Checklists - a tick in the box

At the Rebreather Forum 3 conference held in Florida in May 2012, a number of presentations were made which advocated the use of checklists as a means to prevent diving incidents from occurring, or at least reducing the likelihood of occurrence.

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The reason why the presentations and consensus statement arrived at this position was because there is considerable evidence from aviation, medicine and other fields and disciplines that shows the proper use of checklists reduces the probability of incidents occurring.

Simple examples of how checklists have improved safety include making sure the limb for amputation has been actively and correctly identified, positive confirmation of the dose and identity of the drugs being administered or making sure the correct engine is being shutdown in the event of an aircraft engine fire.

Whilst these may appear to be really obvious situations which should not need an additional level of oversight, there are a considerable number of documented events where these things had gone wrong because the wrong selection or decision was made.

However, just because you have a checklist it doesn’t mean you won’t prevent incidents from occurring. An oft-quoted line, “In all of the CCR fatality investigations I have been involved in, there wasn’t a single checklist present on the diver,” can be countered with, “All of the commercial airliners which have crashed in the last ten years have had checklists (hardcopy or electronic) in the cockpit.”

This counter doesn’t mean that checklists don’t have their use, they do, but to make them effective, the community has to create the environment where their use is the norm and also allows divers to be challenged if they are not completed properly. Given the culture in some parts of the community, this will be a major challenge.

The Checklist Manifesto

Between October 2007 and September 2008 there was a World Health Organisation study to investigate the effectiveness of checklists in operating theatres and hospitals to reduce the numbers of incidents, accidents and fatalities; at the time there were 150,000 people dying every year in hospitals following surgery.

Despite these statistics, there was considerable resistance, especially from the more senior doctors, surgeons and consultants because they did not believe they made the mistakes and felt that they should be trusted to carry on with the status quo.

However, despite the protestations, the trial was run across eight hospitals in eight cities around the world. The results were staggering. “Overall, in this group of nearly 4,000 patients, 435 would have been expected to develop serious complications based on our earlier observation data. But instead just 277 did.

Using the checklist had spared more than 150 people from harm—and 27 of them from death,” and, “The rate of death was 1.5% before the checklist was introduced and declined to 0.8% afterward. Inpatient complications occurred in 11% of patients at baseline and in 7% after introduction of the checklist.”

The checklists themselves were really simple but they required an active element to tick off items against a list rather than being verbally completed from memory. However, it wasn’t the checklist per se that was the most important factor in improving the safety in the surgical theatres, it was empowering the very junior staff to prevent procedures from starting or progressing until the checklist items had been completed.

This empowerment came from the most senior management within the hospitals and, in effect, provided ‘top cover’ for the nurses and assistants to tell a consultant or surgeon to not progress, no matter how much they protested.

This was a massive change to the culture in the operating theatre where it had always been considered that the surgeon or consultant was ‘God’, but now one of the most junior staff could question this authority.

By providing a means by which someone else confirms that the checklist is completed, it ensures that someone doesn’t pay lip service to the checks. (Whilst it can’t reduce this possibility to zero, it seriously reduced the opportunity).

This is the same process used in multi-crew flight deck operations where one pilot reads the checklist out loud and the other actions it, confirming that the action has been completed when they have done so. This process is known as “challenge and response”.

Notwithstanding the above, care must be taken to ensure that there are not checklists for checklists, or that checklists are appropriate for their intended use. A single checklist cannot cover equipment preparation, pre-dive equipment/configuration checks, in-water emergencies, or post-dive dismantling of equipment and therefore there is considerable skill required to target checklists and their application.

Diving checklists

Many diver training organisations provide verbal checklists in their training manuals and try to instill the habits and cultures to use them effectively and regularly. Examples include BWRAF (BCD, Weights, Regulators, Air and Final Check), GUE EDGE (Goal, Unified team, Equipment, Environment, Decompression, Gases and Exposure) and BAR (Buoyancy, Air and Releases).

The idea being that these are ‘last ditch’ checks completed just before the diver gets in the water and provide some assurance that their equipment is ready for use and will provide them with a working gas supply and adequate buoyancy.

However, there is significant evidence that these checks are not completed regularly or effectively. The non-completion of checks happens at all levels of diving, from beginners in blue water holiday environments to technical OC and CCR divers with multiple stages.

The reason why they are not completed varies from relaxed or complacent attitudes to checks, being rushed, ‘rent a buddy’ and not being sure what they are expecting, not wanting to question another diver and so on. This situation is made worse when divemasters or instructors do not undertake buddy checks either and therefore set a bad example for their charges to follow: “my instructor isn’t doing a buddy check, why should I?”

Following RF3.0 a number of agencies provided CCR checklists for use on their courses, some of which were small enough to be clipped onto the unit at all time, whereas others were the size of a training slate.

Evidence of effectiveness of checklists in diving

A recent study by DAN in the summer of 2013 appears to have shown the benefit of completing checklists by conducting a trial where the group was split into a control group who could choose to complete formal checklists before they started their dive, and the subject group who were given a checklist to use just before they entered the water. The checklist group had fewer reported incidents than the control group and a number of issues were detected which would have otherwise been missed had the checklist not been followed.

A full analysis is expected to be published shortly in the scientific literature. Now this is only one study and only involved one environment so there are likely to be some biases involved, but it certainly showed the merit of using checklists.

Another example was the Guam  (...)