The secret to the medical checklist nudge

In the field of medicine, there is perhaps no better nudge than Peter Provonost’s medical checklist. Adapted from pre-flight preparations by airline crews, the medical checklist is a six-step set of routine actions for preventing Intensive Care Unit line infections that doctors may otherwise forget to do because of time constraints, stress, or distractions. The success of this checklist in Michigan hospitals has been well documented. After two years the checklist had prevented 43 infections and eight deaths, saving $2m dollars in costs. (The graph below comes from a lecture by former Congressional Budget Office Director Peter Orszag.)


Changemakers, an initiative by the non-profit social entrepreneurship group Ashoka, is preparing to launch a competition to generate medical nudges (more on that in a later post), and the contest organizers have selected the checklist as one of their case study examples. They remind us why the checklist is such a brilliant idea. It’s not the six simple steps. It’s the observing nurses who provide instant feedback ensuring that the medical checklist is followed.

Pronovost’s masterstroke came next: asking ICU nurses to observe doctors’ behaviors after the lists were posted. If they didn’t follow the list, nurses should intervene. Nurses were also to ask doctors daily whether lines ought to be removed, so as not to leave them in longer than necessary.

“When we first said it, the nurses said, ‘Hey, I’m gonna get my head bit off’,” recalls Pronovost. “And docs said, ‘You can’t have nurses second-guessing me in public’. So I pulled all the teams together and said, ‘Is it acceptable that we can harm patients here in this country?’ And everyone said, ‘No’.”…

(Provonost) made the nudge public – involving nurses and reframing the issue as one about harming patients, not authority, Provonost created a cultural shift, empowering everyone in ICU to nudge each other toward right choices to preventing infections.

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