The pre-anesthesia induction patient safety (PIPS) checklist: Testing dynamic versus static implementation strategies

Background: Retrospective studies and large-scale reviews suggest multiple properties of effective checklist implementation, such as active leadership, ongoing feedback, and local modification. We hypothesized that the use of these effective checklist implementation strategies would yield better results as compared to a more fixed implementation strategy of the Pre-anesthesia Induction Patient Safety (PIPS) checklist. Methods: We conducted a prospective, pre-post, pragmatic cohort trial of a checklist implementation using a prospective difference-in-difference design observing simultaneous implementation of the same PIPS checklist in two community hospitals. At one hospital, we created a multidisciplinary committee of stakeholders to oversee implementation and provide active leadership, ongoing feedback, and local modification of the checklist (“Dynamic Implementation”). At the second hospital, a single clinical champion implemented the checklist with no local modification (“Static Implementation”). We examined checklist compliance and proximal outcomes three months before and nine months after implementation. We conducted surveys and interviews to examine attitudes and implementation barriers. Results: We observed 477 anesthesia inductions. The “Dynamic” cohort demonstrated significantly greater checklist compliance post-implementation compared to the “Static” cohort (B = 0.26, p < .001 for observable action and B = 0.24, p < .001 for verbal compliance). We were underpowered to detect changes in errors, or near-misses, but observers captured anecdotal checklist-related patient safety evidence, suggesting more research should be done in this area. There were no differences between cohorts on changes in team communication, or attitudes toward checklists. Participant interviews showed that two of the major criticisms of the PIPS checklist, ambiguity and redundancy, were more effectively resolved with the “Dynamic” implementation. Conclusions: Dynamic implementation yielded significantly better compliance with the checklist than a more static approach. However, barriers such as time pressure and lack of team buy-in remain. Larger scale studies are needed to determine the full impact of the PIPS checklist on safety related outcomes such as near-misses.