce the risk of negative patient outcomes
- Improve the level of quality, safety and reliability toward
- Increase competence and confidence for improved
- Increase quality of care delivered by yourself and your team
- Decrease mortality rates
- Improve patient care experience
- Improve team skills
- Increase heightened morale of your dental team
- Prevent distraction-induced errors