Correspondence  |   December 2018
When Checklists Fail: Human Factors Learning from Aviation and Safety by Design
Author Notes
  • University of Cambridge, Addenbrooke’s Hospital, Cambridge, United Kingdom (M.Z.A.M.). m.mariyaselvam@nhs.net
  • (Accepted for publication September 6, 2018.)
    (Accepted for publication September 6, 2018.)×
Article Information
Correspondence
Correspondence   |   December 2018
When Checklists Fail: Human Factors Learning from Aviation and Safety by Design
Anesthesiology 12 2018, Vol.129, 1192-1193. doi:10.1097/ALN.0000000000002470
Anesthesiology 12 2018, Vol.129, 1192-1193. doi:10.1097/ALN.0000000000002470
There has been appreciable literature on the use of checklists to prevent errors that could lead to patient harm.1  In this letter, we use a recent commercial aviation event to explore the limitations of checklists and introduce the concept of engineering design to prevent error, and examine parallels in health care. In April 2018, following a cabin depressurization on Southwest Airlines, images were posted online showing passengers wearing oxygen masks incorrectly, covering their mouths only. This provoked debate blaming passengers for not listening to the preflight briefing during which the instructions, “place the mask over your nose and mouth and breathe normally,” are given.2  There are many reasons why this simplistic analysis of the error and blame is counterproductive, and why other solutions, such as engineering safety into the design of the oxygen masks, are more likely to succeed than using checklists alone. The Southwest Airlines preflight announcement2  is a checklist that imparts 34 pieces of information, providing a high cognitive load in a situation in which other distractions and anxiety may be present. Only exceptional individuals have a working memory that tolerates retention of more than half a dozen pieces of information. Information retention of frequent flyers may be blunted over time due to a phenomenon known as “creeping complacency” and “alert/warning fatigue.” We propose a simple, safety-design engineered solution for these rare events to improve compliance. Currently the airline oxygen mask is cylindrical with a round aperture. The elongated shape of a simple face mask and its elastic strap, however, can be presented to unaccustomed users in the correct vertical orientation, providing the visual and haptic signals to nudge appropriate placement covering the nose and mouth.